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jemini

(ultra) low dose accutane

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I am currently on accutane for the second time. My first run was at 60mg for 5 months. It cleared me for about a year or so. This time around I asked my derm if I could do an extended low dose. I am 22 with acne just as bad as a teenager, so if I do outgrow it, I don't see it happening around the corner. I originally wanted to try an ultra low dose regimen (10mg a day) after the initial clearing with a higher dose. However, due to Ipledge, plus the unforeseen risks associated with an extended regimen of accutane (1+ years of continuous use) my derm would only allow me to do a 30 mg dose for 8 months.

Anyway, this got me thinking about low dose accutane in general. It is my feeling that the range of therapeutic use for this drug has yet to be fully explored, and that current dosing regimens might be inappropriate for a large number of people. After a bit of research, here is what I have found out:

The research indicates that it is the cumulative dose of accutane that seems to be responsible for its length of acne remission. So in other words, taking 30 mg for 8 months should yield an equivalent remission as 60mg for 4 months. From personal experience, I can tell you right now that 30mg I am currently taking has yielded fewer side effects. Chapped lips are still prevelant but not as bad, and the initial breakout (still present at the low dose) this time around isn't as bad, especially since it seems wound healing isn't as hindered.

A study done in Israel has shown that a low dose (20 mg a day) was highly effective for moderate acne with very few side effects.

It also seems that at high doses accutane causes temporary bouts of rosacea (currently experiencing even at 30mg, face is pink and flushes regularly, never happened before starting medication), it for some unknown reason has the opposite effect at low doses and is sometimes used to treat rosacea at the 5 to 10mg a day range. The posts I have read on the internet seem to indicate that this seems to be very effective where other treatments have failed and free of side effects. Obviously, credibility from these posts is questionable.

I feel that low dose extended dosages should be an option for people who fear the side effects from accutane. I also feel that indefinite ultra low dose regimens should be an option where a patient has been on several courses of regular dose accutane. This way a person wouldn't have to suffer as the acne returns between courses and go through the hassle of trying all the antibiotics and topicals before a derm is willing to prescribe accutane a second time. A low dose course could be used for several years until a person "grows out" of their acne. I wouldn't use this for teenagers, but for people in their 20's to 30's who have persistent cases.

Unfortunately, not much has been done to analyze the safety and efficacy of low dose regimens such as this, and I definitely think some trials should be done here. For instance, common side effects such as altered lipid profiles and liver enzymes are prevalent at higher doses, would lowering the dose reduce these side effects, or is it a result of taking the medicine in general. Accutane also has been known to have a steroid effect on bone structure, and bone abnormalities were noted in people taking high doses (1 to 2 mg a day) for several years. Would this happen at the extremely low doses I'm talking about? (0.1mg a day or less)

And is accutane even effective at extremely low doses, say after an initial higher dose was taken to "purge" the acne out.

Input? Opinions? ridiculous remarks? All would be appreciated.

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This week I will be starting ultra low dose accutane for my hyperactive oily skin (seborrhea).

I will be starting at 2.5 mg a day, continue for one month at that dosage and if I feel there isn't much improvement I will than bump it up to 5 mg a day wait 1 month and bump up again if need be. I will continue this pattern and dosage up to but not over 10mg day and take continously for at least 6 months and will pause to see how things go. I will continue this treatment while having my blood monitored as long as I feel necessary to keep my seborrhea at bay. I weigh about 78kg.

At my age and having tried endless methods to get it under control, I finally made the decision to use the only medication available and known to work.

I'm basing it on studies done by Dr. Gerd Plewig. I will post two of his studies following this reply.

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Low Dose, High Rates of Success

Ultra-low dose isotretinoin is all many acne patients need

San Francisco - Low and ultra-low doses of isotretinoin are an effective therapy for many acne patients. This safer and cheaper solution can even be used continuously.

Gerd Plewig, M.D., believes that the doses of isotretinoin typically used in the United States and Europe are far too high. For many patients, as little as 2.5 mg twice a week, which he describes as "a drop of rain on a dusty road" is adequate.

Dermatologists all over the world already are treating some patients continuously with low doses of isotretinoin, according to Dr. Plewig, director, dermatology and allergy clinic, Ludwig-Maximilian University in Munich.

"When you talk to doctors in this country and other countries of the world, they use 10 mg twice a week or three times a week, which is a low or ultra-low dose. But nobody ever bothered to show and demonstrate that it works," he said. Thus, he and his team performed two clinical trials to assess its efficacy.

Study Spotlights Low Dosing In the first trial, 28 patients with acne conglobata and inflammatory acne took a low dose of isotretinoin: 20 mg/kg, 10 mg/kg, or 0.5 mg/kg body weight daily for six months. In the second study, 11 acne patients took an ultra low dose of isotretinoin: 2.5 mg to 5 mg daily or 2.5 mg twice a week for six months. Both trials involved multiple endpoints, including clinical grading, lesion counts, counts of follicular filaments (believed to be precursors to lesions), bacterial colonization, patients' opinion of seborrhea levels, two objective measurements of sebum levels (Sebutape and Bentonite clay), qualitative assessment of sebum using high power, thin layer chromatography, and biopsies to assess size and configuration of sebaceous glands.

