Isotretinoin side effects you need to know about

Read this before you take Roaccutane

 

If you suffer from acne, there’s a very high chance you want to get rid of it – STAT! Isotretinoin, also often referred to by the brand names Accutane or Roaccutane, has a reported success rate of between 70-90% reduction in acne lesions.

 

Something so effective is probably pretty powerful stuff, and so it is with isotretinoin. Along with that power also comes side effects worth knowing about. These include some common, some less common and some contentious.

 

Side effects, what side effects?

Although some commentators feel the risks of isotretinoin are overstated, I think it’s useful to have the information to hand. You can then weigh up the pros and cons yourself and decide if this is the right medication for you.

 

What is isotretinoin?

Isotretinoin (13 cis retinoic acid) is an acne medication available since 1982 ¹. It is a synthetic retinoid derivative of Vitamin A.

 

Prescribing guidelines

In Australia, isotretinoin is a medication only able to be prescribed by a General Practitioner or Dermatologist. Although current prescribing guidelines recommend it for “severe cystic acne unresponsive to conventional therapy”, I often see patients who have been prescribed this for moderate to mild acne or patients who report not being fully aware of the potential side effects of this medication.

 

Side effects

It is worth making the point not everyone who takes this medication will get side effects or, even if they do, will experience them to the same degree. In the case of isotretinoin’s side effects, some of them may be related to your genetic susceptibility. Retinoids, in general, influence gene expression.

 

Responsible prescription of this medication will see it used at the lowest dose for the shortest amount of time and carefully monitored.

 

Common side effects

Isotretinoin is a well-known teratogen

This is a fancy word for the ability of a substance to cause congenital disabilities.

Exposure of the fetus to isotretinoin can cause cleft lips, ear and eye defects, mental retardation and stillbirth.

 

Guidelines for women taking isotretinoin recommend a concurrent prescription of birth control for one month prior and two months after the course of medication.

 

Liver function

 

Moderate increases in the liver aminotransferase enzymes, AST and ALT, are a well known side effect of isotretinoin. Although direct evidence is lacking, these changes may be linked to the destruction of liver cells, which then release the AST & ALT into the blood. This effect seems to resolve with the cessation of treatment. Monthly testing while on the treatment and follow up testing after the treatment is recommended².

 

Increased Cholesterol

A common but usually transitory side effect is changes to blood lipid markers. Elevated triglycerides, total cholesterol and LDL cholesterol, are often seen in people using isotretinoin for longer than three months. These changes may be caused by alterations in the APOE genes, which decrease the removal of cholesterol from the blood.

Changes to mucous membranes

The changes isotretinoin causes to sebum function also impact mucous membranes elsewhere in the body, resulting in a sensation of dryness ².

 Dry eyes (xerosis) and dry, cracked lips (cheilitis) are experienced by 30-50% of patients ³.

 Use of isotretinoin for two months or more has been found to reduce tear secretion. It also affects the release of oil from the Meibomian glands. This substance helps to keep the eye lubricated. These long-term effects of isotretinoin can cause blepharitis, changes to vision and contact lens intolerance ⁴.

 

Less common but still worth knowing about

Mental health

There is evidence to suggest isotretinoin increases the risk of mental health conditions such as suicide ideation, depression and mania in susceptible individuals. These adverse effects happen gradually and may not emerge until after discontinuation of treatment ¹.

 

Isotretinoin may reduce the growth of nerve cells in the hippocampus, a brain region involved in emotions, learning and memory. Research in mice shows the volume of the hippocampus was also decreased².

 

Increased risk of depression may be due to the gradual reduction of two critical neurotransmitters involved in mood, dopamine and serotonin. Long term monitoring of mental health should be considered ¹.

 

It is thought genetic factors make some people more susceptible to mental health side effects². If you have a personal or family history of mental health conditions factor this into your decision to use this medication.

 

Muscle and joint pain

Between 16-51% of people report weakness or stiffness in muscles and joints while on isotretinoin⁵ . The effects may be more pronounced in those who also do regular vigorous exercise². A published case study investigated the case of an 18-year-old boy who developed severe hip pain within three days of being prescribed isotretinoin. Symptoms resolved on stopping the medication.

 

Hair loss

Longer term and higher use of isotretinoin may result in hair loss or thinning².

 

Contentious side effects

Inflammatory bowel disease

There has been no definitive proof of a link between isotretinoin and inflammatory bowel disease. Suggestions have been made that the relationship is actually due to the prior use of antibiotics, especially those in the tetracycline class ⁶. This class of antibiotics is commonly used as a treatment before isotretinoin is considered.

 

Decreased Female Fertility

Studies in animals have shown isotretinoin reduces ovarian reserve². A review of 79 women taking isotretinoin for 12-18 months showed changes in anti-Mullerian levels, antral follicle count and follicle stimulating hormone during treatment. These markers returned to baseline after treatment ended.

 

 Any I’ve missed? What, if any, side effects have you experienced with taking isotretinoin.

 Let me know in the comments below.

 

If you enjoyed this you might also like:

 

Acne – what is the underlying cause?

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References:

1. Fakour Y. The Effect of Isotretinoin ( Roaccutane ) Therapy on Depression and Quality of Life of Patients with Severe Acne. Iran J Psychiatry. 2014;(October):237-240.
2. Melnik BC. Apoptosis May Explain the Pharmacological Mode of Action and Adverse Effects of Isotretinoin, Including Teratogenicity. Acta Derm Venereol. 2017;97:173-181. doi:10.2340/00015555-2535
3. Moy A, McNamara N, Lin M. Efffects of isotretinoin on Meibomian Glands. Optom Vis Sci. 2015;92(9). doi:10.1097/OPX.0000000000000656
4. Norouzi H, Rabei HM, Sheibani K. Evaluation of Tear Function among Acne Vulgaris Patients Undergoing Treatment with Isotretinoin. 2016;1(1):1-6.
5. Landau M, Mesterman R, Ophir J, et al. Clinical Significance of Markedly Elevated Serum Creatine Kinase Levels in Patients with Acne on Isotretinoin. Acta Derm Venereol. 2001;81:350-352.
6. Femia AN, Vleugels RA. Toward Improved Understanding of a Potential Association between Isotretinoin and Inflammatory Bowel Disease. J Invest Dermatol. 2013;133(4):866-868. doi:10.1038/jid.2012.428