Acne affects many young people and can have a profound effect on self-image. Treatment is based on a stepwise approach starting with topical treatments and escalating to oral treatments. Isotretinoin is a vitamin A derivative which is a very effective treatment for acne which is nodulo-cystic or scarring. Isotretinoin has a number of side effects, including reports of low mood and suicide. In the UK the pharmaceutical licence restricts prescribing to dermatologists. Published guidelines recommend a variety of different dosing schedules of oral isotretinoin for acne. Whilst there is no clear consensus on the optimal dosing strategy to reduce relapse, the available literature suggests 0.5-1.0 mg/kg/day with a cumulative dose of 120-150 mg/kg and treatment duration of at least 6 months. In practice, dosing of isotretinoin may be influenced by tolerability of physical and psychological adverse effects. We present a quality improvement project using retrospective cases to evaluate our departmental isotretinoin dosing practice in young people to determine whether (1) we optimise dosing to reduce relapse based on published guidelines, (2) how screening and monitoring for physical and psychological health, in conjunction with acne related quality of life (QoL), influenced clinicians ‘dosing decisions. Forty-two young people were included. Results showed 53% patients reached a cumulative dose of 120 mg/kg, and treatment duration was less than 6 months in 36%. Reasons for dose limitation were physical (26%) and psychological (21%) adverse effects. Measures of depressive symptoms improved in 74% and acne related QoL improved in 89.5% of cases at the end of treatment. Our data show that target total dose, dose duration and peak dose was not achieved in many of our patients and that physical or psychological adverse effects are limiting factors in achieving therapeutic targets. No serious adverse effects were reported and the measures of depressive symptoms and acne related quality of life improved during treatment. Uncertainty remains as to how to optimise dosing to reduce relapse rate. Further research is needed to determine the relapse rate of adolescence acne following isotretinoin treatment and the optimal dosing strategy to reduce relapse including the possibility of low dose isotretinoin regimens.
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