Survey: No Consensus on Post-Isotretinoin Acne Management

Isotretinoin is one of the most effective treatments available for moderate to severe acne, as it affects multiple aspects of the disease pathogenesis. Notably, use of isotretinoin is shown to inhibit the sebaceous gland. It is no surprise that the drug is widely used in the US, with data suggesting that at least 10% of eligible female patients and 20% of eligible male patients are treated with isotretinoin.

With thousands of patients treated with isotretinoin annually, clinicians are left to decide what treatment regimen is best for post-isotretinoin acne management (PIAM). A recent survey of acne specialists in the Journal of Drugs in Dermatology suggests there is no consensus on this aspect of patient care.

The survey was conducted via email to 10 dermatologists, comprising the Board of Directors of the American Acne and Rosacea Society (AARS). The results offer a snapshot of treatment preferences for nine dermatologists in the acne space as one dermatologist was ineligible to participate due to clinical inactivity.

While two-thirds of respondents routinely initiate maintenance treatments (MTs) immediately (66.7%) or 1 month (33.3%) post-isotretinoin completion, there was significant variability in PIAM—as well as in isotretinoin dosing itself. Topical retinoids (TRs) were the most common MTs for females (66.7%) and males (100%). Responses show that most respondents schedule initial (77.8%) and subsequent (66.7%) post-isotretinoin follow-up visits.

Surprised By the Variability

Adam J. Friedman, MD, FAAD, a member of the AARS Board of Directors and lead author of the report on the survey, says he was surprised by the variability in both isotretinoin dosing strategies and post treatment practices among expert dermatologists. “Given how common acne is and how transformative isotretinoin can be, you’d hope for a more unified approach. That said, the inconsistency isn’t entirely shocking when you consider the lack of formal guidelines for post-isotretinoin care,” says Dr. Friedman, who is Professor & Chair of Dermatology, Residency Program Director, Director of Translational Research, and Director of Supportive Oncodermatology in the Department of Dermatology at George Washington University School of Medicine and Health Sciences in Washington, DC. “This is an area where clinical inertia and individual experience often guide practice in the absence of hard data.”

Despite its notable efficacy, isotretinoin is associated with acne relapse rates as high as 60%, depending on dose and duration of therapy, Dr. Friedman notes. “That’s why what comes after the course matters just as much as the treatment itself. Consistent, evidence-driven post-care is essential to prevent relapses, reduce the burden on patients, and avoid the need for repeat courses, which carry their own risks and challenges. Maintenance therapy isn’t just an afterthought, it’s part of the treatment continuum,” he says.

‘Go-to’ Regimens

Dr, Friedman says a topical retinoid is his “go to” for PIAM for men, starting within a month after completing isotretinoin. “It’s a logical step down that sustains the normalization of follicular keratinization and anti-inflammatory activity achieved during systemic therapy,” he says.

For women with hormonal acne patterns or a history of relapse, introduction of spironolactone to maintain clearance may be an option, Dr. Friedman observes, though he points out that many female patients take spironolactone concomitantly with isotretinoin. “The goal is to transition patients from control to long-term stability, and that requires a proactive, rather than reactive, approach,” he says.

The current pilot survey is just a first step, according to Dr. Friedman, who says he and his team are already collecting data from a larger sample of dermatologists across geographic regions, practice settings, and years in practice.