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Rational use of systemic isotretinoin in acne.

Acne affects a significant proportion of people, especially young people. Systemic isotretinoin, an oral retinoid, can be considered to be a 'wonder drug' that has revolutionised the treatment of acne vulgaris, massively improving outcomes in nodulocystic acne. Werner Sinclair discusses the reasons for global guidelines on the use of systemic isotretinoin and provides a timely call for moderation in its use. (2)

Isotretinoin can 'cure' acne in a significant proportion of cases and is highly effective in all forms and grades of acne vulgaris, even in lower doses. However, in South Africa there is a massive trend towards the universal use of lower dosages of systemic isotretinoin for lesser degrees of acne vulgaris, and it is prescribed by dermatologists and general practitioners alike.

Global and South African guidelines for the use of systemic isotretinoin are: grade IV (nodulocystic or conglobate acne); scarring acne; lesser grades of acne not responsive to at least 3 months of oral antibiotics combined with a topical retinoid, or at least 4 cycles of hormonal therapy in females; dysmorphophobic patients; and Gram-negative folliculitis. In Europe there are severe restrictions on its use. Similar restrictions apply in the USA concerning pregnancy prevention.

The global guidelines on maintenance treatment for acne, after initial clearance, recommend topical retinoids, and hormonal treatment in females.

The use of systemic isotretinoin may result in serious side-effects. Teratogenicity is the best-known serious adverse effect, and the risk of 'retinoid embryopathy' is as high as for thalidomide; mucocutaneous side-effects include initial worsening of acne, xerosis and cheilitis, retinoid dermatitis, and staphylococcal infections of the skin; ocular complications include dry eyes that can persist indefinitely; and severe depression can occur as a rare and idiosyncratic event requiring prompt attention.

The main reason for adhering to global guidelines is to protect patients against the drug's adverse effects. Healthcare professionals must be protected against litigation for possible negligence when they do not prescribe the drug according to the guidelines and adverse events occur. We also cannot risk losing access to the drug, one of dermatology's most valuable assets, as a result of inappropriate use.

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Title Annotation:Editors Choice
Publication:South African Medical Journal
Geographic Code:6SOUT
Date:May 1, 2012
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