Clear Skin or Bust!

March 17, 2008 8:18 AM

My Accutane treatment isn't showing results. Should I take a higher dosage, stick it out or give up?

I've been on Roaccutane for 2 1/2 months now and have yet to see any major positive changes.

My dermatologist started me on 30 mg/day; after a month, I had minimal side effects and asked him if I could try a higher dose. By the 2nd month, I had increased to 60 mg/day; after a full month of this dosage, nothing changed - there is perhaps a small reduction in the amount of acne, but not more than any other fluctuations I've experienced over the years. I also have not had the extreme dryness/peeling/hair loss that are reported as symptons of Accutane.

I understood that a 'course' of Accutane consists of a certain amount of the drug in total per kg of body weight, so I reasoned that I could finish it and be acne-free sooner if I increased the dose, as long as I continued to tolerate it well. At my most recent appointment, I told my dermatologist this and asked him if we could try a higher dosage, since I should definitely be seeing more improvement this far into the treatment. He said that I wasn't seeing any effect because 60 mg/day was too high, and he had only allowed me to take that much to prove me wrong. He bumped me back down to 40, claiming that because this is the "ideal" dose for my body weight, it would be more effective despite being lower.

Is he right? Shouldn't I be taking progressively higher doses until they yield results, especially given my apparent high tolerance of the drug and lack of serious side effects? I am feeling demoralized as I had very high hopes when I finally decided to try Accutane after 10+ years of serious acne. It now seems that I'm wasting my time and money, and I feel that my dermatologist's unwillingness to try a higher dose is an obstacle to my successful treatment.

Questions:

1) How much is an average daily dosage of Accutane, and how variable is this? Is a higher dose effective more rapidly? What is the largest dose someone might take?

2) Is Accutane simply not effective on some people? Does my lack of results so far indicate there might be no use in my continuing this treatment?

3) I would also be interested in hearing others' experiences with Accutane/Roaccutane: how much did you take, and how quickly did you improve?

posted by xanthippe to health & fitness (20 comments total)

I would also be interested in hearing others' experiences with Accutane/Roaccutane: how much did you take, and how quickly did you improve?

I took it when i was about 16 or 17. I don't remember my dosage, but I experienced side effects within hours of the first dose (extremely dry skin, irritated by sunlight, chapped lips). It took about two months before my skin started clearing up if I remember correctly. Accutane came at the end of a fairly long line of treatment, and I honestly don't know if it was the drug that cleared me up, or just finally getting through puberty. I feel that the drug probably sped along the ending of my acne outbreaks.

I had really crazy cystic acne in addition to just regular pimples/blackheads, if that helps.
posted by spikeleemajortomdickandharryconnickjrmints at 8:23 AM on March 17, 2008

I'm sorry that I don't have more specific information for you, but I took Accutane when I was in high school/college. I believe I took it for 4-5 months. I recall being extrememly dry. Nothing I tried to use in the way of creams or salves took care of the dryness. That said, it wasn't an immediate improvement, and I still did have the occasional new outbreaks while taking it. I believe it did suddenly start showing improvement and I was happy to do away with the blood tests and dryness. My recommendation is to trust the derm, but if you're skeptical there's no reason you couldn't make an appt with another doc to get another opinion. I've had 4 different derms over the course of 10 years until I found one I was happy with.
Good luck!
posted by mcarthey at 8:25 AM on March 17, 2008

I also took it in high school. I had constant acne on my chin, back, and somewhat on my chest. The Accutane completely cleared my back and chest acne and I haven't had any since.

As far as my facial acne goes, while on the meds, I got worse before I got better. Maybe you just need to stick it out. By the end of the treatment, I felt better about my skin, but now as a 24 year old I still get the occasional zit. I'm not sure if I would recommend increasing your dosage because Accutane affected my mood and made me feel rather depressed.

