From the Guidelines
The next step in managing cystic acne after topical tretinoin and oral doxycycline is typically oral isotretinoin (Accutane, Absorica). The standard dosing regimen is 0.5-1 mg/kg/day divided into two daily doses for a total cumulative dose of 120-150 mg/kg over 4-6 months, as supported by recent guidelines 1. This approach is warranted when severe nodular or cystic acne fails to respond to conventional therapy with topical retinoids and oral antibiotics. Isotretinoin works by reducing sebum production, normalizing follicular keratinization, decreasing Cutibacterium acnes colonization, and providing anti-inflammatory effects.
Before starting isotretinoin, baseline laboratory tests including lipid panel, liver function tests, and pregnancy test for females are required, as emphasized in the guidelines 1. Monthly monitoring of these parameters is necessary during treatment. The medication is highly teratogenic, so two forms of contraception are mandatory for females of childbearing potential, along with enrollment in the iPLEDGE program. Common side effects include dry skin, dry lips, dry eyes, and potential mood changes. Less common but serious side effects include elevated triglycerides, liver enzyme abnormalities, and rarely, pseudotumor cerebri.
Alternative options if isotretinoin is contraindicated include hormonal therapy (for females) with combined oral contraceptives or spironolactone, or intralesional corticosteroid injections for isolated cystic lesions, as suggested by recent studies 1. However, oral isotretinoin remains the most effective treatment for severe cystic acne, with strong recommendations from multiple guidelines 1. It is essential to carefully consider the benefits and risks of isotretinoin and alternative treatments in the context of individual patient needs and preferences.
Key considerations for the use of isotretinoin include:
- Careful patient selection and monitoring
- Baseline and monthly laboratory tests
- Mandatory use of two forms of contraception for females of childbearing potential
- Enrollment in the iPLEDGE program
- Regular follow-up to assess treatment response and potential side effects.
By prioritizing the use of oral isotretinoin for severe cystic acne, clinicians can improve treatment outcomes and reduce the risk of long-term sequelae, such as scarring and psychosocial burden, as supported by the most recent and highest quality evidence 1.
From the Research
Next Step in Management of Cystic Acne
After topical tretinoin and oral doxycycline, the next step in management of cystic acne is:
- Isotretinoin therapy, which has been shown to be effective in treating cystic or conglobate acne that is unresponsive to therapy with oral or topical antibiotics, topical tretinoin, or topical benzoyl peroxide 2, 3, 4
- The usual oral dosage of isotretinoin for patients with cystic acne is 1-2 mg/kg/day in two divided doses, and administration should continue for 15-20 weeks 2
- Isotretinoin is unique in that acne remission continues after discontinuance of therapy, with 27 of 32 patients treated with isotretinoin clearing completely, and all patients being in remission averaging 38 months in duration 4
- However, isotretinoin can have adverse effects, including mucocutaneous tissues and serious ones, and its use should be limited to patients with severe conditions that do not respond to older therapies because of its cost and potential side effects 2, 3, 5
Patient Selection and Monitoring
- Patients with severe cystic acne that is unresponsive to conventional treatment should be considered for isotretinoin therapy 2, 3, 5
- Careful clinical and laboratory monitoring is imperative, including monitoring of serum lipids, as isotretinoin can cause elevated triglycerides and lowering of the high-density lipoprotein fraction 3
- Patients should be instructed to report any adverse effects, and the dosage of isotretinoin should be adjusted accordingly 2, 3