Trials Yield Significant Improvement Results of the first trial in which low doses of isotretinoin were used revealed significant improvements in all parameters tested. Numbers of follicular filaments, and lesions dropped, as did levels of bacteria and sebum. Sebaceous glands shrank, as well.

At the end of the second study, which investigated ultra-low doses of isotretinoin, efficacy was maintained on many of the parameters. There were significant reductions in numbers of active lesions and follicular filaments as well as objective measures of sebum levels. Patients' ratings of seborrhea improved, and levels of P. acnes on the skin diminished.

"The endpoint or the lowest point of a retinoid being effective for the treatment of seborrhea, persistent low grade acne, or maintenance therapy for patients with bad acne probably is around 2.5 mg or 2 mg, or maybe even 1.5 mg," Dr. Plewig said.

The best candidates for low and ultra-low doses isotretinoin therapy, Dr. Plewig said, include patients with severe acne who were controlled with higher doses and require a lower-dose maintenance therapy, individuals whose facial acne has persisted from adolescence into adulthood, and people with sebaceous gland hyperplasia. "Some patients come only because of their oiliness. ... For these patients, I think the low or ultra-low dose is very good, and it's cheap, too," he said.

Severe Patients Still Receive Low Doses Dr. Plewig keeps doses of isotretinoin relatively low in patients with severe acne. "I pretreat patients with severe inflammatory acne with systemic corticosteroids to begin with...about 1 mg/kg body weight for about seven to 14 days, taper it off, and then give an antibiotic, usually an erythromycin, a macrolide," he said. "And then I start with the isotretinoin [0.2 mg/kg to 0.4 mg/kg body weight]. It is so much better. We used to start immediately with isotretinoin or tried antibiotics, but often it takes too long, the patients are miserable, and it is so much better for them because you can have a faster final result, a better final result with cooling down the skin first, then adding your active treatment."

Continuous Use Offers Versatility A great benefit of using lower doses of isotretinoin is that it can be used continuously. There are other important advantages, as well. "In terms of pharmacoeconomics, it is cheaper to use lower doses, it is better tolerated by patients, has fewer side effects, fewer laboratory abnormalities, and of course the patients like it when they have continuous elegant treatment," Dr. Plewig said.

Despite the safer side-effect profile with low-dose isotretinoin, Dr. Plewig emphasized that, at any dose, the drug should still be considered teratogenic and be used with great caution in women of childbearing age.

http://www.dermatologytimes.com/dermatolog...il.jsp?id=65528

Prof. Dr. Dr. h. c. G. Plewig

Klinik und Poliklinik ;>für Dermatologie und Allergologie

Ludwig-Maximilians-Universität München

Frauenlobstraße 9 – 11

D-80337 München, Germany

Tel.: +49-89-51 60 60 00

Fax: +49-89-51 60 60 02

E-mail: [email protected];derma.med.uni-muenchen.de

Background: Excessive seborrhea, coarse-pored skin, minimal acne and oily scalp hair comprise a well-known clinical entity. It causes considerable concern, has social impact, and affects the quality of life in some individuals. Some patients seek treatment for seborrhea. No effective topical sebosuppressive medication is available. Oral isotretinoin is the only remedy for men. In women, oral isotretinoin is the most effective remedy, followed by antiandrogens.

Patients and methods: Eleven patients in three groups were treated for 6 months with very low dose isotretinoin. The influence on seborrhea was measured during oral treatment with 5 mg/d, 2.5 mg/d, or 2.5 mg 3× weekly.

Results: Sebum production, measured with Sebutape®, was reduced by up to 64 %. Acne lesions regressed by as much as 84 %. Follicular filaments were reduced by 66 %. Microcomedones were reduced on average up to 86 %. Quantitative bacteriology showed a reduction of Propionibacterium acnes but no increase of Staphylococcus epidermidis. Biopsies revealed a 51 % reduction in sebaceous gland size. With Bentonite™, a reduction of lipids was demonstrated with 2.5 and 5 mg isotretinoin/d but not with 2.5 mg 3× weekly. There was a shift within the lipid fractions: triglycerides dominated, followed by squalenes and free fatty acids.

Conclusions: Good results were achieved in all patients. The small number of patients did not permit a statistical analysis of the three isotretinoin doses studied, but there was a tendency toward better results with the two higher doses.

Zusammenfassung

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Here's my biggest concern with low doses for extended periods, is that even a few mg's a week for months/years on end might still exert a steroid effect on bones, and even with a few breaks here or there it might cause serious problems 5 or 10 years down the line. But in any case, I wish you the best in your trials and hopefully you will be successful.

