it's the NHS, was referred from GP, I'm late 20s, doctor was same age or younger and has literally just finished training. I've had acne for over 15 years having tried every antib known to man for years without any results, for the last few years it's mostly mild on my face and back though often with a bit of cystic nodular acne and suspectible to the occasional severe breakout. Very psychologically damaging.
I found the young derm's bedside manner to be rude, abrasive and overly inquisitorial e.g. by openly downplaying the extent of my acne based on what was seen on that day and was asked don't I have any photos to prove how bad it gets etc in a way which made me feel like nothing I said would be fully believed.
Secondly I have concerns re my dose; there was no dialogue over the proposed length of the course, the cumulative dose etc.; i was weighed at 80kg and was handed a prescription for 20mg for 8 weeks and told we'll see how it goes from there. Is this common fromyour experiences? My concern is that an inexperienced derm doesn't want to take the slightest risk with a patient who looks to have mild acne (but doesn't) - thereby putting me on a baby dose throughout the cycle without sufficient mind to the cumulative, meaning it will come back a year or two after the cycle possibly prompting another one down the line and far more damage to my health than I would have had in one cycle. It's been over a month and I haven't had the slightest side effect, e.g. dry lips or skin.
On 12/2/2015, 505, corbone said:it's the NHS, was referred from GP, I'm late 20s, doctor was same age or younger and has literally just finished training. I've had acne for over 15 years having tried every antib known to man for years without any results, for the last few years it's mostly mild on my face and back though often with a bit of cystic nodular acne and suspectible to the occasional severe breakout. Very psychologically damaging.
I found the young derm's bedside manner to be rude, abrasive and overly inquisitorial e.g. by openly downplaying the extent of my acne based on what was seen on that day and was asked don't I have any photos to prove how bad it gets etc in a way which made me feel like nothing I said would be fully believed.
Secondly I have concerns re my dose; there was no dialogue over the proposed length of the course, the cumulative dose etc.; i was weighed at 80kg and was handed a prescription for 20mg for 8 weeks and told we'll see how it goes from there. Is this common fromyour experiences? My concern is that an inexperienced derm doesn't want to take the slightest risk with a patient who looks to have mild acne (but doesn't) - thereby putting me on a baby dose throughout the cycle without sufficient mind to the cumulative, meaning it will come back a year or two after the cycle possibly prompting another one down the line and far more damage to my health than I would have had in one cycle. It's been over a month and I haven't had the slightest side effect, e.g. dry lips or skin.
He is just doing his job. Given the risks associated with the drug he is hesitant in the prescription for someone who has no active acne. I have thought about this when going to my Derm. I can go a week or two without a single pimple, but then I have weeks where I can get big cystic nodules all at once. I have been on accutane before so I know the procedure.
Being on 20mg isnt a bad thing at all, there are a ton or studies done that 20mg is just as effective as the higher dose with alot less side effects, and given your type of acne I would think it would be the way to go. I personally want my next course to be a 20mg course.
There also is alot of speculation about the whole accumulative dose theory. It isnt proven, and there is also alot of studies saying that it is BS. If this course doesnt work, you can always go on another course for longer. Accutane isnt something that you can only take once and if you mess up the dose your SOL. The chances of side effects dont increase with taking it multiple times, every time you take it, its like talking it for the first time.
At least from what ive read and what my derm told me.
On 07/12/2015, 2125, Jones4545 said:
He is just doing his job. Given the risks associated with the drug he is hesitant in the prescription for someone who has no active acne. I have thought about this when going to my Derm. I can go a week or two without a single pimple, but then I have weeks where I can get big cystic nodules all at once. I have been on accutane before so I know the procedure.
Being on 20mg isnt a bad thing at all, there are a ton or studies done that 20mg is just as effective as the higher dose with alot less side effects, and given your type of acne I would think it would be the way to go. I personally want my next course to be a 20mg course.
There also is alot of speculation about the whole accumulative dose theory. It isnt proven, and there is also alot of studies saying that it is BS. If this course doesnt work, you can always go on another course for longer. Accutane isnt something that you can only take once and if you mess up the dose your SOL. The chances of side effects dont increase with taking it multiple times, every time you take it, its like talking it for the first time.
At least from what ive read and what my derm told me.
