From the Guidelines
The next treatment option for acne after minocycline and tretinoin is typically oral isotretinoin (Accutane). The usual dosage is 0.5-1 mg/kg/day for 15-20 weeks, with a cumulative dose of 120-150 mg/kg, as recommended by the most recent guidelines of care for the management of acne vulgaris 1.
Key Considerations Before Starting Isotretinoin
Before starting isotretinoin:
- Obtain baseline blood tests (lipids, liver function)
- Ensure effective contraception for females (two forms recommended)
- Discuss potential side effects with the patient Isotretinoin is highly effective because it targets all four major factors in acne pathogenesis: excess sebum production, abnormal follicular keratinization, Propionibacterium acnes proliferation, and inflammation, as supported by recent studies 1.
Monitoring and Side Effects
Common side effects include dry skin, lips, and eyes. Monthly monitoring of blood tests and pregnancy tests for females is necessary during treatment. Improvement is usually seen within 8-12 weeks, with many patients achieving long-term remission after one course. Although other options like spironolactone are available for certain cases of acne, particularly in women 1, isotretinoin remains the most strongly recommended treatment for severe, scarring, or recalcitrant acne that has not responded to standard oral or topical therapies, according to the latest guidelines 1.
From the Research
Treatment Options for Acne
When minocycline and tretinoin are ineffective, the next treatment option for acne can be considered as follows:
- For patients with moderate inflammatory acne, treatment with low-dose isotretinoin (0.2-0.4 mg/kg/day) until acne recovery, independent of cumulative dose, has been shown to be effective 2.
- For patients with predominant papulopustular acne, fixed combination topicals are recommended, with treatment tailored according to the severity of disease 3.
- In cases of nodular/conglobate acne, oral isotretinoin or fixed combinations plus oral antibiotics in men, and these options may be supplemented with oral anti-androgenic hormonal therapy in women, are recommended 3.
- Isotretinoin is also approved by the US Food and Drug Administration for treating severe recalcitrant nodular acne, but is often used to treat resistant or persistent moderate to severe acne, as well as acne that produces scarring or significant psychosocial distress 4.
Considerations for Treatment
When considering the next treatment option, it is essential to evaluate the patient's response to previous treatments and identify the underlying causes of treatment failure, which can be categorized into disease progression, non-drug-related reasons, drug-related reasons, poor adherence, and adverse events 3. Non-antimicrobial treatments, such as topical and oral therapies, can be highly efficacious at controlling acne, especially when used as maintenance therapy, and should be considered to minimize the use of antibiotics and reduce the risk of antibiotic-resistant bacteria 5.