I would see another dermotologist and get their opinion.
posted by LiveToEat at 8:36 AM on March 17, 2008

If I were you I'd just give up on it. I'm 25 now and only just recently conquered my acne. I used prescription acne medication for about 4 years until it became less practical to get the prescriptions filled, and I never actually noticed any change at all in the amount of acne I got until after I quit. Of course I'm not suggesting that quitting helped my acne, but it definitely seems like the medicines weren't part of the equation.
One of the reasons I decided to quit was that I got hit pretty badly by various side effects. I would repeatedly be asked why my face was so red but the rest of my body was ghostly pale, and it got quite obnoxious.
I'm not sure if this was what caused it or if it was just good timing (correlation vs causation is always a tricky beast to figure out), but after quitting I decided to be more assertive in my war by washing my face at least three times a day and changing my pillowcase more frequently. I've also been getting a bit more sunlight than I used to, but wikipedia tells me that's not supposed to actually have any long term effect.
posted by GoingToShopping at 8:38 AM on March 17, 2008

I started it when I was around 21. First month was 30 and, then 4 months of 60 and then another one at 30, if I recall. (or it may have been 20 and 40)

It took almost the whole six months before I actually saw real improvement.
But I had ALL the side effects: intense dryness everywhere, bone and muscle aches, the works.

Yet, it was all worth it. I would stick it out for the rest of the course if I were you.
posted by odi.et.amo at 8:40 AM on March 17, 2008

Thanks for the encouragement, odi.et.amo.

What about my lack of side effects? Should I be going for a higher dose? I did have a bit of redness but it didn't last, and my dryness is corrected by a light application of lotion in the morning and at bedtime.
posted by xanthippe at 8:54 AM on March 17, 2008

Also, I would like to avoid seeking out another dermatologist. My question was intended to focus on getting information that would help me in dealing with my current one. Thanks.
posted by xanthippe at 8:55 AM on March 17, 2008

xanthippe, do you faithfully take your pills with food? I've read that Accutane needs a large, fatty meal to be completely absorbed. I'm not a doctor, but I imagine if you skip the fatty meal, it's as if you're taking a much smaller pill.
posted by Sfving at 9:00 AM on March 17, 2008

I had minimal side effects when I was on it, just occasional chapped lips. It's been awhile so I don't remember exactly, but I kind of had a gradual reduction in acne over the full 4-5 months or however long it was. It definitely wasn't quick. I tried a lot of stuff that didn't help at all before Accutane and have never worried about acne in the 10+ years after, so I'd recommend you stay on it a bit longer at whatever dose the dermatologist gives you.
posted by Durin's Bane at 9:16 AM on March 17, 2008

You have a doctor that allowed you to take a non-helpful extra dose of a drug known to have major side effects in order to prove a point and you *don't* want to find a new dermatologist?
posted by jacquilynne at 9:25 AM on March 17, 2008 [1 favorite has favorites]

What about my lack of side effects? Should I be going for a higher dose? I did have a bit of redness but it didn't last, and my dryness is corrected by a light application of lotion in the morning and at bedtime.

Lack of side-effects doesn't mean a drug isn't working. Side-effects are exactly that. Just be grateful you're not getting them. And despite how large tales of Accutane's side-effects loom, many people experience minimal or no ill-effects.

You have a doctor that allowed you to take a non-helpful extra dose of a drug known to have major side effects in order to prove a point and you *don't* want to find a new dermatologist?

This part of your tale is a bit strange. Maybe your doctor misspoke or was joking? Or you misunderstood. Prima facie, this borders on malpractice.

In any event, 9 weeks is a bit early to call the treatment a failure. It's worth 4 months at least and longer (and repeated) treatments are common. Then, if there's no change, it might be time to question what exactly is causing your acne.
posted by outlier at 9:49 AM on March 17, 2008

Nthing the new doc suggestions even though you don't want it. Competent physicians do not get in contests to prove patients wrong. A doctor who would knowingly prescribe a medicine for you beyond the therapeutic dose is not following the standard of care. Allowing you to take that for a month to "prove you wrong" is just stupid.

Looking at RxList it seems the standard dosage is for Accutane is 1 milligram per kilogram of body weight. If you weight about 120lbs, then 60 mg is the approximate dose. If your doctor is giving you the correct dose, but mind-gaming you to put you in your place, then he's just a jerk.
posted by 26.2 at 9:53 AM on March 17, 2008

Keep taking your prescribed course, at the current does. You lack of side-effects doesn't mean that your dose isn't high enough, it means that you're very lucky.