I disagree strongly. There's a lot of evidence re the cumulative dose. There aren't studies showing it is "BS" in any way.The studies show time and time...and time again that the higher the cumulative dose, the lower the relapse rate. There are studies which show that a low dose is as effective as a higher dose in terms of clearance and at the same time produces less sides - for the avoidance of doubt, this has nothing to do with permanent remission, the course needs to be longer to reach the necessary cumulative dose.There are studies which show that cases of severe acne may require a higher cumulative dose to prevent relapse than mild acne.
Ultimately the total dose will have to depend on a number of factors specific to the individual and that is the flaw of the studies,but to say that there isn't a link between cumulative dose and remission is against the evidence we have and, although a well-meaning comment from you, a potentiallyharmful and damaging statement to make. Because it's a serious drug with serious consequences; a course for 6 months at best probably will bring about some long-term liver damage, whether you notice it or not - if the acne comes back a year or two after the course, you've played roulette with your health, and going on another course thereafter again adds to the dangers pretty substantially.
20mg is a fine, and probably optimal, starting dose for many people, however obviously not for me. Extrapolating what you want to be on for my dose is irrelevant. I weigh 80kg, it's not just severity of the acne which is taken into account. The other fact is that the derm will have to take into account sides/effects i've experienced whilst on the drug at the next appointment. It is pretty rare for a patient not to experience any side effects or effects to speak of at all - that is, unlike 99.9% of people on this, I have no dry skin or lips, my skin has been completely normal for me, spots come and go, I don't feel the dose...because for me...it is a baby dose, and obviously will have to put up at the next appointment, so I guess it's a moot discussion at the end of the day. The fact that there was no discussion over the desired dose/course length is obviously concerning and I'm going to have to fight to get it put up; the derm is mid 20s (?), literally fresh out of med school, and has been licensed to conduct these appointments for a couple of months,and has no experience to speak of with the drug and so has been and will be overly conservative. If I had gone privately and had seen any derm who had 5 years plus experience I probably would have had no concerns whatsoever. You have to understand, I'm not crazy, I don't want a high dose, I want as low a dose as possible to reach the cumulative; putting me on 40mg, 0.5mg/kg, would have been sensible and I could have stayed there for the majority of the course, unless the last 8 weeks on say 60mg at most, and I would have reached the cumulative. Because I've been dosed at 20mg for 8 weeks, it's going to be much harder getting there in 6 months, and I'm going to have spend more time at 60mg to get there, which I don't want to do for obvious reasons pertaining to side effects.
Definitely express your concerns at the next appt. you're pretty much stuck with that derm unless you're willing to go private so speak up, bring studies if you can and ask for hi reasoning behind dosage. I think starting at a lower dose is a good idea as to not shock your body.
On December 8, 2015 at 1114 PM, corbone said:
I disagree strongly. There's a lot of evidence re the cumulative dose. There aren't studies showing it is "BS" in any way.The studies show time and time...and time again that the higher the cumulative dose, the lower the relapse rate. There are studies which show that a low dose is as effective as a higher dose in terms of clearance and at the same time produces less sides - for the avoidance of doubt, this has nothing to do with permanent remission, the course needs to be longer to reach the necessary cumulative dose.There are studies which show that cases of severe acne may require a higher cumulative dose to prevent relapse than mild acne.
Ultimately the total dose will have to depend on a number of factors specific to the individual and that is the flaw of the studies,but to say that there isn't a link between cumulative dose and remission is against the evidence we have and, although a well-meaning comment from you, a potentiallyharmful and damaging statement to make. Because it's a serious drug with serious consequences; a course for 6 months at best probably will bring about some long-term liver damage, whether you notice it or not - if the acne comes back a year or two after the course, you've played roulette with your health, and going on another course thereafter again adds to the dangers pretty substantially.
