Thread by @DrJohnBarbieri

Isotretinoin is a highly effective treatment for acne and the only acne treatment that can provide a lasting remission. However, there are many misconceptions about isotretinoin. In this updated Tweetorial, let's bust some common isotretinoin myths! #dermtwitter #JBAcneTips 1/19

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. 2/19
jaad.org/article/S0190-…

Those treated with isotretinoin are less likely to be diagnosed with mood disorders or start an antidepressant than those treated with oral antibiotics (likely because their acne gets better!). 3/19
onlinelibrary.wiley.com/doi/10.1111/bj…

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. 4/19
sciencedirect.com/science/articl…

While it is prudent to monitor for depression in all acne patients, we should not fear isotretinoin causing or worsening depression. I would argue acne associated depression is an INDICATION to consider isotretinoin.
5/19

Myth #2 - Isotretinoin has a lot of difficult side effects and you will be miserable on such a "strong" treatment: This absolutely does not need to be the case! While commonly associated with dry skin and lips, this can be managed with moisturizers or by using a lower dose. 6/19

Although we often are in a "race to the finish" due to iPLEDGE, lower daily dose regimens (0.25-0.4mg/kg/day) have been found to be similarly effective to higher dose regimens. It takes longer, but higher satisfaction and similar rates of remission.
7/19
onlinelibrary.wiley.com/doi/10.1111/j.…

By combining lower dose regimens with treating to clinical endpoints (e.g. clear x2-3 months) rather than arbitrary dosing targets, we can individualize treatment what the patient needs and lessen the burden of side effects. 8/19
onlinelibrary.wiley.com/doi/10.1111/ij…

Myth #3 - Isotretinoin and IBD: Although there were early reports of isotretinoin being associated with inflammatory bowel disease, subsequent high quality studies have found there is no significant association between isotretinoin and IBD. 9/19

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. 10/19
jaad.org/article/S0190-…

Myth #4 - 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. 11/19
ncbi.nlm.nih.gov/pmc/articles/P…

For instance, while we monitor lipids to prevent pancreatitis, meaningful triglyceride elevations are rare (<1%) and isotretinoin associated pancreatitis may be idiopathic rather than triglyceride associated, calling into question this practice. 12/19
onlinelibrary.wiley.com/doi/abs/10.111…

Our recent international Delphi in @JAMADerm supports that checking triglycerides and ALT 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. 13/19
jamanetwork.com/journals/jamad…

Some have even recommended eliminating lab monitoring given the low usefulness to clinical decision making. After a discussion of the literature, I think no monitoring is a reasonable approach for patients who would prefer to avoid this testing. 14/19
…y-wiley-com.ezp-prod1.hul.harvard.edu/doi/10.1111/bj…

Myth #5 - 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. 15/19
ncbi.nlm.nih.gov/pmc/articles/P…

I suspect as with many isotretinoin labs we are more often treating the numbers rather than treating the patient. I am not aware of any high-quality reports of isotretinoin causing lasting liver damage, making it less likely routine liver monitoring is high value. 16/19

Myth #6 – Acne scarring cannot treated at the same time while on isotretinoin: The general consensus is that most treatments for acne scarring (excluding fully ablative laser treatments) can be safely performed while still on isotretinoin. 17/19
jamanetwork.com/journals/jamad…

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 also must not let isotretinoin myths prevent us from using for those who need it. 18/19

Q&A: What have you heard about isotretinoin for acne? What questions or concerns do you have? 19/19