Deciding to embark on a course of Isotretinoin can be perplexing, especially since there are a lot of mixed messages on the internet and at times, the publicly available scientific evidence can be a bit patchy, conflicting or simply hard to find.
That’s why we wrote this guide which compliments the most recent British Association of Dermatologist’s patient information leaflet and should give you all the information you need to make an informed decision as to whether or not you think isotretinoin (Roaccutane/Accutane) is the right medication for you.
What is isotretinoin (Roaccutane / Accutane)?
Isotretinoin is a prescription-only medication used for acne and some other similar skin conditions. It is a type of medication called a retinoid and can only be prescribed by doctors who are experienced in using it, usually a Consultant Dermatologist. As such, your GP is not authorised to prescribe nor monitor its use.
Roaccutane and Accutane are the brand names for the drug isotretinoin and how it is more often referred to. It has been available for use in the UK for approximately 40 years and, as such, we have a lot of experience prescribing it.
Isotretinoin is usually prescribed as a capsule but is also available as a cream and a gel. This guide does not focus on these, but they are useful to know of as they can be helpful for mild acne.
How effective is isotretinoin?
9 out of 10 (90%) of people report a significant improvement in their acne after their treatment course has been complete (i.e after approximately 5-6 months).
There is no other available acne treatment that can produce such consistently positive results.
Although highly effective, it is important to remember that while some people will get complete control of their acne, most people will still develop the odd spot here and there while on treatment, but the number will be far fewer in number, size, severity and will also disappear faster.
Does isotretinoin cure acne?
Studies have shown that approximately 70-90% of people will see either a complete cure or only a minor reoccurrence of their acne, so mild that only topical treatments are required.
In those unlucky few who do see a complete return of their acne, there is evidence to show that a second course, often at a higher dosing schedule, is enough to finally put their acne to rest.
How will isotretinoin help my acne?
- Reduces greasiness (seborrhoea) – Isotretinoin shrinks sebaceous glands and so reduces grease production in the skin, by up to 90%. This is why dry skin is the main side effect and why many people will notice their skin and hair become less shiny while on treatment.
- Reduces bacteria – Grease can cause bacteria to grow. Isotretinoin reduces grease production but also inhibits the growth of bacteria on skin which reduces the chance of them causing infections, pus spots and cysts.
- Reduces blocked pores (comedones) – Isotretinoin stops comedones from forming and is also effective at clearing existing comedones that may be open (blackheads) or closed (whiteheads). However, large closed comedones might not clear with Isotretinoin and are best treated before starting a course of Isotretinoin. Examples of treatment including hyfrecation and manual extraction which are best performed by a skilled clinician.
- Reduces inflammation – Isotretinoin has an anti-inflammatory effect and clears inflamed spots like papules, pustules and nodules. Isotretinoin stops new inflamed spots from developing and causes existing inflamed spots to flatten and resolve.
- Reduces cysts – Isotretinoin is good at reducing cysts that arise in acne.
What will isotretinoin not help with?
- Pigmentation – When skin becomes inflamed it often reacts by producing more pigment in that area. This is called post-inflammatory hyperpigmentation and is often more pronounced in skin of colour. Isotretinoin does not treat this hyperpigmentation although there are several other treatment options available for this.
- Scarring – Although isotretinoin can soften scars, it does not get rid of them. The main aim of isotretinoin is to prevent scarring which is why seeking treatment early often leads to better results.
- Redness – Isotretinoin will reduce inflammation but occasionally persistent redness at the site of healed very inflamed spots can occur. If this occurs, then laser treatment may be indicated.
- Pores – Isotretinoin will reduce pore size while you are on treatment, but this is temporary, and the pores will return to their normal size within a few months of stopping treatment.
Side effects and how to control them
Almost everyone who is treated with isotretinoin will experience at least one side effect during their treatment course. However, for the vast majority of people these are tolerable and easily managed. The side effects also tend to be greater as the dose is increased (see next section for more information on dosing) and if too much the dose can be reduced to find the best fit for you.
