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It seems I have been giving this “speech” quite often at the office in the past few weeks, so why not here? All the acne medicines are neither weaker nor stronger than each other. They are different from each other and have to be tried by each patient to see whether they suppress the acne well enough. The one medicine that produces results that are quite different from the others is isotretinoin/13-cis retinoic acid, a derivative of vitamin A, which has been used in drug doses since the late 1930s. Its brand name is Accutane. It can produce adverse reactions, such as storing up in livers and causing liver inflammation, only allowing it to be given for months at a time. Isotretinoin was one of the copious compounds studied from vitamin A, which turned out to be quite different, and close to a cure for most people’s acne.
The first 14 humans studied in the late 1970s at the National Institutes of Health by Dr. Gary Peck took five to six times the daily dose given today. For 13, their acne cleared, and the other one was almost clear in five months. Since then, it has been used worldwide with amazing success.
It isn’t perfect. I likely have given it to 2,000 patients and have seen only eight real failures, where it never worked, and only 29 people who had to quit taking it in the first month. There are recurrence rates of about 20 percent to 25 percent. But those often aren’t nearly as severe as the pretreatment levels. And curiously, medicines that didn’t function too well pre-Accutane can act more effectively afterward. The average course is four to six months. Your acne clears and stays away indefinitely. You may get an occasional zit or two. A steady stream of them constitutes a real recurrence.
All the other medicines, lasers and lights can be quite efficacious but rarely clear a patient’s acne in a sustained manner like isotretinoin. And you have to try each of them, usually in combination. It’s potluck, because nobody knows how to choose the best one for any one person. When they work well enough, there is no telling how long you will need to take and rub on the prescriptions. Many an acne-bearing adult has done it for decades.
Acne is a disease. Washing, scrubbing, rubbing, picking, digging, scraping, jack-hammering and dynamiting don’t work. It is not a mechanical process. It can cause scars permanently that trouble people. Witness the millions spent annually trying to correct them.
Acne treatments are all choices. Even not to treat is a treatment choice. If and when the acne has created a sufficient medical, physically or psychologically scarring illness, how should it be treated? In September, isotretinoin will have been available in the U.S. for 26 years. The only truly established medical problem is that it cannot be taken if you are pregnant. It misdirects tissue development, causing evil birth defects. The other hypothetical discussion of it increasing adolescent depression and suicide is arguable and must dealt with on a case-by-case basis. I have seen clinically depressed patients who have taken it safely.
Should you wait to fix your acne until after lifelong scars have permanently formed? Or until you have spent so much moola on it that you would have saved a lot of dough by fixing it much earlier?
Depending on each person’s personal feelings and means, I have a low threshold for prescribing isotretinoin, because it fixes the problem better than anything can. But pills also can be effective. If the disease has been prolonged, there just may come a time to finally fix it, before the scars set in, and the money runs out.
Rook’s Dermatology textbook (the Bible), remarks on its cost-effectiveness and effectiveness, “Funding bodies should look more logically at the way isotretinoin is prescribed, so that it can be used earlier in acne to prevent the many physical and psychological problems of the disease.” Or, using red-neck logic of Larry the Cable Guy, “Git ’er done!”
