Thread by @DrJohnBarbieri

Isotretinoin can be a highly effective treatment for #acne and is the only acne treatment that can provide a lasting remission. However, there are many misconceptions about #isotretinoin. In this Tweetorial, let's bust some common isotretinoin myths! #dermtwitter 1/13

Myth #1 - Isotretinoin and depression: Multiple meta-analyses have found that there is no population level association between isotretinoin use and depression. In fact, isotretinoin may be associated with decreased depressive symptoms. 2/13
jaad.org/article/S0190-…

In addition, patients being treated with isotretinoin can expect an average of >50% improvement in quality of life by month 2 and a 4-fold to 5-fold improvement from baseline with a full course of isotretinoin. 3/13
jamanetwork.com/journals/jamad…

However, these studies are looking at a POPULATION level. There are also studies describing depressive symptoms in INDIVIDUAL patients being treated with isotretinoin, including positive challenge/dechallenge responses. 4/13
sciencedirect.com/science/articl…

Therefore, while we should not fear isotretinoin causing or worsening depression, given the association between acne itself with depression as well as rare reports of idiosyncratic reactions to isotretinoin, it is prudent to monitor for depression in all acne patients. 5/13

Myth #2 - Isotretinoin and IBD: Although there were early reports of isotretinoin being associated with inflammatory bowel disease, subsequent higher quality studies have confirmed there is no notable association between isotretinoin and IBD. 6/13
pubmed.ncbi.nlm.nih.gov/26545085/

In fact, oral antibiotics are associated with inflammatory bowel disease and it may be that prior oral antibiotic exposure was an ignored confounder in many early studies of isotretinoin and inflammatory bowel disease. 7/13
jaad.org/article/S0190-…

Myth #3 - isotretinoin requires frequent lab monitoring: Several studies have called into question the need for frequent lab monitoring on isotretinoin. Abnormalities are very rare and of unclear clinical significance. 8/13 ncbi.nlm.nih.gov/pmc/articles/P…

For instance, while we monitor lipids in an effort to prevent pancreatitis, meaningful TG elevations are rare (<1%) and isotretinoin associated pancreatitis may be idiopathic rather than TG associated, calling into question this practice. 9/13
onlinelibrary.wiley.com/doi/abs/10.111…

Given the limited clinical utility of lab monitoring, checking lipids and potentially liver function tests at peak dose and possibly at baseline is likely all that is needed (and even this may be low value). Minimizing labs reduces unnecessary pain, fear, and cost. 10/13

Myth #4 - isotretinoin "hard on the liver": LFT abnormalities are just as common at baseline as on therapy, suggesting many may not be related to isotretinoin. In addition, elevations are typically mild and unlikely to be clinically meaningful. 11/13
ncbi.nlm.nih.gov/pmc/articles/P…

I suspect with many isotretinoin labs we are more often treating the numbers rather than treating the patient. I am not aware of any consistent reports of isotretinoin causing lasting liver damage, making it less likely routine LFT monitoring is high value. 12/13

While #isotretinoin is not without risks and side-effects, it can be a life changing treatment for many patients with #acne. We should use it thoughtfully, but we should not let isotretinoin myths prevent us from prescribing it for the patients who need it. 13/13

Q&A:
What have you heard about isotretinoin for acne? What questions or concerns do you have?

Thanks everyone for the awesome engagement and positive feedback! For more acne Tweetorials, check out:

https://twitter.com/DrJohnBarbieri/status/1289994703807512578?s=20