Accutane side effects and how to avoid them

Accutane side effects include joint pain, weight loss, and sun sensitivity

By Kristi C. Torres, Pharm.D. | Sep. 20, 2023

Accutane (isotretinoin) is a prescription medication in the class of oral retinoids. It is indicated in the treatment of nodular acne that is resistant to other forms of treatment. Accutane is not a first-line treatment for acne. Your healthcare provider will try other medications to treat your acne, alone or in combination. You may try several oral and topical acne treatment options before Accutane is deemed appropriate for your severe acne.

Accutane works by reducing sebum production on the surface of the skin. Sebum is the medical term for the oily secretions that occur on the skin. Sebum is known to clog pores and hold onto bacteria on the skin’s surface. This propagates the formation of nodular acne.

When is it appropriate to use Accutane? There are a few different factors to this. First, Accutane is approved for the treatment of a particular type of acne. The acne must consist of multiple nodular lesions where the lesions are 5mm in diameter or more. Patients must be at least 12 years old and verified not pregnant. Female patients must have a negative pregnancy test before filling each 30-day prescription. This is verified and tracked via a risk evaluation and mitigation strategies (REMS) system known as iPLEDGE that is accessed by prescribers and pharmacies. Females must also agree to utilize a form of contraception while on Accutane or its generic products. It is important that a female patient does not conceive while taking Accutane, as there is a risk of significant birth defects.

Prior to the initiation of Accutane, patients will try other types of therapy to avoid the potential for serious side effects if possible. Benzoyl peroxide and salicylic acid are two common over-the-counter topical products that many acne patients try first. These can be found in washes, gels, creams, or medicated pads for application. There are also topical retinoid creams such as Differin (adapalene) and Retin-A (tretinoin). There are a variety of oral antibiotics appropriate for acne treatment as well. Vibramycin (doxycycline), EES (erythromycin), and Bactrim DS (trimethoprim/sulfamethoxazole) are each recommended as options by the American Academy of Dermatology. If these options or a combination are unsuccessful, your prescriber may deem Accutane an appropriate option.

Common side effects of Accutane

The most common and frequently occurring side effects of Accutane are back pain, high triglycerides (hypertriglyceridemia), and arthralgia. Each of these occurs in more than 1 in 5 patients who take Accutane, according to the manufacturer.

Other adverse events associated with Accutane include:

Musculoskeletal pain (joint pain)
Elevated hepatic enzymes (liver enzymes)
Hypercholesterolemia
Weight loss
Hair loss
Vomiting
Weakness
Xerostomia (dry mouth)
Xerosis (dry skin)
Xerophthalmia (dry eyes)
Sun sensitivity
Nose bleeds

Serious side effects of Accutane

Teratogenesis (severe birth defects)
Visual impairment
Toxic epidermal necrolysis
Suicidal ideation
Stroke
Stevens-Johnson Syndrome
Spontaneous fetal abortion
Seizures
Retinal hemorrhage
Proteinuria
Pancreatitis
Night blindness

Accutane and hair loss

While hair loss is not one of the most commonly occurring adverse events with Accutane use, it can be one of the more bothersome possible side effects for those in which it occurs. A recent retrospective review study found a very low incidence of hair loss associated with Accutane overall. The range of patients who experience hair loss is estimated to be between 0.28% and 12%. There are many other factors to hair loss that make it difficult to ascertain what hair loss would be attributable to Accutane use versus other external factors. However, in those where alopecia (hair loss) occurred, it tended to be in patients who were older at the time of treatment, had higher cumulative doses of isotretinoin, and had longer durations of isotretinoin treatment. Unfortunately, even if you stop Accutane, the hair loss may continue.

Accutane and depression

You may have heard that the use of Accutane is associated with the induction of depression or with higher rates of depression. In fact, many published studies do not support this association at all. Patients with acne have higher rates of depression regardless of the type of treatment they are taking. Actually, there is data to support that symptoms of depression and overall mental health improve with Accutane. This could be related to the negative social aspects of the presence of acne and how that affects a person’s self-esteem. As they feel better about their skin and outward appearance, this could have a positive effect on the symptoms of depression.

Due to the association of acne and depression, your doctor may inquire about any history of mental health problems with you or your close family before prescribing brand-name Accutane.

Accutane and weight gain

Accutane has been shown to be associated with insulin resistance. This incidence is typically associated with an induction of diabetes and weight gain. However, data does not show that active Accutane treatment is linked to an increase in body mass index (BMI) anymore or less than other non-retinoid treatments for acne. There may be a risk for latent diabetes related to insulin resistance, which is masked by Accutane treatment and no gain in weight. Some patients may even lose weight. Once Accutane is stopped, patients with pre-existing risk factors may experience weight gain and symptoms of diabetes, as Accutane may increase blood sugar.

How soon do Accutane side effects start?

The side effects of isotretinoin products may be apparent within one to two weeks of starting treatment. Dry lips and dry skin are typically some of the first symptoms to appear. It is important to note that for many patients, the acne itself may actually worsen for the first one to two months of treatment before it starts to improve. This is related to the process of inhibiting sebum production and initial changes to the skin’s surface.

How long do Accutane side effects last?

Accutane side effects can occur throughout the duration of treatment. Typically, treatment lasts 4-5 months, though it may be longer or shorter depending on your acne case and your provider.

What are the long-term side effects of Accutane?

When taken according to approved packaging instructions, Accutane and its generics have no serious long-term effects on the patient being treated. Dry skin, specifically the lips, may persist for quite some time while on Accutane and following treatment. This should be mitigated using skin moisturizer and lip moisturizer to prevent skin breaks and subsequent infections that may become troublesome.

Birth defects associated with Accutane use during pregnancy can cause permanent disability or disfigurement of the child.

