dramatic results with low dose accutane

From: Rdl000@_.com
Date: Wed May 16, 2001 6:33 pm

I must say that I am astonished (yes, astonished) with the impact low-dose accutane has had on reducing my rosacea symptoms.

I have had rosacea now for nearly 2.5 years. Symptoms are daily flushing and burning, always around mid-day, moderate background redness, some telangiectasia (throught to be mostly from sun damage), and relatively mild ocular rosacea characterized by bloodshot eyes. Over this time, I have tried the usual oral + topical antibiotics, antihistamines, beta blockers, TCAs, and, most recently, a 5-treatment photoderm series (using Bitter Sr protocol). None of these, including photoderm, has had anything resembling the impact that low-dose accutane has had. (See previous post for details on my photoderm experience.)

At any rate, I was quite intriqued by the discussion concerning accutane in Geoffrey’s book, in particular the fact that investigators have noted that accutane has

(1) resulted in a reduction of facial skin temperature by up to 1 degree C within 3 days of treatment,

(2) led to a 40 percent reduction in blood flow through the cheeks (as measured by laser doppler)

(3) eliminated facial burning in 18 patients within several weeks of taking accutane.

This last observation is contained in the paper: Efficacy of Low-Dose Isotretinoin in Patients With Treatment-Resistant Rosacea, (Archives of Dermatology, Vol. 134 No. 7, July 1998).

After reading this paper, I was convinced that it was worth trying another round of accutane. My derm had put me on 40-60 mg/day 6 months after I was diagnosed, and this high dosage really dried out my face, and increased the flushing and burning. I briefly tried low-dose accutane last summer, but did not pursue since I wanted to start the photoderm ASAP.

My first experiment was to initially take 40 mg/day and see what impact this would have, now that my rosacea symptoms have advanced since my initial experience nearly two years ago. I did this for 6 days, until I started to feel my face drying out, and then did not take any accutane for the following 7 days. Here is what I observed: at about day 3, the facial burning subsided quite noticeably, and I am certain this was due to the accutane. However, in the following days, as the plasma concentration of accutane increased, the burning returned, and indeed, for several days right after stopping accutane (when plasma concentration was presumably at its highest), my flushing and burning were essentially as bad as ever. Then, as the plasma concentration gradually decreased, I noticed a reduction in burning just as I had at day 3. Obvious conclusion is that there is a rather narrow range of plasma concentration that significantly reduces burning and flushing. Corollary is that typical weight-derived dosage produces concentrations that are way too high, and indeed leads to increased flushing.

So, after the 6 days at 40 mg/day, and the 7 days off, I began taking 20 mg of accutane every two days. This 10 mg/day is precisely the dosage given to the 22 participants in the study in the above reference. (These people were selected because they had rosacea for mean time of 6 years, and nothing else had worked.). I am now 20 days into this dosage, and I am seeing reduced redness each day. The daily facial burning is completely gone, and my face feels remarkably cooler even during my normal daily flush cycles. For first time in longer than I can remember, my face actually feels normal throughout the day, with maybe some slight tingling if I am concentrating really hard (my flushing appears to be sns-mediated, and flushing during mental calculation is typical of this). This dwarfs any minor improvement I had seen as result of the photoderm. The bottom line is that I am seeing exactly what had been reported in literature: a substantial cooling of the facial skin, and complete elimination of the incessant daily burning.

Two other observations: my ocular rosacea has also improved in that my eyes are much less bloodshot, presumably due to reduced flushing. And, again due to decreased flushing, my telangiectasia are much less prominent. This improvement is much more pronounced than that achieved via 5 photoderm treatments.

I strongly believe that the key is to find one’s personal “sweetspot” in terms of accutane dosage and hence corresponding plasma concentration to achieve optimal reduction of rosacea symptoms. One way is to increase dosage to point that your lips are just a little dry (nothing that can’t be contained with a good chapstick …), but face does not feel unusually dry. The weight-derived dosage that derms prescribe for cystic acne is WAY off this optimal point. Even Singer’s 1998 review paper on drug therapy for rosacea says that accutane should be administered at 0.5 mg/day per kg of body weight, which is still 35 mg/day for 150 lb individual. (Personal note: I am 6 ft 5 inches tall and weigh 200 lbs - this would be 45 mg/day for me.)

