What drives acne relapse? New study examines isotretinoin results

What drives acne relapse? New study examines isotretinoin results

New research suggests that increasing cumulative isotretinoin dosage could significantly reduce acne recurrence and the need for re-crosslinking, offering hope for long-term skin clarity.

A current oneJama Dermatology The study evaluates the factors associated with relapse after isotretinoin treatment for acne.

Isotretinoin treatment for acne

Isotretinoin, commonly called Accutane, is the only approved treatment for severe acne. Although isotretinoin is extremely effective for most people with acne, some have relapses. As a result, patients prone to acne relapses are treated with additional courses of isotretinoin.

It is crucial to understand whether certain factors such as patient characteristics, isotretinoin dosage and treatment regimen influence acne relapse. This information can be used to design optimal isotretinoin treatment regimens that maximize treatment outcomes and minimize adverse effects. Improved understanding will also allow clinicians to better manage patients' expectations of treatment outcomes, including the possibility of relapse, and to formulate effective maintenance plans.

Previous studies have documented acne relapse rates ranging from 9.4% to 65.4%, with 1.7-23.1% using isotretinoin repeatedly. This variability has been attributed to unrepresentative populations, incomplete follow-up, small sample sizes, and different isotretinoin dosing regimens. The inconsistency in definitions of acne relapse may also contribute to inconsistencies in clinical reports.

About the study

Female patients were significantly more likely to experience acne relapse compared to men, with a 43% increased risk, highlighting the need for gender-specific treatment considerations.

Researchers in the current study examined the frequency of acne recurrence after isotretinoin treatment and factors that may increase the risk of acne recurrence. All data were obtained from the MarketScan Commercial Claims database between January 1, 2017 and December 31, 2020.

The analysis included patients with at least one acne diagnosis according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code. All patients were 12 years or older and receiving isotretinoin treatment for acne.

The index date reflected the date the first course of isotretinoin was completed. The prescriptions were also analyzed to determine isotretinoin treatment regimens.

Acne relapse was identified when a patient was prescribed for systemic acne treatment with oral antibiotics such as doxycycline, minocycline, trimethoprim-sulfamethoxazole, amoxicillin, cephalexin, spironolactone, and isotretinoin for recent acne exposure. Recurrence of isotretinoin was also determined based on individual recording of another prescription for isotretinoin after the index date.

Study results

The study included 1,856,012 patients with acne, 19,907 women and 9,403 men. The average duration of initial courses of isotretinoin prescribed by dermatologists was 5.6 months, with a maximum daily dose of 0.93 mg/kg/d and a cumulative dosage of 132.4 mg/kg. The median follow-up time for this treatment was 24.9 months.

In this study, 19,907 patients reported acne relapse, resulting in an acne relapse rate of 12.9 per 100 person-years. The median time to acne relapse was 7.5 months.

Approximately 2.1%, 25.8%, 15.6%, 25.2%, and 31.3% of patients were prescribed a systemic acne prescription within one month, one to three months, three to six months, six to twelve months, and over twelve months, respectively, from the index date.

The study found that maximum daily doses above 1 mg/kg/day did not provide additional protection against acne relapse, challenging the traditional belief that higher daily doses lead to better long-term results.

Patients with acne relapse were often treated with oral antibiotics after completion of the isotretinoin regimen. COX proportional hazards regression modeling revealed that females had a significantly higher risk of acne relapse compared to males. Cumulative dosage of isotretinoin was also associated with a significantly reduced rate of acne relapse.

Approximately 8.2% of patients underwent isotretinoin recurrence at an estimated rate of 4.3 per 100 people. The median time to a second course of isotretinoin was 2.8 months and included a maximum daily dose of 0.82 mg/kg/d and a cumulative dose of 52.6 mg/kg for 2.3 months.

Among the 22.2% of patients who received a second course of isotretinoin of four months or longer, 26.7% of patients demonstrated readmission at least six months after completion of the first course. Multivariable modeling revealed that female gender, age and cumulative dosage were associated with reduced isotretinoin recurrence rates.

Stratified analyzes showed that female gender was significantly associated with reduced isotretinoin repeat in both adolescents and adults. Higher cumulative dosage was associated with reduced acne relapse rates. Patients with conventional treatment and maximum daily doses of isotretinoin demonstrated lower rates of acne relapse than patients with low maximum daily doses.

Conclusions

Study results indicate that a daily dose of isotretinoin was not associated with a significant decrease in the risks of acne recurrence or isotretinoin recurrence rates in individuals on conventional and high cumulative doses. However, a higher cumulative dosage of isotretinoin may potentially reduce the risk of acne recurrence and isotretinoin recurrence rates.

Future research is needed to formulate optimized strategies to prevent acne relapse in high-risk individuals.

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