PureWow recently wrote an article about the “Accutane nose” effect. Users on social media claim Accutane use can lead to a slimmer nose – a subtle nose job. For an expert’s perspective on use of isotretinoin in 2025, I reached out to San Diego dermatologist Neal Bhatia, MD, FAAD.
Have you heard about “Accutane nose” and what are your thoughts on it?
I can’t say I’ve heard of it. It sounds far-fetched. The only thing I can think of is, if the patient had a change similar to rhinophyma, could that be a potential reduction from the effect of it? Maybe that’s possible. We use isotretinoin in treating rhinophyma so maybe the impact on the pilosebaceous complex and change in stroma are what the patient is experiencing. The actual nasal tissue, structure, and the bones aren’t changing, so I can’t see how that’s improved.
What are other misconceptions about isotretinoin side effects?
Where to begin! There are a lot of things that happen from the mechanism of the drug as a type of retinoid that are to be expected, such as dryness, cheilitis, and muscle aches. To call these side effects is a misnomer because they are anticipated, and we counsel patients to be aware of them. At the same time, they are rarely dose-limiting and can be managed in multiple ways to maintain compliance with the course.
Everyone wants to find an issue with isotretinoin, but they don’t realize what a special drug it is. We’ve just come out of a pandemic where everyone had an issue with antibiotics, and the threshold of when we put patients on isotretinoin has significantly changed for the better. People want to complain but they don’t know what they DO want, and as a result they don’t get better. If people trust the right information, they will not delay a lot of care. I blame the parents more than the kids. Most of my obstructions are from mothers: the soccer moms who spend all day on the internet and they get nothing but misinformation. But there are a few fathers who are just as bad! In the end we as dermatologists get stuck playing defense, and we waste a lot of time while the kid ends up with more scarring and trouble with persistent acne.
What’s your recent experience in presenting isotretinoin as a treatment option to your acne patients?
There is more concern about and so much bashing of antibiotics than isotretinoin because of concerns over antibiotic resistance. We’re stuck with a whole bunch of negativities. That’s why everyone’s turning to direct-to-consumer portals. However, these customers aren’t getting anything of prescription grade, and it leaves them in the dust.
It’s like going to dinner with someone who doesn’t know what they do want, yet they know what they don’t want. They can’t order from the menu and when it comes time they usually order the wrong thing. The same issue happens in the clinic. The parents don’t want to listen to reason, their choices are often a mistake, and the result is detrimental to their kids. Hence the paradox with shared decision making.
It’s hard because we are living in an era of shared decision making and customer service in medicine. The problem is having the knowledge and the ability to make an objective decision. When it comes to social media knowledge vs. academic knowledge, where do you draw the line? When a patient comes in, they don’t come in with questions but opinions based on their search on the internet. This creates a defensive environment and delays outcomes.
How has the management of patients on isotretinoin changed over time?
Two of the biggest changes are with lab monitoring, which is cut down from monthly to twice over the course of treatment. The number of labs is also decreased as we only check triglycerides and ALT. The other change is the ease of using the iPLEDGE system. With management, we have new technologies in dosage with more favorable absorption that has really changed prescribing. We can prescribe isotretinoin at lower dosages that may be taken without food.
Which acne cases should a dermatology clinician consider isotretinoin as a treatment option?
My own threshold has changed for keeping patients on antibiotics. We are limited with the number of topical therapies that are covered by insurance, and this has changed prescribing habits. Isotretinoin works and at the right dosage for the right patient you can get them out of their own way when it comes to their acne.
What’s your advice to dermatology clinicians when addressing objections about isotretinoin?
I would let patients talk themselves in a corner. Then I would have printouts of all the potential misconceptions – irritable bowel disease, depression, and any other consequence. I would have those articles ready to provide to the parents or patient and say, “Whatever you’ve read, these are the facts.” You have to go back to who has the facts – a Google search or literature. As a dermatologist, you have to be up to date on literature, and that’s where the rubber meets the road. If you aren’t up to speed with what the patients will come in with regarding their own misconceptions and bad searches, it’s going to be a battle you aren’t going to win.
It comes back to the welfare of the patient. You would be amazed how many parents are the worst enemy for acne. I’ve seen mothers grab at their kids’ faces and pop their pimples. All you are doing is adding scars. Try to get the patients alone away from the parents. Tak about the impact of acne and scarring, and how aggressive they want to be. I talk to them and say, “You have one chance to make your face not full of scars when you’re 30. This is your one chance.” That tends to move things in the right direction.
Is there anything else dermatology clinicians should know about isotretinoin?
Don’t be afraid. We have good technology and dosage strategies. I would not be afraid to get patients on isotretinoin. I think we may want to save antibiotics for other things to reduce resistance. Especially with the trunk and cystic flares, we need to think about what to do to reduce scarring potential.
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