Dr. Emmy Graber talks mental health, micronized formulations, and considerations for repeat courses.
“The issue about depression and mood changes on isotretinoin has obviously received a lot of attention. It’s something we talk about a lot,” said Emmy Graber, MD, MBA.
Dr. Graber is the director of The Acne and Rosacea Meeting (ARM), a 2-part virtual meeting series designed to comprehensively address acne, acne scarring, and rosacea for the practicing dermatologist, including topical, oral, and laser therapies, as well as the psychological toll these conditions take on patients.
Dr. Graber’s talk included the role of spironolactone, isotretinoin, and diet for the management of acne.
Isotretinoin, she said, can be safely prescribed for some acne patients.
“If a patient has a history of depression, their depression has been stable, [and] they’re on medication that has not changed for many years… I will still prescribe isotretinoin,” said Dr. Graber.
Importantly, she noted, the prescribing dermatologist should contact and inform the patient’s mental health care professionals.
“I almost never have a mental health professional tell me that they think it’s a bad idea, and oftentimes they’re very supportive of starting the isotretinoin as an aid to… help clear their acne, which may be—for many patients—the root of their depression. So yes I do prescribe isotretinoin when patients have a history of depression, but I consider it on a case-by-case basis and it’s always a great idea to communicate with the healthcare professionals.”
Newer formulations of isotretinoin make it possible for patients to have a lower dose with a similar treatment outcome, possibly with fewer side effects.
“That means we… can deliver a lower dose of isotretinoin, but have it absorbed just as well as a higher dose at either a fasted or fed state. So for example, there’s now micronized isotretinoin, and we know from studies that the 32 mg of the micronized isotretinoin is absorbed, just as well as the 40 mg of nonmicronized lidose formulation.”
However, some patients may have limited formulation options depending on insurance coverage, she noted.
In terms of dosing, “Studies show that the amount of patients that relapse after isotretinoin—depending on the study that you look at—hovers somewhere around 20%,” said Dr. Graber.
Extending the duration of initial treatment may be a solution for avoiding relapse.
“There’s more evidence coming out showing that if we achieve a higher cumulative dose, or… continue the isotretinoin after they’ve been cleared (so you reach your clearance point—their faces great their backs looks great) and then you continue with your isotretinoin for one to two months longer—that may minimize the necessity of a second course of isotretinoin. So something to consider when dosing isotretinoin.”