QShould we push our isotretinoin patients to a higher cumulative dose closer to 220mg?

Medically Reviewed by Nick Brownstone, MD

Isotretinoin is the most effective treatment for severe nodulocystic acne vulgaris, and it is the only treatment option for acne that offers the potential for remission or permanent cure. I am quick to offer it to my patients when I see scarring. But the current literature is divided on the ideal dosing of isotretinoin to optimize treatment response. Many studies support a cumulative dose of 120 to 150mg/kg to decrease the risk of relapse and retrial. But could pushing patients closer to 220mg/kg further reduce the number of patients who have to undergo a second course down the road?

In a prospective, unblinded, observational study, 180 patients with severe, unresponsive, nodulocystic acne received isotretinoin until 1 month after new lesions stopped developing. Mean age of participants was 19.3 years and 51.9% were female; 74.1% were white and 25.9% were defined as non-white.

After treatment ended, patients were divided into a high cumulative dose group (≥220 mg/kg) and a low cumulative dose group (< 220mg/kg).

Patients were monitored for 12 months after their last day of isotretinoin because previous studies have found that 80-90% of patients experienced relapse (defined as the need for prescription acne medication) within 12 to 24 months after finishing a course of isotretinoin.

At 12-month follow up in the study above, the relapse rate was 47.4% in the lower-dose treatment group (<220mg/kg) compared with just 26.9% in the ≥220mg/kg group. Laboratory abnormalities (which included liver enzymes, cholesterol and triglycerides) during the treatment period were uncommon and not significantly different between the 2 dosing groups. Retinoid dermatitis was significantly more common in the high-dose treatment group (53.8 vs 31.6%), however.

I personally now will push many of my severe acne patients to a cumulative dosage of 180mg/kg-220mg/kg before completing isotretinoin treatment. I also treat one month past the patient’s last pimple even if they’ve already hit their target cumulative dosage. I find in these patients that if their acne does come back after their isotretinoin course is finished, it’s usually mild and I’m able to manage it with a prescription tretinoin cream for maintenance. I always warn patients at the start of isotretinoin treatment, however, that they may need to undergo a second course down the road so they are aware of the risk that their acne may return.

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References:

1. Blasiak R, Burkhart, C. High-Dose Isotretinoin Treatment and the Rate of Retrial, Relapse, and Adverse Effects in Patients with Acne Vulgaris. JAMA Dermatol. 2013; 149; (12):1392-1398. Doi:10.1001/jamadermatol.2013.6746
2. Coloe J, Du H, Morrell DS. Could higher doses of isotretinoin reduce the frequency of treatment failure in patients with acne? J Am Acad Dermatol. 2011;65(2):422-423