Acne, Acne Scarring, and Accutane (oh my!)
By Marie Leger, MD PhD
Laura Chinn’s memoir starts with her first pimple. “I had no clue how much that little zit was going to change my life,” she says. “Out of all the other tragedies of my childhood, the acne was the loudest and most obnoxious. It was constantly screaming at me, “You look different than everyone! You should kill yourself because of that!”
Chinn’s memoir uses her skin as a way to punctuate stories of her youth. I loved reading it because she validates something I see with my patients all the time. Acne is super traumatic! To everyone, but especially to young people. Middle school is brutal enough. But middle school with acne is just not fair to anyone.
The first chapter of Chinn’s book is called “Toxins” because her parents were hippies who ate raw goat testicles, etc. Because I grew up in California, studied at UC Berkeley, and practice medicine in New York City, this is very familiar territory to me. A lot of my patients think their acne is caused by toxins, and many of them have already restricted their diets and skin care regimens in some seriously monastic ways. Studies on this—that are hard to design and imperfect—do show that highly processed foods and some dairy products may exacerbate acne. But I have yet to meet a patient with cystic, scarring acne who was able to control it just by eliminating dairy, gluten, or gummy bears. Which is good news, in some ways. Your acne is not your fault! Eat chocolate and cheese if you want to!
There are so many ways to clear acne–topical medications, hormonal treatments, light based devices, etc.–which makes finding the right approach for people really rewarding. People getting married in a month need a different approach than pregnant women or teenage lifeguards or college students or women breaking out suddenly in their 30s or people who have a tough time following routines.
The gold standard for treating patients with scarring or treatment resistant acne is isotretinoin, also known by one of its brand names–accutane. The fall is a particularly good time to use this medication, because it makes you sensitive to the sun, so it’s hard for active people to use it in the summer. A lot of people are scared of isotretinoin, which is understandable. If you google it, some very terrifying things come up. Some of these things are real, some are weird rabbit hole level stuff.
One of my smart colleagues at the University of Pennsylvania, John Barbieri, recently addressed some isotretinoin myths on #DermTwitter (That is a thing! Follow him.) To summarize and add my own insights:
Myth 1: You need labs every visit on this medication.
Not true. I don’t order labs on everyone every visit. Some pediatric dermatologists don’t check labs at all with needle-phobic patients. Unless there is a reason to, I check labs before starting and once again at the highest dose we use, following a recent consensus statement by international experts. You do have to check in with your doctor every month—the medication is federally regulated and we need to check pregnancy tests and talk every visit—but most of the time no bloodwork is needed. And since the pandemic, we can do follow up visits via telemedicine as long as you are in New York State! For now at least! Hopefully this will not revert to a pre-pandemic need for in person visits in the future.
Myth 2: Isotretinoin causes depression.
It’s more likely that untreated acne causes depression. Study after study shows that isotretinoin use is associated with lower, not higher rates of depression at a population level. And one recent large study in Denmark comparing people with treated vs untreated acne found a significantly increased risk of depressive symptoms and a lower mental health related quality of life in people with untreated acne.
This is something I have noticed treating patients in my own practice—there is nothing more fun than watching shy young people come out of a funk when their skin gets better. To be honest, isotretinoin is my favorite medication to prescribe. We screen patients for depression symptoms at every visit and take this seriously—people are not statistics—but I have never had a patient where I thought isotretinoin caused depression.
Myth 3: You can’t treat acne scars while taking isotretinoin.
You actually can! When I was a resident, we used to tell patients that they had to wait six months after finishing isotretinoin to start treating acne scars. But newer guidelines based on more data agree that most acne scar treatments—including microneedling, radiofrequency microneedling, and non-ablative laser treatments—can be safely performed while patients have active acne and even at their visits for isotretinoin follow up. This saves time and makes people happy.
Myth 4: This medication is just too harsh.
The side effects that my patients on isotretinoin complain about the most—dry skin, sun sensitivity, chapped lips, joint pain—can be managed by lower doses. I use this approach with people all the time—and studies show that lower doses for longer periods of time are as effective as higher short term courses (shortest being about 5-6 months) . A British actor I know is always on a low dose of isotretinoin because he can’t afford to get breakouts. We can manage and even eliminate most isotretinoin side effects just by dropping the dose.
That’s all I’ve got today! More on acne soon.