The aim is to keep side effects to a minimum whilst simultaneously improving your acne. With appropriate Consultant-led monitoring and management almost 100% of people will be able to complete a full course.
Common side effects
Dryness (Lips) – This is the first side effect that is noticed and experienced by 95% of people. It can easily be managed by applying a lip balm regularly throughout the day and to try avoiding licking your lips and picking any flaked skin. Recommendation for good lip balms can be requested during your consultation.
Dryness (Inside your nose) – This can cause itching, discomfort and occasionally small nose bleeds. Apply a greasy ointment like petroleum jelly to the inside of the nose at least 3 times per day or more if they are very dry. Recommendation for good ointments can be requested during your consultation.
Dryness (Skin) – You should also apply a non-comedogenic moisturiser (one that does not block pores) regularly throughout the day. You may also need to stop some of the topical products you normally use as they may be too harsh for your skin while on isotretinoin. A big no-no is if you are already using a topical retinoid and you continue to use it while using isotretinoin (which is also a retinoid). The two together will make your skin extremely dry. We would also advise that you avoid soaps, exfoliators, and cosmetic acids. Recommendation for good emollients, cleansers and soap alternatives can be requested during your consultation.
Dryness (Eyes) – This side effect does not often require treatment but if you wear contact lenses try to avoid where possible. Some people may benefit from the use of artificial tears. Recommendations for good lubricating eye drops can be requested during your consultation.
Dryness (Vaginal) – This side effect does not often require treatment but can be improved by using vaginal hydrating products and lubricants during sexual intercourse.
Muscle aches and pains – Isotretinoin can cause stiffness, aches and pains. Lower back pain is particularly common. This side effect is usually mild but may require the occasional use of paracetamol. It is often exacerbated by intense or strenuous exercise includes weight-lifting and cardiovascular work-outs.
In rare events some people have reported severe inflammation of their lower back (sacroiliitis) and in some tendons e.g. Achilles tendon, plantar fascia and tendons around large joints like the knee and shoulder.
Headaches – Mild headaches are very common at the start of a course of Isotretinoin.
Severe headaches that are worse in the morning, worse when coughing and sneezing and accompanied with nausea and vomiting is a rare side effect of isotretinoin (1 in 10,000 chance). If this occurs treatment must be stopped immediately.
Tetracycline medications such as Doxycycline, Oxytetracycline and Lymecycline must be stopped a week before starting Isotretinoin to reduce the chance of this rare side effect.
Temporary flaring – It is common to experience a slight worsening in your acne during the first month of treatment. This is occasionally referred to as ‘purging’. If severe, a short course of oral steroids can be administered alongside the isotretinoin. Occasionally it will be given prophylactically to reduce the risk of this side effect.
Infections and healing – As a result of the skin becoming dry while on isotretinoin, the risk of skin infection is increased as the skin becomes cracked at a microscopic level. Any skin wounds you experience may also take longer to heal and your skin may feel more fragile.
Photosensitivity – Isotretinoin can make you much more sensitive to the sun, and so you may find you burn more easily. Protect yourself while outside, even when its is cloudy, by considering hats, long sleeved shirts/trousers and using SPF30 (at least). You should also avoid sun beds and tanning salons.
Uncommon side effects
Liver injury – Your liver is the organ that processes isotretinoin and stops it building up in your body. Occasionally, isotretinoin makes the liver work a little too hard and temporarily upset it. This is why blood tests are required (see section below on blood tests). If this occurs the dose may need to be reduced or in some cases stopped altogether.
Alcohol is also processed by the liver and so we advise avoiding its consumption during your treatment period or at least minimising it.
Raised triglycerides – Cholesterol and triglycerides are found in your blood. Isotretinoin can temporarily raise both but more so for your triglycerides. High triglyceride levels can be a problem in the short term for your pancreas or liver and in the long term for you blood vessels. This is why blood tests are required (see section below on blood tests).