Accutane contraindications

Accutane is mandated to have a boxed warning by the Food and Drug Administration (FDA) and absolutely can not be used by patients who are pregnant or may become pregnant. You must agree to use one of the approved forms of birth control while taking Accutane. If you are female, your prescriber will require a negative pregnancy test result prior to releasing each month’s prescription. Your pharmacy is also required to verify these results before dispensing the medication. This is all recorded in the REMS program known as iPLEDGE. Your healthcare provider is not allowed to prescribe Accutane without registering and participating in this program. This REMS program is utilized for Accutane, its generics, and all other branded forms of isotretinoin. Isotretinoin capsules are marketed under the following names in addition to Accutane:

Absorica
Amnesteem
Claravis
Myorisan
Sotret
Zenatane

If pregnancy occurs while being treated with one of these products, the medication should be stopped immediately, and the patient should be referred to an obstetrics or gynecology provider (OB-GYN) for counseling. You should also not start Accutane if you are breastfeeding.

Accutane warnings

Accutane contains several warnings related to its use in addition to the contraindications listed above. While these warnings do not mean you can not take Accutane, your prescriber should monitor you very closely for these adverse events. It is important to check in with your doctor regularly to discuss them and seek medical advice when you have concerns or think the use of isotretinoin is causing an allergic reaction.

WARNING	DETAILS
Psychiatric disorders	The manufacturer warns that Accutane may cause depression, psychosis, and rarely suicidal ideation. If signs of these disorders become present or worsen, notify your prescriber immediately.
Pseudotumor cerebri	Accutane has been associated with some cases of benign intracranial hypertension (pseudotumor cerebri). This appears to be related to the concurrent use of tetracycline antibiotics, and therefore the use of tetracyclines while on Accutane should be avoided.
Skin reactions	There is a small chance of more serious skin reactions to the use of Accutane. Erythema multiforme can occur and presents as extreme redness and swelling, often in the face. More serious reactions, such as Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN), can occur.
Pancreatitis	Acute pancreatitis is a risk with Accutane treatment. This is an increased risk with higher triglyceride levels. If triglyceride levels can not be controlled while taking Accutane, you may not be able to continue treatment, especially once symptoms of pancreatitis occur.
Lipids	Elevated triglycerides can happen in as many as one in every four patients who take Accutane. Your doctor may do regular blood work to monitor your cholesterol.
Hearing impairment	We don’t fully understand why, but Accutane has been linked to hearing impairment and tinnitus (ringing in the ear). If you notice your hearing is abnormal, you should consult your physician immediately. Hearing impairment may persist even after you stop Accutane.
Hepatotoxicity	Mild to moderate elevations in liver enzymes have been reported in patients taking Accutane. If liver enzymes do not normalize in a timely fashion, your prescriber will likely stop Accutane and do more tests.
Inflammatory Bowel Disease (IBS)	Symptoms associated with IBS, such as abdominal pain, rectal bleeding, and diarrhea, can occur in patients on Accutane and may persist even after discontinuing therapy.
Skeletal	Accutane may be linked to lower bone mineral density and leave patients at a higher risk of bone fractures, osteoporosis, and delayed bone healing.
Vision impairment	Decreased night vision, or night blindness, as well as other visual impairments, can occur with Accutane. You should stop Accutane immediately if they do and consult an ophthalmologist.

According to the FDA, There are no active recalls for Accutane or any related isotretinoin products. Accutane is not a controlled substance but must be dispensed in accordance with the REMS guidelines. It is not habit-forming.

Accutane should be administered for up to 20 weeks or until 70% of the acne has cleared, whichever comes first. Doses are typically guided by the patient’s weight. Children are dosed at 0.5 mg to 1 mg per kg of body weight daily. Adults are dosed up to 2 mg per kg per day. This is often divided into two daily doses.

Accutane interactions

These specific drugs should not be taken with Accutane as they have a high risk for severe interactions, including impaired drug absorption, ototoxicity, and intracranial hypertension:

Amikacin
Demeclocycline
Doxycycline
Eravacycline
Gentamicin
Minocycline
Neomycin
Streptomycin
Tetracycline
Tobramycin

Other types of drugs that should be used cautiously when taking Accutane include:

Vitamin A oral and topical products: May cause additive toxic effects as Accutane is a retinoid as well.
Progesterone products (including oral contraceptives): Dosing must account for the potential of deceased absorption of the hormone.
Phenytoin: May increase bone loss.
Corticosteroids: Additive effect of the risk of osteoporosis.

How to avoid Accutane side effects

Accutane should be taken every day unless your prescriber instructs you to stop. Missing doses could prolong your acne treatment and lower your chances of success with treatment. You may take Accutane for up to 20 weeks or until 70% of your acne has cleared. Accutane can be taken with or without food and is typically dosed twice daily in the morning and evening. Accutane can be taken by anyone over 12 years of age.

Many side effects of Accutane can not be avoided. Still, it is important to monitor for the more serious adverse events and interactions listed above and discuss with your prescriber immediately if they occur. You should not do any skin waxing while taking Accutane. This can be very painful and leave you at risk for a more severe skin reaction.

How to treat side effects of Accutane

Dry lips, eyes, and skin are normal and expected side effects of Accutane. Utilizing oil-free moisturizers and lip balm consistently will help make these more tolerable. Using sunscreen and avoiding sun exposure is important to avoid serious sunburns.

Ensure you comply with instructions from your prescriber, such as getting blood labs drawn regularly. This is important for them to look for hypertriglyceridemia or elevated liver enzymes. If you experience more serious side effects such as worsening depression, suicidal thoughts, visual changes, hearing impairment, or stomach pain, consult your healthcare professional immediately.