Accutane often takes months to start having noticeable effects, and it fairly common for acne to get worse around week 6 or so, before it starts to improve.
posted by emd3737 at 10:22 AM on March 17, 2008

Wait, you asked for the wrong dosage and your doctor gave it to you just to prove you wrong? WTF? Accutane is big medicine and not to be fucked with, as surely he knows. I know you don't want a new doctor but this is really weird and I think you should get one. Not solely because of this one episode, but also because of what it says about his approach to treatment. Don't you want someone whose main concern is your health and not winning some misguided pharmaceutical pissing contest?

As for your original question, you've come this far and you've got no bad side effects, so why not stick it out? It's the side effects that normally make people want to quit. I don't think I really started to see results until the fourth month and was suffering with the most horrific side effects that whole time. But it's the rare person who is not significantly helped by Accutane. I don't see that you have anything to gain by quitting now.
posted by Enroute at 10:38 AM on March 17, 2008

I thought I asked for the right dosage - actually, I weigh 70 kg so according to 26.2's answer above, even 60 mg was too low!

My question here is to clarify that, not to discuss whether I should see a different dermatologist. Specifically:

-Is he prescribing me an appropriate dose, and should I ask him again to give me a higher dosage? Why?

-Is he correct in insisting that I take a dosage much lower than what I have demonstrated I am able to tolerate?

Thank you for any more on-topic answers.
posted by xanthippe at 10:53 AM on March 17, 2008

It took me about 5 months into the 6 month cycle to get improvement. It it a miserable time for a while because your acne can get worse, plus you're dealing with the side effects of dryness.

But I say wait it out. It was worth it. Can't speak personally about dosages though.
posted by JauntyFedora at 11:05 AM on March 17, 2008

If you specifically want to know about your dosage of a potentially high-risk drug, you need a medical second opinion, not a random guess from a random mefite. "See a different doctor" IS the answer to your question.
posted by restless_nomad at 11:51 AM on March 17, 2008

From RxList (other sites give similar information):

A single course of therapy for 15 to 20 weeks has been shown to result in complete and prolonged remission of disease in many patients ... The recommended dosage range for Accutane is 0.5 to 1.0 mg/kg/day given in two divided doses ...

Looks like you're still very early in the typical treatment course. And while 60mg would not be unusual, it is on the upper end of the prescribed range. The difference between 60 and 70mgs isn't anything to analyse, there's so many other factors involved. Dose per body mass is just a rule of thumb. In reality, most drugs will have an effect proportional to metabolic body mass, which is weight^.67. The linear dose / kg is just an approximation over adult weights.

(There does seem to be some divide in the literature about whether docs should give high doses in order to complete the course fast, or give low doses and seeing what happens. But this is what your doctor went to school for, and Accutane isn't a drug to mess with. He's well within standard procedures here.)

Failure to take Accutane with food will significantly decrease absorption. Before upward dose adjustments are made, the patients should be questioned about their compliance with food instructions.

Make sure you're doing this.
posted by outlier at 11:51 AM on March 17, 2008

I've done two courses of Accutane - once in my late twenties, and once in my mid-thirties. I weigh around 70 kg. The first course, I was on 40 mg/day for 4 months. My acne went away for a while, then came back. The second course, I was on 60 mg/day for 6 months. This course ended about 6 months ago, and so far the acne has not come back (fingers crossed).

My first dermatologist didn't mention any issues around dosages or even tell me that he was being conservative with the dosage. My second dermatologist told me she was surprised I was on such a *low* dose, and wasn't surprised that I had to repeat the treatment.

As to why your physician wants you to remain on a low dose, I think that doctors generally want to be conservative with powerful drugs like Accutane because of the risk of side effects. The goal is to resolve the issue with as low a dose as possible. If you want a less conservative approach, you may need to find another doc.

My recommendation, based solely on my experiences, is to persist with a higher dosage if you can - the joy of being (permanently?) zit-free is worth it.
posted by acridrabbit at 7:37 AM on March 18, 2008

To answer your question, I took three courses of accutane (with blazing side effects) and in every instance the acne came back a year later.
I still have acne today but I can't deal with the side effects so I'm sticking with spironolactone (it's got something to do with hormones and is helpful)
posted by chickaboo at 6:18 AM on March 19, 2008