20mg is a fine, and probably optimal, starting dose for many people, however obviously not for me. Extrapolating what you want to be on for my dose is irrelevant. I weigh 80kg, it's not just severity of the acne which is taken into account. The other fact is that the derm will have to take into account sides/effects i've experienced whilst on the drug at the next appointment. It is pretty rare for a patient not to experience any side effects or effects to speak of at all - that is, unlike 99.9% of people on this, I have no dry skin or lips, my skin has been completely normal for me, spots come and go, I don't feel the dose...because for me...it is a baby dose, and obviously will have to put up at the next appointment, so I guess it's a moot discussion at the end of the day. The fact that there was no discussion over the desired dose/course length is obviously concerning and I'm going to have to fight to get it put up; the derm is mid 20s (?), literally fresh out of med school, and has been licensed to conduct these appointments for a couple of months,and has no experience to speak of with the drug and so has been and will be overly conservative. If I had gone privately and had seen any derm who had 5 years plus experience I probably would have had no concerns whatsoever. You have to understand, I'm not crazy, I don't want a high dose, I want as low a dose as possible to reach the cumulative; putting me on 40mg, 0.5mg/kg, would have been sensible and I could have stayed there for the majority of the course, unless the last 8 weeks on say 60mg at most, and I would have reached the cumulative. Because I've been dosed at 20mg for 8 weeks, it's going to be much harder getting there in 6 months, and I'm going to have spend more time at 60mg to get there, which I don't want to do for obvious reasons pertaining to side effects.
talk with your derm, give him the benefit of the doubt.I know you think you know what you're talking about, but you are trying to say you know more about one of the most prescribed acne medication, than a board cert derm. That is crazy. If he was a GP, I would say you're probably right. Don't post questions on threads like this if you aren't willing to consider others views. You might be the one who is wrong.
9 hours ago, Jones4545 said:
talk with your derm, give him the benefit of the doubt.I know you think you know what you're talking about, but you are trying to say you know more about one of the most prescribed acne medication, than a board cert derm. That is crazy. If he was a GP, I would say you're probably right. Don't post questions on threads like this if you aren't willing to consider others views. You might be the one who is wrong.
No, I'm saying I know more than you. Much more. Aderm wouldn't argue re cumulative dose or that it was a very low/baby dose for me- having to argue these points is really frustrating because they are indisputable. Ifind your posts rather annoying because they arebanal and picking fault with reasonable things I am saying - if you wanted to respond to me, you might say i) suggest ways of going to another derm, ii) talking to the derm's supervisor, iii) suggesting ways to diplomatically get a higher dose iv) structure the period in a way to successfully get the correct cumulative dose v) suggest spending time at the higher dose of 60mg won't be so bad and that it's worth finding out how i react to 20mg first, vi) suggest that my IB will be better/avoided on the lower dose...among others...your response of "your wrong wibble wibble mibble mibble" is smackable.
However, Iam questioning the competence of a derm younger than me. I've had acne for 15 years, and have read about isotretinoinfor at least 10. I also have a degree in medicine, so what?The drug is barely covered. I hate to pull the "i know more than you" line, but it's pretty obvious from everything i've said that i know what i'm talking about.To become a derm in the UK, she has taken some further exams and passed some extra time doing core training - she has zero experience prescribing the drug and dealing properly with patients, that's the problem with very junior doctors but they have to learn somehow.I lived with people taking these multiple choice exams, the drug is featured but there's a hell of a lot more to dermatology than accutane. In the NHS, aderm in practice, outside exam time,knows the fact sheet they hand out and a little bit more, but not much more. They know the factors involved in prescribing a dose -it's guesswork. The NHS operates certain guidelines whichis supervised by a team leader, an experienced derm;there is a framework they operate under with the starting dose almost always 20-40, usually 0.5mg/kg, typically they won't go higher as a starting dose. And then will check bloodwork again after 4-8 weeks, usually they will recall the patient after 4 to up the dose; so EVEN if she had started me on 20, she could have recalled me after 4 weeks and upped it to 40mg for another 6-8 weeks. The NHSusually never go higher than 80mg a day at any point in the cycle. So yeah, I know the framework she is operating under, I've largely summed it up. She has gone as low as they go for the longest time period which considering my bodyweight and acne IS unreasonable given the guidelines she is supposed to be using.
I won't respond to you again.
