Acne is common among adolescents and adults. Guidelines for treatment of acne were last published by the American Academy of Dermatology in 2016.

Acne is common among adolescents and young adults, but its prevalence appears to have increased in people of all ages due to prolonged wearing of masks during the COVID-19 pandemic. Guidelines for treatment of acne were last published in 2016.

Our article earlier this year on Drugs for Acne1 stated that the oral retinoid isotretinoin (Accutane, and others) is the most effective drug available for patients with severe nodulocystic acne, but warned that depression, suicidality, myalgia, hypertriglyceridemia, and other adverse effects can occur. One of our readers objected to our listing depression and suicidality, which are the subject of a prominent warning in the package insert, in the same sentence as indisputable side effects such as hyperlipidemia and myalgia.

Depression and suicidal ideation have been reported in patients with severe acne after starting treatment with isotretinoin, including some cases in which symptoms resolved after discontinuation of the drug and reappeared after rechallenge.2 A cause-and-effect relationship has not been established, however, and acne itself is associated with symptoms of anxiety and depression.

Two large population-based cohort studies conducted in Canada and the UK found no evidence that treatment of acne with isotretinoin was associated with an increased risk of depression, suicide, or other psychiatric adverse effects.3 In a small US cohort study in 132 patients 12-19 years old with moderate to severe acne, use of isotretinoin did not increase depressive symptoms compared to use of topical drugs and oral antibiotics, and treatment of acne appeared to decrease symptoms of depression.4 A prospective, observational study in 346 patients ≥16 years old with moderate acne found that treatment with isotretinoin for 30 weeks reduced symptoms of anxiety and depression.5 Other studies have reached similar conclusions.

1. Drugs for acne. Med Lett Drugs Ther 2016; 58:13.
2. JD Bremner et al. Retinoic acid and affective disorders: the evidence for an association. J Clin Psychiatry 2012; 73:37.
3. SS Jick et al. Isotretinoin use and risk of depression, psychotic symptoms, suicide, and attempted suicide. Arch Dermatol 2000; 136:1231.
4. CY Chia et al. Isotretinoin therapy and mood changes in adolescents with moderate to severe acne: a cohort study. Arch Dermatol 2005; 141:557.
5. SE Marron et al. Anxiety, depression, quality of life and patient satisfaction in acne patients treated with oral isotretinoin. Acta Derm Venereol 2013; 93:701.

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The pathogenesis of acne is multifactorial: follicular hyperkeratinization, bacteria, sebum production, androgens, and inflammation all play a role. The gram-positive microaerophilic bacteria Propionibacterium acnes promotes development of acne lesions by secreting chemotactic factors that attract leukocytes to the follicle, causing inflammation.

The oral retinoid isotretinoin (Accutane, and others) is the most effective drug available for treatment of acne.1 The FDA has recently approved a new oral isotretinoin product (Absorica – Cipher/Ranbaxy) for treatment of severe, recalcitrant nodular acne.

Isotretinoin can completely clear severe nodulocystic lesions, in some cases leading to remission that can persist for years after treatment is stopped. Mucocutaneous adverse effects include dry skin, dry eye, epistaxis, nasopharyngitis, cheilitis, alopecia, eczema, skin fragility and photosensitivity. Musculoskeletal symptoms, hypertriglyceridemia, hepatitis, pancreatitis, pseudotumor cerebri, depression and psychosis can occur.

The manufacturer’s package insert states that isotretinoin has been associated with inflammatory bowel disease, but a recent population-based cohort study found no significant association.2 The drug is a potent human teratogen (pregnancy category X); the prescriber, the pharmacist, the distributors, and the patient must register with iPLEDGE, a computer-based risk management program (www.ipledgeprogram.com).

The recommended dosage is 0.5 to 1 mg/kg/day given in 2 divided doses for 15-20 weeks. Unlike other formulations of isotretinoin, which are highly lipophilic and must be taken with a high-fat meal to achieve therapeutic plasma levels, Absorica can be taken with or without food, but serum concentrations are higher when it is taken with food. It should be taken with a full glass of water to reduce the risk of esophageal irritation. Absorica has not been shown to be more effective or better tolerated than generic formulations of isotretinoin.

1. Drugs for acne, rosacea and psoriasis. Treat Guidel Med Lett 2013; 11:1.

2. RO Alhusayen et al. Isotretinoin use and the risk of inflammatory bowel disease: a population-based cohort study. J Invest Dermatol 2012 Oct 25 (epub).

