When people think of isotretinoin, the first skin condition that comes to mind is acne. This is one of the most prescribed FDA-approved oral drugs for zapping zits, and it is extremely effective at it.
But many rosacea patients may be surprised to know that it is an option for their condition too. Isotretinoin’s anti-inflammatory and oil gland shrinking properties can help control the bumps and skin thickening manifested by certain types of rosacea. But when used without proper medical advice, it can lead to serious adverse side effects.
If you’re considering using isotretinoin for rosacea, it’s important to go into it with eyes wide open. Here are some FAQs about this powerful drug:
What is isotretinoin?
Isotretinoin is a retinoid, or Vitamin A derivative. This drug class includes some of the most touted skincare ingredients, including retinol, retinoic acid, adapalene, tretinoin. Most retinoids are administered directly on the skin, but isotretinoin is taken orally.
Isotretinoin, like other members of the retinoid family, acts as a chemical messenger that binds to retinoic acid receptors (RARs) found in the nucleus of cells (Layton, 2009). When binding occurs, the cell’s activities change, which is manifested as the effects of the drug. Our skin cells have an abundance of these RARs, which explains why it reacts so drastically to retinoids.
This includes minimizing transepidermal water loss (Zasada et al., 2019), inhibiting collagen degeneration by metalloproteinases (Mukherjee et al., 2006), dramatically decreasing oil production (Layton, 2009), curbing the skin’s inflammatory response (Dispenza et al, 2012). The latter two reasons are thought to be the main mechanisms for isotretinoin’s efficacy at controlling rosacea symptoms.
How does isotretinoin work on rosacea?
Isotretinoin is extremely effective at controlling acne, so it should come as no surprise that, among rosacea subtypes, it is most effective on the papulopustular form. These two skin conditions share the clinical symptom of pus-filled bumps on the skin (Mikkelsen et al., 2016), something that isotretinoin targets effectively by reducing oil production and modulating the inflammatory response (Plewig et al., 1982).
Gollnick et al. (2010) found that isotretinoin achieved a 90% reduction of lesions, 24% remission rate, and 57% marked improvement compared to oral doxycycline that resulted in 83% reduction of lesions, 14% remission rate, and 55% marked improvement in 573 patients with severe inflammatory or phymatous rosacea.
A study by Rademaker (2018) followed patients with mild to moderate papulopustular rosacea who were prescribed a very low dose protocol for isotretinoin through the course of five years. This regimen effectively cleared the skin of 91% of patients who finished the study.
Erythema or redness is not noticeably improved by the range of isotretinoin dosage commonly used for rosacea, but a small study by Uslu et al. (2012) shows the promising results of intermediate dose isotretinoin on erythema index, sebum level, and papule and pustule counts.
Isotretinoin is not the first line of treatment for most types of rosacea given its side effects (more on that later), but for cases wherein other drugs have proven ineffective, or in cases when the breakout is severe, it becomes a viable option.
Along with corticosteroids, isotretinoin is the treatment of choice for rosacea fulminans, an extreme manifestation of rosacea characterized by an acute eruption of deep, coalescing nodules and cysts (Park and Del Rosso, 2012; Angileri et al., 2021).
Isotretinoin is also used to improve the appearance of patients with phymatous rosacea. The thickened skin resulting in a bulbous nose is caused by oil glands that become enlarged. The sebum reducing properties of isotretinoin can help with that (Rivero and Whitfeld, 2018).
What should I know before starting isotretinoin for rosacea?
Isotretinoin can have serious side effects.
Isotretinoin is a well-known teratogen that may cause physical malformations, neurological deficits, cardiovascular issues, and hormonal imbalances in babies (Draghici et al., 2021). These issues are primarily seen when it is the mother who is on an isotretinoin regimen. As such, birth control measures are strictly put in place before, during, and for a few months after taking this drug.
Teratogenicity aside, isotretinoin has other side effects including uncomfortable dryness of the skin, eyes, and lips. Rarely, it may cause liver or pancreas issues and blood lipid imbalances.
It is important to consult a dermatologist before trying out isotretinoin for rosacea, and to continue seeing them to monitor progress and side effects. Other treatments may be prescribed to help alleviate dryness.
There is no established isotretinoin dosage for rosacea.
The decision of how much isotretinoin to take and how often to take it differs among studies--there is evidence supporting low-dose and intermediate-dose isotretinoin for rosacea, but ultimately it is based on the individual’s response to the drug. Your dermatologist will prescribe a beginning dose, and regularly monitor improvement. Depending on the reaction, the dose may be increased or decreased accordingly.
Isotretinoin takes time to work.
As they say, Rome wasn’t built in a day. On average, it can take 3-4 months of isotretinoin therapy to see noticeable improvement in rosacea symptoms (Park and Del Rosso, 2011). The best way to find out if this drug works for you is to faithfully keep to the regimen your doctor prescribed and to regularly visit to monitor progress.
Rosacea breakouts can recur if isotretinoin therapy is stopped.
