Ask the Pharmacist

Q) A dermatologist has suggested we consider putting our son on the drug Accutane to treat his acne. His skin is really bothering him, but I have heard some negative things about that drug. What should we do?

A) Despite the fact that Accutane (and other drugs that use the same active ingredient, isotretinoin, such as Clarus) has been available for many decades now, the decision as to whether to use it has remained a difficult one despite all the research that has been conducted over the years.

This is really not too surprising given that the drug treats a condition, acne, that no matter how severe it may be, is not going to shorten your lifespan or relegate you to a hospital ward. But this is a fairly narrow minded view of this condition. Severe acne should not be dismissed as a mere cosmetic issue as its presence has the ability to substantially harm the self esteem and thereby the mental health of those who suffer from it.

Researchers have consistently found that people with acne are more likely to develop depression, anxiety, poor self-image, a decreased quality of life and a sense of being alone. In a young person, the demographic that most commonly deals with this condition, it can cause them to make decisions that have the potential to negatively impact the rest of their lives. These can include minor ones such as deciding not to participate in activities or raise your hand in class to major ones such as failing to pursue one’s dreams and aspirations. In short, severe acne is not a condition to take lightly.

For the majority of people with acne, there is a wide variety of cleansers, creams, hormone pills and antibiotics that can more than adequately control this condition. However, there is a not insignificant cohort in which none of these treatments seems to make much of a difference. As such, their acne can continue unabated and leave some of those not only with the mental health considerations we discussed above but also with the potential to suffer permanent scarring from the deep and painful cysts and nodules that this condition can produce.

Enter Accutane, a unique drug which can offer a prolonged or even permanent cure and has been hailed by many as a “life-changer”. Unfortunately, the use of Accutane has also been associated with a number of side effects. Some of these are common and usually very manageable, but some are significant and can be frightening to contemplate. There are also a lot of myths that have built up over the years about this drug that have caused some to shy away from using it despite the fact that more recent research has proven these allegations to be untrue.

I thought we should discuss some of these in order to help patients and their families make more informed decisions.

The first allegation I wish to discuss is whether Accutane does in fact “cure” acne. This is mostly true. In fact 85% of those who receive an appropriate dose are virtually clear of acne by 16 weeks. 13% require 5 or 6 months to clear and virtually all of the rest are cleared by 1 year of treatment.

In a world that turns drugs that exert a positive effect in one out of 15 people into billion dollar valuations, this degree of success from Accutane is astounding. This may be because it is the only treatment that works on all four causes of acne: clogged pores, the reduction of the bacteria P. Acnes on the skin, inflammation and excess skin oil. For some, the cure is permanent, for others (estimated to be somewhere between 1 in 5 and 1 in 3) the acne can come back, usually only after a prolonged period of time. If this occurs, it can treated again with another 4 to 5 month course or other options can be pursued.

So, given this startling degree of efficacy, just what are the negatives. Well, for one, Accutane can cause severe birth defects, miscarriages and pre-term births. This is why, if you are a person capable of becoming pregnant, Canadian guidelines strongly recommend that you use two effective forms of birth control starting at least one month before & continuing until at least one month after treatment. This potential side effect also precludes you from donating blood until at least 30 days after your last dose, or from breastfeeding.

Another allegation which may well be true is that Accutane, when combined with alcohol, may be dangerous to your long-term health. While there are no definitive guidelines, Accutane on its own can permanently damage the liver so, combining it with alcohol, another known liver toxin, can potentially increase the chances of this happening. The combination can also cause your cholesterol and triglycerides to rise which may put you at risk of cardiovascular effects (although these levels tend to return to normal when the treatment is finished). As such, most dermatologists preach absolute abstinence from alcohol along with regular blood work to ensure the drug is not harming your internal organs.

Another rumour is that Accutane will make you go bald. This is not really true. A few people will notice some degree of hair thinning while being treated but the vast majority of these return to their normal degree of hair thickness after the drug is finished.

It is also a fact that Accutane can affect your eyes. Very commonly it can cause them to feel dry and irritated although there are a number of effective remedies for this. It can also make it harder to see at night which may make it dangerous for some to drive at night while taking the drug, an important consideration for some of us.

Over the years, Accutane has been linked to inflammatory bowel diseases like colitis and Crohn’s. The best data we have on that seems to dispel this as a myth and, in fact, there is evidence to suggest the drug might actually lower the risk of being diagnosed with Crohn’s.

For many, the biggest drawback to considering treatment with Accutane is whether it has the potential to make one depressed or suicidal. Between 1982 and 2000, the FDA in the U.S. received 431 reports of varying degrees of mental health issues while taking the drug. As a result, there have been numerous studies designed to address this and see if it is indeed what we term a cause and effect issue.

In sum, these studies have failed to prove that Accutane is to blame for the deleterious effects some people experience with their mental health. In fact in 2017, researches reviewed 31 previous studies and found that the cumulative results seemed to indicate that treating acne with isotretinoin resulted in a decrease in depressive symptoms. Given how seriously we take mental health today, it is critical that both health professionals and family members check in on the status of recipients of this drug regularly, but it appears that fear of this effect is probably not based on facts and should not prevent those who might benefit from the drug from taking it.

All in all, there is a lot to consider here, making this a difficult decision indeed. Accutane should never be taken as an initial treatment or for mild to moderate cases of acne. But as a pharmacist who once practised next door to two of our local universities, I have personally seen its transformational effects on the skin of some of my patients and on their personalities as well as they start to re-engage with their peers.

For more information about this or any other health related questions, contact your pharmacist.