Hair thinning – This is uncommon and almost always temporary. It is normally only seen at high doses and does not mean treatment needs to be stopped unless affecting you severely.
Reduced libido and erectile dysfunction – There are rare reports of reduced libido in both men and women. There are also rare reports of men struggling to establish and maintain an erection.
Decrease in night vision – This is rare (1 in 10,000 chance) but if you notice it then you should stop Isotretinoin. It is usually temporary, but very rarely can be permanent. Some professions may be impacted, such as drivers, airline pilots, people in the military, and those who operate heavy machinery. If any of these are the case, you should not take isotretinoin.
Calcification – There is an unproven yet possible risk of tendon calcification if isotretinoin is taken for prolonged periods of time (~over one-to-two years). Most isotretinoin courses last no longer than 5-6 months and so this side effect is very rarely reported.
This is a tricky one as the link between isotretinoin and low mood, self-harm and suicide has yet to be fully proven, but it has gathered a lot of media attention. By and large, the vast majority of people feel much happier after their course of treatment has been completed as they can visibly see an improvement in their skin. Unfortunately, there have been rare reports of depression/mood-disturbance (between 1 in 1,000 and 1 in 10,000 chance) with some people also developing suicidal ideation while on treatment (less than 1 in 10,000 chance).
It is not clear if it is the medication that causes this or that individuals themselves already had underlying or undiagnosed mental health issues. It is a rare but important concern and normally, if you have a history of mental health illness or have previously attempted suicide then you must discuss this with your dermatologist before starting treatment. You may be required to contact a Psychiatrist or Psychologist for assessment before being considered eligible for isotretinoin. If you feel like your mood is deteriorating on treatment you must stop treatment immediately and contact your Dermatologist.
Pregnancy, Breastfeeding & Fertility
Pregnancy – Women must not get pregnant while on isotretinoin or for one month after completing their course. This is because isotretinoin is highly teratogenic i.e. it causes severe birth defects. Isotretinoin also increases the risk of miscarriage.
Before starting isotretinoin women of childbearing potential should use at least one, and preferably two, forms of contraception for at least one month before starting treatment. This includes the intra-uterine coil (Mirena or Copper), the implant or combined oral contraception pills (COCP). Barrier contraception (condoms and caps) should be used in conjunction, not on their own.
Despite the effective use of contraception, there remains a very small risk of pregnancy. If you do fall pregnant, you must inform your dermatologist immediately, stop taking the medication and seek help from a family planning clinic.
During your consultation, your dermatologist will discuss the Pregnancy Prevention Programme (PPP) with you. This is a programme established to minimise the risk of pregnancy while taking isotretinoin. You can either opt in or opt out. It’s your choice.
Breastfeeding – You should not breastfeed while taking isotretinoin and for a month after completing treatment. Isotretinoin is found in the breastmilk of people who are taking it.
Fertility – Isotretinoin does not affect fertility. One month after finishing a course of isotretinoin, you may get pregnant with no additional risk to the unborn baby.
There are no risks to a pregnancy if a man taking isotretinoin fathers a child even though small amounts of isotretinoin are found in semen.
How does the whole process work and what will it cost?
Despite what you may have heard, isotretinoin treatment does not have to be complicated, it just needs to be safe. Below are the main aspects to be aware of during your treatment, followed by a summary and our pricing structure.
Appointments – Every patient will require an initial video consultation to assess if isotretinoin is the right medication for you. If so, a ‘follow up’ schedule will be devised by you and your doctor.
The exact length of a course of isotretinoin varies between people and depends upon a few factors. Primarily, it is based upon how much medication (the dose) you can tolerate each day taken over a length of time up to a maximum amount. The higher the daily dose you can tolerate the more ‘cumulative’ doses you build up meaning you reach the maximum quicker, thus shortening your course. It is important to note that dose increases need to be gradual as your body needs to get used to higher doses. You cannot simply start at a high dose. Furthermore, not everyone can tolerate high doses.
