Isotretinoin (Accutane): What to Expect

When patients come to me after trying every over-the-counter product and several rounds of antibiotics with little improvement, isotretinoin is often the conversation we end up having. It’s the most effective acne treatment available, but it’s also the one patients have the most questions and misconceptions about, so I want to discuss what it actually involves.

What Isotretinoin Does

Isotretinoin is an oral retinoid, a vitamin A derivative, that works differently from every other acne treatment. Topicals and antibiotics manage acne. Isotretinoin is the one medication that can put it into long-term remission by shrinking the oil glands themselves, reducing oil production, calming inflammation, and slowing the skin cell turnover that clogs pores in the first place. That’s why it’s reserved for the cases that need it most.

Who I Consider a Candidate

I typically recommend isotretinoin for patients with:

• Severe nodular or cystic acne that hasn’t responded to oral antibiotics or other conventional treatments
• Acne that’s scarring the skin, where waiting on other treatments risks permanent damage
• Acne that keeps coming back every time a course of antibiotics ends
• Acne causing significant emotional distress, even if it isn’t the most severe case I’ve seen

It isn’t usually my first recommendation for mild to moderate acne, since most of those cases respond well to topical treatment or a shorter course of oral medication with far fewer monitoring requirements. I also screen carefully for pregnancy plans, since isotretinoin causes serious birth defects and can’t be used during pregnancy under any circumstances. Every patient who can become pregnant is enrolled in iPLEDGE, the FDA’s mandatory monitoring program, which requires two forms of contraception and monthly pregnancy testing throughout treatment.

What a Course of Treatment Looks Like

Most courses run four to six months, dosed based on body weight and adjusted over time to reach a cumulative target that research has shown gives the best results. I start patients on baseline bloodwork, mainly a lipid panel and liver function tests, and I repeat this periodically throughout treatment since isotretinoin can raise triglycerides and liver enzymes in some patients. I see patients monthly to check in on side effects, review labs, and refill the prescription, which iPLEDGE requires.

It’s common for acne to look worse in the first few weeks before it gets better. I let patients know this beforehand, so it doesn’t feel like the treatment isn’t working.

Side Effects to Expect

Most people on isotretinoin experiences some degree of:

• Dry skin, lips, and eyes. This is the most common side effect. A lip balm and a good moisturizer are essential. Some patients need lubricating eye drops.
• Increased sun sensitivity. Sunscreen is important during treatment.
• Nosebleeds or dry nasal passages, from the drying effect on mucous membranes.
• Temporary joint or muscle aches, more common with higher doses or in patients who are very physically active.

Less common but important to monitor for:

• Mood changes. The relationship between isotretinoin and depression has been debated for years, and a link hasn’t been definitively established, but I still take any mood changes a patient reports seriously.
• Elevated cholesterol or liver enzymes, which is why routine bloodwork matters and why I adjust or pause treatment if labs move outside a safe range.
• Rare bowel-related symptoms, which any patient should report to me right away.

The overwhelming majority of patients tolerate isotretinoin well and finish their course without serious issues. The side effects that come up are usually manageable with the right skincare routine and don’t require stopping treatment.

Life During Treatment

Patients often ask me about whether they can continue exercising. The answer is yes. If you develop joint or muscle pain, you may need to reduce the intensity of your workouts. Keep in mind that isotretinoin can also make your skin more sensitive, so friction and sweating may cause skin irritation.

Can I get waxed or have other cosmetic procedures? I ask patients to avoid waxing, laser hair removal during treatment, since skin heals more slowly.

Will my acne come back? For most patients, no. A meaningful portion of patients achieve permanent clearance after one course. According to the NEJM acne review only 20 percent of patients require a repeat isotretinoin course. A smaller group needs longer-term maintenance with topical treatment, but a full relapse to pre-treatment severity is uncommon.

Is It Right for You?

Isotretinoin is a powerful medication that requires careful monitoring throughout treatment. For patients with severe or treatment-resistant acne, it is often the treatment that provides lasting results. If your acne has not responded to other treatments or is beginning to cause scarring, it may be time to discuss whether isotretinoin is the right choice for you.

Learn more about my approach to acne treatment or schedule a consultation to discuss your options.

FAQs

How long does isotretinoin take to work?

Most patients begin to notice improvement after about two months, with continued clearing throughout the remainder of the treatment.

Do I need to avoid alcohol on isotretinoin?

I recommend limiting your alcohol intake because both alcohol and isotretinoin can increase triglyceride levels.

Is isotretinoin the same as Accutane?

Accutane was the original brand name for isotretinoin. While the Accutane brand is no longer available, the medication itself is still prescribed under several other brand names.

Can I take isotretinoin more than once?

Yes. Most patients achieve lasting improvement after one course of isotretinoin, but if acne returns, a second course may be recommended.