When should a patient be started on isotretinoin therapy?

Isotretinoin is the mainstay of therapy for severe acne. It is indicated for patients with severe, scarring, nodulocystic acne and those with moderate to severe acne who have failed an adequate trial (3 to 6 months) of conventional therapy (retinoid and/or benzoyl peroxide [BP] plus an oral antibiotic). Isotretinoin is also beneficial for patients with severe hidradenitis suppurativa, acne rosacea, and gram-negative acne who are unresponsive to conventional therapy. However, it is not as effective in these diseases as it is in severe acne vulgaris, and relapses are more frequent. The recommended dose is 1.0 mg/kg/day for 20 to 24 weeks. Isotretinoin should be used as monotherapy for acne vulgaris.

Goldsmith LA, Bolognia JL, Callen JP, et al: American Academy of Dermatology Consensus Conference on the Safe and Optimal Use of Isotretinoin: summary and recommendations, J Am Acad Dermatol 50:900–906, 2004.