Vogue wrote an article about the ‘Hollywood Dose’ – microdosing isotretinoin for clearer skin. The concept of a reduced dose was once popular among models and actors who were looking for a flawless, glowing look. Yet dermatologists say prescribing isotretinoin at levels lower than the traditional dose can be beneficial for some everyday acne patients, too. Low-dose isotretinoin offers fewer and less severe side effects, though a longer course is needed for lasting results.
For an expert take on this prescribing practice, I interviewed Brooklyn, N.Y., dermatologist Hilary Baldwin, MD, FAAD. Dr. Baldwin will present on several medical dermatology topics at the upcoming ODAC Dermatology Conference, including the acne treatment landscape and integrating cosmeceuticals for barrier repair.
How common is the practice of microdosing isotretinoin? Is this just a celebrity trend or is this a valid approach for the everyday acne patient?
When I first heard the term, I thought it referred to the extremely low dose used for cosmetic purposes only by celebrities and models. Looking it up on the internet, I see that it refers to what acne experts call low dose, which has been a practice for many years for selected patients. True microdosing (10 mg 1-2X/week) is used to reduce oiliness of the skin, make pores less visible, and give an overall matte finish to the skin – it is not intended for acne as it would take many years to reach a dose that would be effective for acne.
Commenting on what I would call low dose (10-20 mg/day), this is common practice and a valid approach for some acne patients. This would include males, post-menopausal women, and any patient who is intolerant of regular dosing (.5-1 mg/kg or 30-60 mg/day for a 125 lb. person). Intolerance may be related to side effects like dry lips, eyes, or nose; joint pain; or laboratory abnormalities. Low dose greatly reduces the risk and severity of side effects. However, low doses will need to be combined with long duration of use to accomplish the promise of isotretinoin: durability of response. Isotretinoin doesn’t just make people better while they are taking it; it is the only acne medication that has the ability to actually cure acne. Eighty percent of patients finishing a course will never have acne again. It turns out that daily dose doesn’t matter as long as the course of treatment is not cut short. Cumulative dose is what is important; most of us aim for 120-150 mg/kg final dose before discontinuing. For example, 60 mg/day for 4 months provides the same likelihood of cure as 30 mg/day for 8 months or 10 mg for 24 months. When caring for a woman of child-bearing potential, 24 months of a potentially teratogenic drug is ill-advised.
Have you prescribed microdoses of isotretinoin and, if so, for which types of patients? What have been the results?
Long-term, low-dose isotretinoin is as effective as short-term, high dose with fewer side effects. When a low dose is taken for a short course, it will work while the drug is being taken, but the results will likely not be durable. I do not use isotretinoin for quick fixes, only for remission and when conventional treatments have failed.
How does the efficacy of microdosing isotretinoin compare with the results achieved by other acne therapies on the market?
If low dose is used long term so that the cumulative dose reaches around 120 mg/kg, it is as effective as regular dosing.
Isotretinoin’s side effects are well publicized. Is there any research on the impact of microdosing on side effect occurrence?
There will be less nuisance side effects like dry lips, eyes, or nose. In my experience, joint pain is also reduced. Lab abnormalities are less likely.
Taking any amount of isotretinoin requires a fair amount of paperwork and testing. Have you found microdosing patients willing to comply or are these barriers that lead them to pursue other therapies?
If patients have acne severe enough to warrant isotretinoin, no barriers are high enough to prevent its use. Honestly, if they think it is too much work, they are by definition not candidates.
Insurance coverage beyond the standard six-month course is another barrier. Have you found patients willing to pay out of pocket to microdose isotretinoin?
Few insurance companies actually stop therapy at the six-month mark. When they do, they will allow restart after two months off therapy. Many patients are willing to pay for the drug during the gap period.
What else should dermatology clinicians know about microdosing isotretinoin?
Don’t forget that conventional, food-dependent isotretinoin needs to be taken with a fatty meal. Food-dependent formulations are better for patients who are on a low-fat diet or have high lipids.
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