On 12/10/2015, 524, corbone said:
No, I'm saying I know more than you. Much more. Aderm wouldn't argue re cumulative dose or that it was a very low/baby dose for me- having to argue these points is really frustrating because they are indisputable. Ifind your posts rather annoying because they arebanal and picking fault with reasonable things I am saying - if you wanted to respond to me, you might say i) suggest ways of going to another derm, ii) talking to the derm's supervisor, iii) suggesting ways to diplomatically get a higher dose iv) structure the period in a way to successfully get the correct cumulative dose v) suggest spending time at the higher dose of 60mg won't be so bad and that it's worth finding out how i react to 20mg first, vi) suggest that my IB will be better/avoided on the lower dose...among others...your response of "your wrong wibble wibble mibble mibble" is smackable.
However, Iam questioning the competence of a derm younger than me. I've had acne for 15 years, and have read about isotretinoinfor at least 10. I also have a degree in medicine, so what?The drug is barely covered. I hate to pull the "i know more than you" line, but it's pretty obvious from everything i've said that i know what i'm talking about.To become a derm in the UK, she has taken some further exams and passed some extra time doing core training - she has zero experience prescribing the drug and dealing properly with patients, that's the problem with very junior doctors but they have to learn somehow.I lived with people taking these multiple choice exams, the drug is featured but there's a hell of a lot more to dermatology than accutane. In the NHS, aderm in practice, outside exam time,knows the fact sheet they hand out and a little bit more, but not much more. They know the factors involved in prescribing a dose -it's guesswork. The NHS operates certain guidelines whichis supervised by a team leader, an experienced derm;there is a framework they operate under with the starting dose almost always 20-40, usually 0.5mg/kg, typically they won't go higher as a starting dose. And then will check bloodwork again after 4-8 weeks, usually they will recall the patient after 4 to up the dose; so EVEN if she had started me on 20, she could have recalled me after 4 weeks and upped it to 40mg for another 6-8 weeks. The NHSusually never go higher than 80mg a day at any point in the cycle. So yeah, I know the framework she is operating under, I've largely summed it up. She has gone as low as they go for the longest time period which considering my bodyweight and acne IS unreasonable given the guidelines she is supposed to be using.
I won't respond to you again.
All I can do is laugh at this point. Ive seen alot, but you are a first. Ive never seen someone post a discussion topic on a public forum, get mad with someones opinion, then tell them how they should have responded to your question. Why are you even here if you're so smart??
I havnt heard the, "I know more than you" card pulled since junior high, so it gives me an idea of your level of maturity. You have alot of growing up to do. Part of growing up is realizing that your opinion is only that, your opinion. Not right or wrong, and posting a discussion topic on a public forum is asking for other opinions, not for telling people how they should respond to you. Looks like you have some control issues and need to work on it.
Lastly, I will leave you with this, if the process of how the drug was used was indisputable, we would not be having this discussion. Your derm, who knows more than you, sorry to say. Is obviously disputing how accutane is used, if it was indusputable, he would look in his little acutane prescription book and give you the dose you think you should get, but he didn't. You can find on thousands of threads here of how people were prescribed to use the drug differently!!! If it was indisputable, everyone would take the exact same dose/per bw.
Good luck with your treatment, I for one was never disrespectful, but you chose to have every response be rude and disrespectful (also a sign of your maturity). I wish you the best.
On 16/12/2015, 1809, LeftRidingCropInMortuary said:Erm, in the NHS, it has to be a consultant who prescribes, not someone "fresh out of med school".
Does anyone post on this site who knows what they're talking about?!
She's a REGISTRAR not a consultant! She finished a 5 year med degree (like me), did 2 years training called foundation training which she finished this year. She is now a speciality registrarin a hospital. In 6 more years she will be a consultant. I said very specifically she was mid 20s, how could you honestly think she was a consultant?!
For the avoidance of doubt, I'm not a silly, angry person who argues with shopkeepers over small change. I've seen half a dozen GPs over the years for acne, they were all fine. The GP who referred me, first time I met him, had a pleasant engaging manner, knew about acne and the drug and had experience. I just had a problematic bad appointment with an inexperienced young girl who didn't know what she was doing beyond some basics, I was wondering if others had similar experiences - not really "oh well she's a derm and so everything she says is correct". A big part of being a doctor is making the patient have faith in you, the fact I have zero in this girl is a sign she messed up.
Corbone, for the avoidance of doubt, I don't actually give a fuckabout your spots or whether your derm kissed your ass enough. Do you think the world revolves round you? Why the fuck would you a (presumably failed) doctor ask randoms on the internet questions, get angry when they give the "wrong" answers and discuss "smacking" them?!
