Comparison of guidelines and consensus articles on the management of patients with acne with oral isotretinoin

Abstract

Guidelines and consensus on the management of patients with acne aim to give evidence-based, expert-group recommendations. This review compares current guidelines and consensus articles to provide a compilation of recommendations on the treatment of acne with oral isotretinoin. Ten common, relevant, clinical questions are addressed, based on published recommendations, including the indications of isotretinoin, the proposed daily dose, the cumulative isotretinoin dose and the laboratory monitoring needed. Recommendations on special considerations are also addressed, including the timing of procedures and the question of an association of depression or inflammatory bowel disease with isotretinoin. A major limitation is the use of different classification systems for acne across guidelines. The recommended daily dose ranges from 0.3 to 0.5 mg/kg in the European guidelines to up to 1 mg/kg in the US guidelines. A specific duration of treatment of at least 6 months is only recommended in the European guidelines. All guidelines report the need of strict pregnancy prevention measures. The European, French and US guidelines recommend to monitor for symptoms of depression. Important clinical questions that are inconsistently addressed in guidelines include the age indication, the recommendation for a cumulative dose, the timing of procedures, the association of isotretinoin with IBD, the recommendation for preventing acne flares and for appropriate laboratory monitoring. These topics should be clearly included in the recommendations of guidelines as they are often raised in everyday clinical practice.

Endocrinology and immunology of acne: Two sides of the same coin

“…Isotretinoin, the most powerful anti‐acne drug, [ 153–155 ] seems to exhibit more complex effects on the sebaceous gland than initially postulated [ 156 ] (Table 2). Among other pathways, protein domains for collagen and fibronectin were increased, domains for steroid metabolizing enzymes were decreased, the mRNA levels of cellular retinoic acid‐binding protein 2, S100A2, S100A7, S100A9, and involucrin were affected and pathways linked to lipid metabolism were downregulated.…”

Sebaceous gland: Milestones of 30‐year modelling research dedicated to the “brain of the skin”

“…Although largely effective, current therapeutic options for acne and other SG-associated skin diseases involving sebaceous glands [6,100,101] are associated with significant drawbacks. For example, 13-cis-retinoic acid is a potent teratogenic substance [100] and the use of antibiotics becomes more and more questionable considering antibiotic resistance.…”

Efficacy of acne vulgaris treatment protocols according to its clinical forms

“…15 The recommended daily dose ranges from 0.3 to 0.5 mg/kg in the European guidelines to up to 1 mg/kg in the US guidelines. 16 Oktem et al reported that in 704 retrospectively reviewed patients with acne treated with systemic isotretinoin, clinically insignificant and reversible CBC abnormalities were noticed, and the therapy was not discontinued. In this context, frequent biochemical monitoring was not recommended.…”

“…The European, French and US guidelines recommend to monitor for symptoms of depression. 16 Nevertheless, there are studies whose results report that suicide attempts under isotretinoin are rare and most of the patients concerned have a risk-prone profile detectable at the time of treatment initiation. 18 Acne treatment of the third degree has found solutions only through treatment with oral isotretinoin, which opened a new era in the treatment of acne and prevention and reduction of scars.…”