The way a course will run is specific to you but most courses of isotretinoin last approximately 5-6 months.
As per UK Guidelines, and due to the issues around pregnancy monitoring, women usually require more regular reviews and are typically seen monthly, whereas men are normally reviewed on alternate months.
Our current rates are £150 for an initial consultation and a reduced rate of £110 for follow up appointments.
Pregnancy Tests (female only) – Women require a pre-treatment pregnancy test within a week of commencing isotretinoin and typically require a repeat test every 4-8 weeks and 4 weeks after completing their treatment. Women who are unable to bear children (e.g. post-menopausal, have had a hysterectomy etc. are exempt from this). This monitoring is required even if you are on contraception.
We send you a complementary skindoc monitoring pack for your entire treatment course and have an online reporting service too. We don’t believe women should have to pay extra for pregnancy tests just because you have ovaries!
Blood Tests – Everyone will require a ‘screening blood test’ before they commence isotretinoin. This involves a Full Blood Count (FBC), Liver Function Test (LFT) and a Fasting Lipid Profile (LP). If you have known kidney problems you may be asked to book a Renal Function, also known as Urea & Electrolytes (U&E).
These blood tests will then need to be repeated six weeks into your treatment course and after any dose escalation (if applicable). Depending on how you get on with the medication, your doctor may choose to enact three-monthly blood tests also.
Blood tests can be requested via your GP although they are under no obligation to perform these on your behalf as your treatment is being delivered in the private sector and not via the NHS.
A quicker and easier option is to have your blood tests performed privately. There are two ways to do this:
- You may decide to have a healthcare professional perform these for you in a designated clinic whereby you would need to reach out to units in your area and book in.
- A more economical option is to utilise home blood test kits - a finger-prick kit can be posted out for you to perform and then post back. This is the most popular option. We can suggest reputable companies to book with, thus cutting out the middleman (us!) while keeping costs down for you.
Home blood test kits cost approximately £85-100 each whereas private clinics may charge you £200-300 per set.
Medication – The cost of the medication itself depends on the dose that is prescribed to you. The higher the dose, the greater the cost. This is because more capsules are required. We are fortunate enough to have partnered with Phlo Online Pharmacy. They are not part of skindoc but they handle the majority of our prescriptions and have one of the lowest costs for Roaccutane in the UK. They also deliver your medication directly to you and depending on where you live, they can even courier it to you in a matter of hours.
The cost per pack of medication varies greatly between Pharmacies so it is always worth ringing around to compare prices. Expect to pay £20-100 per month of treatment depending on the dose you are taking.
- Initial appointment: £150
- Follow appointments: £110 (on average 5-6 for women, 3-4 for men)
- Blood tests: Home Blood Test Kits (£85-100 each) vs. Private Clinics (£200-300 each) with normally 2-4 being required). Free via your GP if they accept.
- Pregnancy tests: FREE! from skindoc (we send you a pack with everything that you need)
- Medication: Approximately £20-100 per month depending on the pharmacy (5-6 months is the average for a complete course)
All in all, a rough estimate for a complete 1:1 Consultant-led treatment for a woman is in the region of £1000-1400 and for a man it is £900-1200.
Frequently Asked Questions (FAQs)
When should I take isotretinoin?
You should take isotretinoin at the same time every day with a meal that preferably contains some fat. Isotretinoin is better absorbed with fatty food and so is more effective. Healthy foods that contain fats include whole eggs, avocado, olive oil and nuts.
What should I do if I accidentally miss a dose?
Firstly, don’t worry. Isotretinoin stays in the bloodstream for over a week so it will not affect your treatment. However, do not try to make up for missing a dose by ‘double-dosing’ the next day. If you miss a day, you will end up tacking that days’ worth of medication at the end of the course.