Unfortunately, doing a round of isotretinoin treatment is not a permanent cure to rosacea. Depending on the cumulative dose of isotretinoin administered throughout the treatment period, recurrence of flare-ups may occur 15 weeks to 11 months after stopping treatment (Uslu et al., 2011; Sbidian et al., 2016). Another option is to pursue the continuous microdose isotretinoin treatment for an indefinite period of time, though it also requires continuous contraceptive use in women and monitoring (Park and Del Rosso, 2011).
Conclusion
If you have stubborn papulopustular or phymatous rosacea that is resistant to the usual first line therapies, you may find hope in isotretinoin. With the proper medical advice and monitoring, you can minimize the adverse effects and maximize the benefits of this powerful drug.
This content is for general information only and is not a substitute for medical advice.
References:
Angileri, L., Veraldi, S., & Barbareschi, M. (2021). Rosacea fulminans: two case reports and review of the literature. The Journal of dermatological treatment, 32(1), 110–113. https://doi.org/10.1080/09546634.2019.1628175
Dispenza, M. C., Wolpert, E. B., Gilliland, K. L., Dai, J. P., Cong, Z., Nelson, A. M., & Thiboutot, D. M. (2012). Systemic isotretinoin therapy normalizes exaggerated TLR-2-mediated innate immune responses in acne patients. The Journal of investigative dermatology, 132(9), 2198–2205. https://doi.org/10.1038/jid.2012.111
Draghici, C. C., Miulescu, R. G., Petca, R. C., Petca, A., Dumitrașcu, M. C., & Șandru, F. (2021). Teratogenic effect of isotretinoin in both fertile females and males (Review). Experimental and therapeutic medicine, 21(5), 534. https://doi.org/10.3892/etm.2021.9966
Gollnick, H., Blume-Peytavi, U., Szabó, E. L., Meyer, K. G., Hauptmann, P., Popp, G., Sebastian, M., Zwingers, T., Willers, C., & von der Weth, R. (2010). Systemic isotretinoin in the treatment of rosacea - doxycycline- and placebo-controlled, randomized clinical study. Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG, 8(7), 505–515. https://doi.org/10.1111/j.1610-0387.2010.07345.x
Hoting, E., Paul, E., & Plewig, G. (1986). Treatment of rosacea with isotretinoin. International journal of dermatology, 25(10), 660–663. https://doi.org/10.1111/j.1365-4362.1986.tb04533.x
Layton A. (2009). The use of isotretinoin in acne. Dermato-endocrinology, 1(3), 162–169. https://doi.org/10.4161/derm.1.3.9364
Mikkelsen, C. S., Holmgren, H. R., Kjellman, P., Heidenheim, M., Kappinnen, A., Bjerring, P., & Huldt-Nystrøm, T. (2016). Rosacea: a Clinical Review. Dermatology reports, 8(1), 6387. https://doi.org/10.4081/dr.2016.6387
Mukherjee, S., Date, A., Patravale, V., Korting, H. C., Roeder, A., & Weindl, G. (2006). Retinoids in the treatment of skin aging: an overview of clinical efficacy and safety. Clinical interventions in aging, 1(4), 327–348. https://doi.org/10.2147/ciia.2006.1.4.327
Park, H., & Del Rosso, J. Q. (2011). Use of oral isotretinoin in the management of rosacea. The Journal of clinical and aesthetic dermatology, 4(9), 54–61.
Plewig, G., Nikolowski, J., & Wolff, H. H. (1982). Action of isotretinoin in acne rosacea and gram-negative folliculitis. Journal of the American Academy of Dermatology, 6(4 Pt 2 Suppl), 766–785. https://doi.org/10.1016/s0190-9622(82)70067-2
Rademaker M. (2018). Very low-dose isotretinoin in mild to moderate papulopustular rosacea; a retrospective review of 52 patients. The Australasian journal of dermatology, 59(1), 26–30. https://doi.org/10.1111/ajd.12522
Rivero, A. L., & Whitfeld, M. (2018). An update on the treatment of rosacea. Australian prescriber, 41(1), 20–24. https://doi.org/10.18773/austprescr.2018.004
Sbidian, E., Vicaut, É., Chidiack, H., Anselin, E., Cribier, B., Dréno, B., & Chosidow, O. (2016). A Randomized-Controlled Trial of Oral Low-Dose Isotretinoin for Difficult-To-Treat Papulopustular Rosacea. The Journal of investigative dermatology, 136(6), 1124–1129. https://doi.org/10.1016/j.jid.2016.01.025
Uslu M, Savk E, Karaman G, Sendur N. Rosacea treatment with intermediate-dose isotretinoin: follow-up with erythema and sebum measurements. Acta Derm Venereol. 2012;92:73---7.
Zasada, M., & Budzisz, E. (2019). Retinoids: active molecules influencing skin structure formation in cosmetic and dermatological treatments. Postepy dermatologii i alergologii, 36(4), 392–397. https://doi.org/10.5114/ada.2019.87443
