Thread by @DrJohnBarbieri

We’ve busted some common #isotretinoin myths, but what about actual side effects of isotretinoin in the treatment of #acne. In this Tweetorial, we’ll review the most common side effects and how they can be managed. #dermtwitter #MedEd 1/16

https://twitter.com/DrJohnBarbieri/status/1397519427457986563?s=20

The most commonly reported side-effect is mucocutaneous dryness. It is dose dependent, occurring in 75% of those treated with 0.25-0.5mg/kg/day and in nearly 100% treated with 1mg/kg/day. 2/16
europepmc.org/article/med/21…

This can manifest as dry lips, dry skin, and dry eyes. Frequent emollient use (e.g. Vaseline for the lips) can help manage this common side-effect. In addition, a small RCT found 1g/day omega-3 reduced mucocutaneous dryness. 3/16
ncbi.nlm.nih.gov/pmc/articles/P…

With respect to ocular side-effects, isotretinoin can cause meibomian gland dysfunction leading to dry eye, hordeolum/chalazion, and blepharitis. These are often mild and can usually be managed with eye drops or help from our ophthalmology colleagues 4/16
jamanetwork.com/journals/jamad…

Isotretinoin treatment can also be associated with visual changes such as decreased night vision and can result in temporary changes to the structure of the cornea that resolve after discontinuation of treatment. journals.lww.com/claojournal/Ab… 5/16

Muscle aches are another common dose-dependent side-effect, occurring in 2-5% of those treated with 0.25-0.5mg/kg/day and in approximately 25% treated with 1mg/kg/day. If bothersome, reducing the dose can help alleviate this side-effect. 6/16

Arthritis can also occur and in my experience is very dose dependent. Typically lowering the dose can alleviate this side-effect if bothersome. While lower dose regimens will take longer, they can be similarly effective to higher dose regimens. 7/16
onlinelibrary.wiley.com/doi/abs/10.111…

Importantly, several studies have found isotretinoin treatment for acne does not appear to negatively impact strength or endurance, though I still think it is important to counsel high level athletes about this side effect before starting treatment. 8/16
mdedge.com/dermatology/ar…

Although there are reports of premature growth plate fusion in children with ichthyoses treated for years, it does not seem to be an issue for acne. Since growth plate risk is theoretical while the risk of untreated acne is clear, I feel benefits typically outweigh risks. 9/16

While population-based studies do not suggest and increased risk of depression/suicidality, all patients with acne are at risk for these comorbidities and routine screening using PROs (e.g. PHQ-2) in clinic can help identify at risk individuals. 10/16
onlinelibrary.wiley.com/doi/abs/10.111…

Isotretinoin can cause photosensitivity and it is important to counsel patients to take appropriate sun protective precautions while on treatment, particularly in the summer! 11/16

Less commonly, some patients experience hair changes that may be similar to telogen effluvium, though there is a need for high-quality prospective studies. 12/16
journals.sagepub.com/doi/10.1177/12…

There is some limited evidence from small RCTs that 10mg/day of biotin can reduce the development of hair and nail changes by improving the anagen to telogen ratio and increasing skin hydration. 13/16 onlinelibrary.wiley.com/doi/10.1111/ij…

Other rarely reported side effects can include paronychia, pyogenic granuloma, and pseudotumor cerebri, among others. Isotretinoin can cause a transient worsening of acne (acne fulminans), particularly in those with more severe acne at baseline. 14/16
jaad.org/article/S0190-…

Finally, isotretinoin is a teratogen and it is important to counsel patients and take steps to reduce this risk. In the US all patients must be registered in the iPLEDGE program. We have previously made suggestions for how to improve this program. 15/16
jamanetwork.com/journals/jamad…

In summary, while isotretinoin is a highly effective treatment for acne, it can be associated with several important side effects. Understanding how to manage these common side effects can help ensure successful treatment and improve patient satisfaction. 16/16

How do you approach counseling patients on isotretinoin about side effects? What are your strategies to manage and mitigate common side effects?