You are eitheran angry, frustrated, failed doctor yourself orcompletely deluded and you've only read "Medicine for Dummies" or some such.
You must be a nightmare patient! It's probably clear to your doctor that you are a know-it-all who would sue at the drop of a hat. You clearly have no respect for her - repeatedly referring to a professional woman as a "girl".
As I said before, only consultants can prescribe in the NHS see Government website:
In any event, I suspect it's a psychiatrist you need, not a dermatologist.
And by the way, your = possessive; you're = you are.
Now fuck off and squeeze your zits.
On 19/12/2015, 1742, LeftRidingCropInMortuary said:🙂
Just seen your helpful posts and have reported for abuse.
To be clear again, you are absolutely wrong - even the link you provided shows you are wrong. It reads a "consultant led team". I was seen by a registrar who prescribed the drug. She is part of a team in a hospital led by a consultant. She saw me. She prescribed the drug for me. She gave me the prescription. I picked up the drug. There was and will be absolutely no interaction with a consultant.
Talk about thick! Yes, I respect people who prove themselves to be knowledgeable and competent, I've made a thread evidencing I don't believe this is the case here. If I had been dealing with the consultant, this would be an entirely different story; it takes a lot of years of experience dealing with patients and the drug - as said, I've seen half a dozen GPs and they were all decent - it takes a lot, lot longer to become a GP and they had many years of experience.I don't respect you either. You could have posted and said " well I would have thought she would have been a consultant because of xyz" - you would have been wrong, but you wouldn't have been so aggressive and made yourself look like an idiot.
Best of luck and I hope you don't get banned.
Everybody relax. Nobody wins in a forum war.
Back to the subject of the original post. You said that your acne appeared mild during your appointment. Do you have physical scarring?Asking questions and starting you at a lower dose seems perfectly reasonable. I think you're absolutely right about cumulative dose and remission. What exactly are your concerns about long term health damage?
Are you taking the accutane with a meal high in dietary fat? That makes a huge difference.
Has the acne improved since you started?
good questions. very minor scarring . excellentpoint re fat, yes i have. it's pretty mild at the moment, back isn't great at all, but face is very mild. but with short-term clearance to be fair it doesn't matter so much what dose you're on - 10mg- 60mg, the clearance rate will be roughly the same for most people, just greater side effects at the higher dose - the caveat being that the daily dose is only part of the larger picture.
as you say my whole gripe is over cumulative dose and long term remission. i don't have serious concerns about long term health damage, but i accept there are risks and i think regardless i am playing a bit ofroulette with my liver. in short though, the only way for me to get the right cumulative dose is to be on 60mg for a sustained period of time (4 months or so) based on my bodyweight - assuming i would be taking that dose today.
i had my second appointment and it was as i feared and as i tried to articulate above. she put me up to 40mg for 12weeks. she openly said she was cautious and didn't have much experience dealing with the drug and would be reluctant to go much higher. the point is over the course of 4 months, i would have received 3360mg less than half of what i need for a cumulative dose for my bodyweight in 5 months i'll have received about half. there has been absolutely no issue with my blood readings at all. assuming she goes up to 60mg next time around the course will take at least 8-9months to complete. the point is it's a fight. she'll see clearance and think the treatment is going fantastically.
i spoke to her about the cumulative dose and she said itwasn't a big priority for her - her stated priority was the acne clearing, which it hasn't done yet, and then when it has done, to keep running it at a low dose for a few more months.
there's nothing really more to be said really, it's just unfortunate. it's not like she's being negligent or going to kill me. it's just i'm on a dose which is potentially going to be ineffective for long-term remission which pisses me off. and i'm going to be on it for a longer than normal time which is unpleasant and also means i'll be on it during the summer which i expressly don't want to be for various reasons. but it is what it is.
If you're in your late 20s, you may grow out of it completely. Thebiggest factors in accutane retreatment is the age of the patient and the severity of the acne. Cumulative dose is important but it's not everything. You may end up with a better outcome than you think. If you want the body acne to clear up quickly, start showering with 10% benzoyl peroxide wash. I'm pretty sure the liver is safe unless you take vitamin A while your taking Accutane. I looked for case reports of liver damage, and I couldn't find anything.