What should I do if I run out of medication?
Although not ideal, short gaps of approximately a week will not affect your treatment. We advise planning ahead as much as possible to avoid this and booking a follow up at least week before you are due to run out. ‘Emergency prescriptions’ unfortunately cannot be provided.
Is it normal to not experience any side effects?
Lucky you! Although uncommon, some people experience little to no side effects at all. Ultimately, as long as the acne is improving that is the most important thing. If the acne is not improving then it may be that isotretinoin is not being absorbed properly so make sure you take the medication with a meal that contains fat as it improves uptake in your gut. The other reason may the dose is too low.
How quickly should I expect to see an improvement?
Although most people see an improvement within the first eight weeks it can take a while with some people not seeing much benefit for up to 12-16 weeks. This is uncommon though.
I have another skin condition, can I take isotretinoin?
This will be discussed with you when you meet with your doctor however there are some skin conditions that may affect your treatment course. A good example of this is eczema. Eczema makes you prone to dry skin and since the main side effect of isotretinoin is dryness, it may flare your eczema. As a result, many people prefer to stick to a low dose (10-20mg per day) which although still effective, will prolong your treatment.
Can I drink alcohol while taking isotretinoin?
We don’t want to be party-poopers but ideally, no. This is because isotretinoin and alcohol are both eliminated by your liver and as great as livers are they don’t like dealing with both at the same time. If you must, you should ideally keep alcohol to an absolute minimum (less than the recommended 14 units per week) but preferably stop drinking while on treatment.
Can I take isotretinoin if I am vegetarian/vegan?
Isotretinoin capsules contain gelatin and beeswax so this may not align with your ethical and dietary beliefs. We can provide guidance on how to safely take the medicine without the capsule.
Can I take isotretinoin if I have allergies?
Isotretinoin is not recommended in people with established soya and/or peanut allergies. This is because isotretinoin capsules contain soya (which shares some cross-reactivities with peanuts).
Although successful treatment has been given to people with soya and peanuts allergies, it is generally best to avoid this medication, especially if you are known to have an anaphylactic reaction to either. You may want to consult with an Allergist beforehand to check you are safe to use isotretinoin.
Can I take vitamins and supplements with isotretinoin?
Yes. Although always look at the RDA (recommended daily allowance) of Vitamin A and ensure it is not over 100% (>5000 units) per tablet. Isotretinoin is a synthetic derivative of Vitamin A and can cause supplementary Vitamin A to build up to toxic levels (known as hypervitaminosis A) which can make you unwell.
How long should I wait before arranging beauty/cosmetic procedures or tattoo/piercings?
Whilst taking isotretinoin, and for six months afterwards, your skin will be more delicate than usual. The jury is out on this but hair removal using waxing, epilation, dermabrasion, or laser treatment, as well as tattoos and piercings, should be avoided for those six months - although many practitioners will undertake procedures after only two months. It is best to check with your provider and why they are happy to reduce the wait. The evidence is lacking here but there are reports of scarring and poor outcomes when performed before six months.
Can I have surgery while on isotretinoin?
The association between isotretinoin and atypical wound healing remains controversial. It is common practice to delay elective or non-life-threatening procedures for six months as isotretinoin may impair wound healing or induce hypertrophic (thick/raised) scarring. However, more recent research would suggest otherwise. It is therefore important to discuss the pros and cons with your surgeon and if it is reasonable to wait until your course has completed and your skin has returned to normal.
Can I shave while taking isotretinoin?
Shaving is normally tolerated, but since your skin is more delicate using a non-pore-blocking moisturiser afterwards is advisable.
Do I need to fast for my blood test?
Yes. This is to ensure the triglyceride levels are accurate. Fasting means you should not eat or drink other than water, black tea or coffee (no sugar) for 8 hours beforehand.
Can I donate blood?
No. You must not donate any blood products while you are on isotretinoin treatment and for one month after you have stopped it.