Before starting isotretinoin, here's what dermatologists need you to consider

USA Today

11-04-2025

Before starting isotretinoin, here's what dermatologists need you to consider
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If you're someone who's experienced recurring bouts of cystic acne, you'll know there's no one-size-fits-all approach to keeping acne flares at bay. Clearing your skin can feel like a bit of a waiting game, and if you've cycled through rounds of hormonal therapies, oral antibiotics and topical retinoids to no avail, you've likely considered isotretinoin as a possible acne treatment.
Isotretinoin is a powerful oral retinoid that can be prescribed to treat resistant cystic acne. The medication's acne-fighting benefits have been backed by science for decades, but it's important to be aware of a few serious risks. Here's what dermatologists need you to know.
What is isotretinoin? What is Accutane?
Isotretinoin is a potent derivative of vitamin A that shrinks oil glands in the face, chest, back, shoulders and upper arms, says Dr. Richard Antaya, director of pediatric dermatology for Yale Medicine. The medication was first approved by the U.S. Food & Drug Administration in 1982 under its original brand name, Accutane. Accutane itself isn't actually sold in the U.S. anymore, and has since been replaced by different generic formulations of isotretinoin, explains Antaya.
Isotretinoin lowers sebum production in the skin; sebum is a waxy, oily substance that's meant to protect the skin from moisture loss. The sebaceous glands that live under our hair follicles secrete sebum. When we produce too much sebum, and the sebaceous glands become infected, acne may develop, says Dr. Andrew Wong, a primary care physician in Westport, Connecticut, and Fairfield County regional medical director for Hartford Healthcare.
By removing the underlying mechanism of acne (sebum production), isotretinoin unclogs pores and quells skin inflammation. 'I always tell my patients, decreasing the oil (or sebum) takes the wind out of the sails of acne,' says Antaya. The results are palpable: With just one course of isotretinoin, the majority of patients will see a great improvement, and in many cases, a near-complete clearing of acne, Antaya says.
How isotretinoin works, plus who is a good candidate?
Isotretinoin could be a great option for those in search of a long-lasting solution to their cystic acne. That said, the medication does have severe potential side effects, which is why it's not for everyone. There's a few reasons why a dermatologist may prescribe isotretinoin:
Your acne is persistent. You've tried multiple treatments for acne—from topical retinoids to benzoyl peroxide to oral antibiotics—and your acne still isn't clearing up.
You've tried multiple treatments for acne—from topical retinoids to benzoyl peroxide to oral antibiotics—and your acne still isn't clearing up. You have severe, nodular cystic acne. Topical medication is rarely, if ever, effective for treating nodular cystic acne. If you haven't responded well to other oral acne treatments, including oral antibiotics or hormonal therapies, that's when a dermatologist may consider prescribing isotretinoin, Antaya says.
Topical medication is rarely, if ever, effective for treating nodular cystic acne. If you haven't responded well to other oral acne treatments, including oral antibiotics or hormonal therapies, that's when a dermatologist may consider prescribing isotretinoin, Antaya says. You have severe acne scarring: Severe acne can be disfiguring, leaving permanent scars, says Wong. Isotretinoin can't get rid of scarring, but as your skin clears, it may improve the appearance of scars, and help prevent new ones from forming.
More on cystic acne: Cystic acne can cause pain, shame and lasting scars. Here's what causes it.
What are the risks of isotretinoin?
The decision to start isotretinoin isn't one that should be taken lightly—it's a medicine that carries significant risks. Isotretinoin shrinks the oil glands and thins the epidermal barrier, which could cause dryness of the skin, lips and nose. Other potential side effects include joint and muscle pain, eye irritation, elevated blood fat levels and in rare cases, liver damage.
Isotretinoin is known to cause severe birth defects and miscarriages in people who are pregnant, says Wong. For this reason, isotretinoin isn't the kind of medication that can be prescribed on a yearly basis; it has to be renewed every month. 'We have strict safeguards in place to make sure we get positive feedback that someone is doing well with the medicine, and that they performed a pregnancy test during that month,' Wong explains. Patients must enroll and adhere to the iPLEDGE program, an FDA-mandated registry to help prevent pregnancy in patients taking isotretinoin.
Isotretinoin has also been associated with depression and suicidal thoughts, though the American Academy of Dermatology says there currently isn't enough evidence to determine a clear link. Patients will be screened for possible signs of depression or suicidal ideation before isotretinoin is prescribed. 'So, I strongly recommend that if an acne patient suffers from depression, the dermatologist works with the mental health professional to ensure the patient can undergo a course of isotretinoin,' says Antaya.
In case you missed: How do antibiotics work, what happens to your body when you take them? We've got answers.
Can isotretinoin cure acne?
If your dermatologist has determined you're a good candidate for isotretinoin, know that it could take two to three months before you start to see a significant improvement in your acne, and four to six months (or potentially longer!) for it to clear—though the results are long-lasting. After completing a single course of isotretinoin, around 85% of patients will experience a long-term clearing of skin, says Wong.
Today, isotretinoin still stands to be the most clinically effective treatment for severe acne. 'Even though isotretinoin has been available for over 40 years, if you ask most dermatologists, we will still list (isotretinoin) as one of our favorite medications, because it is consistently effective and therefore provides significant benefit, both physically and emotionally, to our patients,' Antaya says.