2 hours ago, acnehardcase said:If you're in your late 20s, you may grow out of it completely. Thebiggest factors in accutane retreatment is the age of the patient and the severity of the acne. Cumulative dose is important but it's not everything. You may end up with a better outcome than you think. If you want the body acne to clear up quickly, start showering with 10% benzoyl peroxide wash. I'm pretty sure the liver is safe unless you take vitamin A while your taking Accutane. I looked for case reports of liver damage, and I couldn't find anything.
Isotretinoin is metabolised by the liver and can cause mild liver dysfunction, that's the reason why patients are advised not to drink alcohol when on the drug because the liver is already working overtime. But you're right that generally speaking the liver is going to be safe, I'm just accepting Murphy's Law.
You are again correct thatthere are other factors besides the cumulative dose; age, type, location, severity and every patient is uniqueBUT no factor has been shown to beconclusively more important than the other. Age is generally a bit of an irrelevance though for over 18s from the research I've seen and the largest body of literature by a country mile is on the cumulative dose being at least 120mg/kg (this has flaws). It appears men have double the chance of relapse as women, and the general relapse rateswhich often appearas high as40%. The problem is most of the research on the drug just plain sucks for a variety of reasons - including in many not taking into account the severity of the acne, and your point above about taking the drug without a fatty meal can mean only 40% absorption, that is, obviouslysomeone can be on 100mg a day but only be absorbing day to day 40mg of that. And there's evidence that for those with mild acne, going up to 120mg/kg isn't necessary at all, fair enough but I should reiterate I wasn't looking for a high dose!
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509883/
However, with a general circa40% relapse rate and those who receive less than the desired cumulative dose having a significant chance of relapsing, I'm not massively confident.
To the guy above, yes I am angry in this thread and I can see how it looks at a cursory glance. Because there was an idiotposting not engaging with my concern re the dose but a general "you're wrong cos doctors are always right and they know more than u ner ner ne ner ner". And then someone drove me mental by actually trying to tell me I was fantasising about being seen by a 25 year old doctor, I was actually seeing a consultant in their 50s or something.
Anyway I've said all I need to say here, thanks acnehardcase for your useful contributions.
On January 2, 2016 at 749 PM, corbone said:
Isotretinoin is metabolised by the liver and can cause mild liver dysfunction, that's the reason why patients are advised not to drink alcohol when on the drug because the liver is already working overtime. But you're right that generally speaking the liver is going to be safe, I'm just accepting Murphy's Law.
You are again correct thatthere are other factors besides the cumulative dose; age, type, location, severity and every patient is uniqueBUT no factor has been shown to beconclusively more important than the other. Age is generally a bit of an irrelevance though for over 18s from the research I've seen and the largest body of literature by a country mile is on the cumulative dose being at least 120mg/kg (this has flaws). It appears men have double the chance of relapse as women, and the general relapse rateswhich often appearas high as40%. The problem is most of the research on the drug just plain sucks for a variety of reasons - including in many not taking into account the severity of the acne, and your point above about taking the drug without a fatty meal can mean only 40% absorption, that is, obviouslysomeone can be on 100mg a day but only be absorbing day to day 40mg of that. And there's evidence that for those with mild acne, going up to 120mg/kg isn't necessary at all, fair enough but I should reiterate I wasn't looking for a high dose!
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509883/
However, with a general circa40% relapse rate and those who receive less than the desired cumulative dose having a significant chance of relapsing, I'm not massively confident.
To the guy above, yes I am angry in this thread and I can see how it looks at a cursory glance. Because there was an idiotposting not engaging with my concern re the dose but a general "you're wrong cos doctors are always right and they know more than u ner ner ne ner ner". And then someone drove me mental by actually trying to tell me I was fantasising about being seen by a 25 year old doctor, I was actually seeing a consultant in their 50s or something.
Anyway I've said all I need to say here, thanks acnehardcase for your useful contributions.
You're like a spoiled kid who doesn't get exactly what he asks for for Christmas and cries about it. Lol grow up man. If everyone except one person on this thread thinks you're being a dick....maybe you're being a dick. If anyone opposes what you say you freak out, that is a huge sign of immaturity. So once again...grow up man, you're really embarrassing yourself, I can't imagine what people think about you in the real world...