When treating patients with cystic acne, isotretinoin is an important part of the conversation. While considered the most effective acne therapy available, it is not without several common adverse effects. Dry skin and chelitis are seen in nearly all patients at any dose, along with dry eyes and acne flares that may cause some to discontinue the medication.
Emerging research suggests that there may be a role for oral omega-3 in decreasing the mucocutaneous dryness of isotretinoin. Omega-3 supplements are a safe, inexpensive, and simple recommendation we can offer to our isotretinoin patients.
In a case-controlled study of 188 patients, patients were randomized to 0.5mg/kg/day isotretinoin alone or 0.5mg/kg/day isotretinoin plus 1 g/day of oral omega-3 for 16 weeks.[1] At week 16, the rate of chelitis was 26% in the isotretinoin-only group compared with 14% in the combination group; similar trends were seen with dry nose (11% vs. 0 %, respectively) and dry skin (11% vs. 2%).[1]
Research also suggests the use of an antihistamine with isotretinoin provides a synergic effect of minimizing cutaneous side effects and increasing clearance of acne lesions and scars. In one study, 20 patients were treated with isotretinoin 0.4 mg/kg per day and 20 patients were treated with isotretinoin (same dose per weight) plus an antihistamine, desloratadine 5 mg/day, for 12 weeks.[2] At week 12, patients in the group treated with isotretinoin and the antihistamine showed a more statistically significant decrease in acne lesion counts, compared with the isotretinoin-only group (reductions of 44.8% vs. 17.8%, respectively, in noninflammatory lesions; 55.8% vs. 22.9% in inflammatory lesions, and 45.6% vs. 18.7% in total lesions (P < .05 for all associations).[2]
In another randomized, controlled, comparative study, 50 patients were treated with isotretinoin and 50 patients were treated with isotretinoin and a daily antihistamine, levocetirizine.[3] Acne assessments were done at baseline, 4, 8 and 12 weeks of treatment. At week 12, compared to isotretinoin-only group, combination of isotretinoin and levocetirizine group showed more statistically significant decrease in score of global
acne grading system (51.0 vs. 38.5%) and acne lesion counts (non-inflammatory lesion: 63.2 vs. 44.5%; inflammatory lesions: 75.9 vs. 62.7%; total lesions: 66.07 vs. 48.7%; all p< 0.05).[3] Acne flares occurred less frequently and adverse skin effects were more tolerable in the levocetirizine group. In addition, higher rates of patient satisfaction occurred in the antihistamine group.[3]
Next time you prescribe isotretinoin, consider these clinical pearls to help minimize some challenging side effects of isotretinoin. Your patients will thank you!
References
1. Mina Mirnezami. "Evaluating the Role of Omega 3 on the Side Effects of Isotretinoin in Patients with the Acne Vulgaris." Majallah-i Dānishgāh-i 'ulūm-i Pizishkī-i Arāk 19.10 (2017): 81-87.
2. Lee, H.E., Chang, I.K., Lee, Y., Kim, C.D., Seo, Y.J., Lee, J.H. and M. Im. “Effect of antihistamine as an adjuvant treatment of isotretinoin in acne: a randomized, controlled comparative study.” J Eur Acad Dermatol Venereol 28:12 (2014): 1654-1660.
3. Pandey D & Agrawal S. “Efficacy of Isotretinoin and Antihistamine versus Isotretinoin Alone in the Treatment of Moderate to Severe Acne: A Randomized Control Trial.” Kathmandu Univ Med J 17.65. (2019):14-19.
Keri Holyoak, MPH, MSHS, PA-C is a dermatology PA in Salt Lake City, Utah. Since 2005 she has worked with Dr. Joseph Jensen at the Dermatology Center of Salt Lake. She resides in Millcreek, Utah with her husband and three adventurous kids. Together they explore the roads less traveled throughout the world.