Isotretinoin Failure

This 20-year-old woman has a 6 month history of cystic acne.  Although she has been on isotretinoin for three month her response has been poor and she continues to develop new lesions.  She started on 40 mg of isotretinoin a day but her acne flared and she was dropped to 30 and then 20 mg per day.  Due to her acne flare on isotretinoin, prednisone was started at 40 mg bid (tapered after two weeks).  She is on a combined oral contraceptive but it only has 20 mcg of ethinyl estradiol and spironolactome 100 mg per day.  She was also placed on desloratadine 5 mg a day, but that did not appear to help either. She is feeling discouraged, and sees a therapist for anxiety and that led to a prescription for BuSpar from her therapist.

EXAMINATION:  The examination shows a pleasant, outgoing woman.  She has acne with inflammatory and cystic features on the cheeks and forehead.  Back and chest are clear although she did have some acne on her shoulders that has resolved.  Her weight is 65 kg.  There is no hirsuitism or striae.

Photos 8.5.21(aftr 12 weeks of isotretinoin)

IMPRESSION:  This 20-year-old woman with severe inflammatory cystic continues to have active lesions after 3 months months on isotretinoin.  Her acne worsened significantly after her first month of isotretinoin at 40 mg a day.    

 

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PLAN:  For the time being, we will continue prednisone at 20 mg a day for the next week and then drop, isotretinoin 20 mg a day, and continue spironolactone 100 mg a day.  I discussed with her either trimethoprim or Bactrim, but we are going to hold off on that, for the time being.    After a literature review,  an article about adding amoxicillin seemed promising.¹

          Questions:

1. At what point would you initiate a work-up for underlying endocrinopathy, such as Cushings?

2.  Have you treated similar patients who flared with isotretinoin and were difficult to control?

3. Have you had experience with adding amoxicillin in situations like this.

 

Reference:

Safety and effectiveness of amoxicillin in the treatment of inflammatory acne.  Guzman AK, Choi JK, James WD. Int J Womens Dermatol. 2018 Jun 8;4(3):174-175Free Full Text.
Comment from Dr. James:

Amoxicillin is a very good drug for acne. I would start at 500 mg tid, very few get any side effects other than of course possible drug eruption, but most have had penicillin in the past and know if they are allergic or not. At three months I would then go to bid. In the paper it was early in my using it, and I was giving it at lower doses, but I find higher dosing better and well tolerated.

You could also start at a lower dose with isotretinioin, sometimes with prednisone as well for the first three to six weeks, almost always tolerate it in this manner, but hard for those who have flared badly to want to take it again. Avoiding this bad flare is why when I use isotretinoin I start the first month at 20 mg per day, then increase. I have had to start at ten mg per day in some that have flared in the past, along with prednisone.