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Many drugs can cause psychiatric symptoms, but a causal connection is often difficult to establish. Psychiatric symptoms that emerge during drug treatment could also be due to the underlying illness, previously unrecognized psychopathology, or psychosocial factors. The withdrawal of some drugs can cause symptoms such as anxiety, psychosis, delirium, agitation or depression.

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The pathogenesis of acne is multifactorial: follicular hyperkeratinization, bacteria, sebum production, androgens and inflammation all play a role. The gram-positive microaerophilic bacteria Propionibacterium acnes promote development of acne lesions by secreting chemotactic factors that attract leukocytes to the follicle, causing inflammation.

The pathogenesis of acne is multifactorial: follicular hyperkeratinization, Propionibacterium acnes bacteria, sebum production, androgens and inflammation have all been implicated. P. acnes, a gram-positive microaerophilic bacterium, plays an important role in the development of acne lesions by secreting chemotactic factors that attract leukocytes to the follicle, causing inflammation.

At a US Senate hearing prompted by the withdrawal of Vioxx, an FDA officer cited 5 drugs as potentially dangerous. It may be useful to revisit Medical Letter reviews of these drugs.

A high-intensity, narrow-band blue light (ClearLight -Lumenis) approved by the FDA for treatment of moderate inflammatory acne vulgaris has been featured in some stories in fashion magazines. This review describes the etiology and treatment of acne, as well as the mechanism of action, clinical studies, adverse effects, dosage and cost of the drug.

The tables in this article list drugs used for treatment of cancer in the USA and Canada and their major adverse effects. The choice of drugs in Table I is based on the opinions of Medical Letter consultants. Some drugs are listed for indications for which they have not been approved by the US Food and Drug Administration. In some cases, such as elderly patients or those with many co-morbid illnesses, the regimen of choice might not be suitable. For many of the cancers listed, surgery and/or radiation therapy may be the treatment of choice or may also be part of the management. Anticancer drugs and their adverse effects are listed in Table II on page 46. A partial list of brand names appears on page 52.

Isotretinoin (Accutane - Roche), an effective oral drug for treatment of acne, will soon be available generically. Concerns about its adverse effects, particularly psychiatric symptoms in adolescents, have been widely reported in the media.

Many drugs can cause psychiatric symptoms, but a causal connection is often difficult to establish. Psychiatric symptoms that emerge during drug treatment may also be due to the underlying illness, previously unrecognized psychopathology, or psychosocial factors. The withdrawal of some drugs can cause symptoms such as anxiety, psychosis, delirium, agitation or depression.

Tazarotene (taz ar' oh teen, Tazorac - Allergan), an acetylinic retinoid marketed for treatment of psoriasis (Medical Letter 1997; 39:105), is also available as a 0.1% gel and cream for treatment of acne.

The tables in this article list drugs used for treatment of cancer in the USA and Canada. The choices of drugs in Table 1 is based on the opinions of Medical Letter consultants. Some drugs are listed for indications for which they have not been approved by the US Food and Drug Administration. For many of the cancers listed, surgery and/or radiation therapy are also part of the management of the disease.

The tables that follow list drugs used for treatment of cancer in the USA and Canada and their major adverse effects. The choice of drugs in Table I is based on the opinions of Medical Letter consultants. Some drugs are listed for indications for which they have not been approved by the US Food and Drug Administration. For most of the cancers listed, surgery and/or radiation therapy are part of the management of the disease. Anticancer drugs and their adverse effects are listed in Table II.

Azelaic acid, a naturally occurring heptanedicarboxylic acid, has been marketed in the USA as a 20% cream (Azelex - Allergan) for treatment of acne. The drug has been available in Europe for several years.

Tretinoin (tret' i noyn; all-trans-retinoic acid; Retin-A), a derivative of vitamin A, has been used for years for topical treatment of acne. More recently, it has also been used to improve the appearance of skin damaged by chronic exposure to the sun, although not approved for this indication by the US Food and Drug Administration.

A topical formulation of 0.75% metronidazole gel (MetroGel - Curatek), an antibacterial, antiparasitic agent, was recently approved by the US Food and Drug Administration for treatment of rosacea.

Tretinoin (all-trans-retinoic acid; Retin-A), a vitamin A metabolite used for years for topical treatment of acne, is now being used (without the approval of the US Food and Drug Administration) to improve the appearance of aging skin. Available by prescription in various concentrations in cream, gel and liquid formulations, tretinoin is chemically similar to isotretinoin (13-cis-retinoic acid; Accutane), an oral drug used for treatment of severe acne which has recently caused concern because of its teratogenicity (Morbid Mortal Weekly Rep, 37:171, March 25, 1988).