BTW, one reason I started accutane now is that my rosacea was progressing to point of getting a few bumps. Accutane stopped these immediately, as documented in above reference as well as essentially all other accutane studies. If you have any bumps when you start accutane, they will heal slower than usual since accutane, in course of shutting down sebaceous glands, does delay healing, which is why you need to be off it prior to photoderm or laser treatments.

As for accutane side effects, my take is that these are only an issue at standard dosages, except that it is very clear that women must never get pregnant on ANY dose of accutane. A leading rosacea researcher even mentioned to me in a private communication that he does not do usual blood work at low dosages, and indeed feels long-term, low-dose accutane treatment is safer than long-term use of systemic antibiotics. I plan to continue current regimen for at least 6 months, and possibly a year depending how it goes. There is evidence that symptoms remain in remission after accutane is stopped.

Accutane is indeed an astonishingly effective drug for treating nearly all rosacea symptoms. (Its effectiveness on acne is why the Am Derm Society has fought the FDA’s attempts to much more tightly regulate accutane prescriptions.) In the final analysis, it is the only thing that has produced significant improvement for me. As Heidi has observed, it may be difficult to convince your derm to prescribe accutane if you are woman of child-bearing age, particulary if your symptoms are relatively mild. In this case, you may have to agree to do standard oral antibiotics + Noritate for a couple of months before derm agrees to accutane. But you might have some success in this argument if you show your derm the above paper, and argue that side effects (with obvious exception of impact on pregnancy) at this low dosage are MUCH reduced relative to those reported at the much higher dosages (up to 100 mg/day) for acne treatment.

Rick

---

From: Rdl000@_.com
Date: Thu May 17, 2001 4:06 am
Subject: Re: Dramatic results with accutaneHi,Although isotretinoin (accutane) and tretinoin (e.g. Retina-A) are similar chemically, tropical tretinoin is strictly off-limits for rosaceans because it increases erythema and accelerates formation of telangiectasias. You may be referring to the article by Ertl etal, which was roundly criticized by Wilkin for the above reasons.

Rick

---

From: Rdl000@_.com
Date: Thu May 17, 2001 2:08 am
Subject: Re: Dramatic results with accutane

Jim,

Actually, I think low-dose accutane, tuned to individual response, is likely to help a very large number of resistant cases.A major trigger for me is daily stress, not so much from meetings and presentations, but just working hard in my office. I still feel a flush kind of coming on, but (a) my face feels MUCH cooler to touch, and (b) if I look in mirror, I am amazed at how little red I am showing even though my system is “trying to flush”.Probably my biggest trigger is driving home in car after full day of skiing in cold Northeast. Too late in year to test that one, but I have wondered myself if it will mitigate this as well. I think there is a chance, given points in my original post concerning lower facial temperatures and reduced facial blood flow as result of accutane.Related comment: if I am in cynical mood about photoderm (which I am), why is it that photoderm “researchers” (term used loosely here) have never published laser doppler measurements of facial blood flow to document claims of reduced flushing after photoderm? Peter Drummond, who studies sns-mediated flushing, routinely uses this technique, as did the authors of the aforementioned study on accutane.

Best,
Rick

— In rosacea-support@_.> wrote:

Hi Rick,

Thanks for relating this. It is likely to help some members. When you are on the low dose accutane, how do your flushing symptoms respond when you are exposed to such triggers as exercise and heat?

Sincerely,
Jim

Related Articles:

• long term accutane experience from Rick
• focus on low-dose accutane
• long term extra low dose accutane
• accutane and pregnancy
• accutane and matrix metalloproteinases (MMP)
• treating rhinophyma with accutane (roaccutane, isotretinoin)
• Accutane moisturizer sunscreen
• Rosacea & Accutane Roaccutane Low-Dose May Clear Resistant Rosacea

Read more about rosacea and accutane.