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Here's my biggest concern with low doses for extended periods, is that even a few mg's a week for months/years on end might still exert a steroid effect on bones, and even with a few breaks here or there it might cause serious problems 5 or 10 years down the line. But in any case, I wish you the best in your trials and hopefully you will be successful.

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I think its a great idea. I wish a derm would run some trials like that over here in the US, I would sign up for sure haha.

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great post.

accutane worked wonders for me,

but the results tapered off 6 months or so after.

i actually asked my dermatologist to prescribe a low dose of accutane with the intent of keeping it for a few years so I wouldnt have to bother with applying benzaclin and moisturizer every night. which is perfectly effective as prevention, but is a pain in the ass.

i think doctors should absolutely start prescribing ultra low doses as a preventative measure for those who are very acne prone, but no longer have serious problems, as a matter of convenience, so we can live like normal people.

there is a slight long term health concern, but i think if 60mg a day for 6months wasnt a problem than why should 5 mg a day be a problem over a long period.

i would be happy to take what I think is a moderate risk at the most for that level of convenience.

if anybody knows of any longterm studies please be sure to post them.

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Yeah, if it wasn't for potential long term problems I would love to see low dose accutane be the norm until something better comes along. Im a bit wasted as I type this so bear with me. Acutane acts as a steroid for bone growth, so it is possible (still unknown and untested) that even low doses for extended periods of time can increase the risk of abnormal calcification and bone growth. The original tests decades ago looked at people who had taken high doses for years, so maybe this doesn't apply, but who knows without an experiment. Also long term dosing might effect the up/down regulation of other receptors such as ppars and perhaps others. Who knows what this could do. 5 years on low dose accutane may increase the risk of a form of diabetes for all we know. I feel low dose accutane shouldn't be given for convenience, since topical retinoids and antibiotics are still much safer to use over the long term, since their targets are much more specific. You are not going to develop bone problems applying differin.

I feel the candidates to be considered are people who have been through several courses accutane with poor or temporary results, quick remission rate. Or in just another 1's case a 30 year case of seborrhea where nothing else has worked and low dose accutane improves the quality of life despite the potential side effects.

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I think a low dose idea is good, but usually in cases where people have done a full course of high dose accutane (30mg +) and their acne comes back soon after, either theyre just really unlucky or more likely their acne is caused by something else aka hormonal problems.

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Guest Kimmay

I wish this was an option.... however, I dont see how taking the drug for years wouldnt produce negative effects.............

I did 2 courses of Accutane and my acne is still here.

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I wrote about this in the "Ask a Dermatologist" thread. I posted pretty much all the studies done on low-dose Accutane, certainly all the ones i could find. Looking at it completely objectively i think it's a real practical solution. The dermatologist didn't agree, but in truth her only argument was "i don't agree because that's what I've been told". It's disappointing she was unable to think for herself. I did some more research and while i couldn't find any more studies I did find an endorsement of low-dose regimes by Albert Kligman (famous Dermatologist inventor of Retin-A) and a report by Roche Pharmaceuticals (the inventors and patent holders of Isotretinion) in there NDA 21-177 which states "Since therapeutic equivalence was demonstrated in the adequately powered total trial population, it would appear that the currently recommended dosing range for Accutane may be too high".

I never bothered to post because i didn't think anyone was interested.

Edit: I don't know enough about long-term usage to comment on its safety, what I'm interested in is 6-8 months low-dose not long-term i don't think TCD is that important.

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Does anyone have any links to articles relating to isotretion and the steroid effect on bones. I'm very interested on reading up on this.

Thanks

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Hi guys. It's been a while since I've been on this forum but I care a lot about acne and I would like to share my experiences with you.

I did 2 "6 months treatments on a 60mg/day dose." That was 2 and 3 years ago. I then did 5 treatments of photodynamic therapy...500$ for each treatment...BTW I'm 19.

and since september 2006 I'm on a 10 mg/day acctuane treatment. And now I'm taking 20 mg/day for the next year.

I used to have cysts on my neck, cheeks, etc. but now I only have cysts on a very local area on my cheeks and they go away but eventually comes back...I popped all the cysts last week on my right cheek and I don't have any for now. I only got like 2 cysts on my left cheek..I think that if you don't pop cysts they will always be there...am I right? Cause they are always at the same places!!

I have no acne anywhere else. And I used to have severe acne!!

I use a clearasile product to hide the redness of my cysts and people can't really see them.

I recommend to you guys Avene Cicalfate restorative cream....you won't believe how good it is.

I hope you'll find my post usefull and If you have any questions, pm me!

Stay strong guys

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I have mentioned this before...I was accutane, also 60mg for around 6 months-----TWICE in around three years, and recently I went a three-a-week dose which consisted of 20mg for 5 months and then the last month was flat out 60mg for one month....did not help cause my skin has gone back to its previous condition and I have a dry eye condition which seems to be chronic (or it could be allergies)......but if I knew that the lower dose regimen was available then I would never have gone full dose because (in hindsight---hindsight being the perfect science) it did not work. Definately felt less side-effects with lower dose :rolleyes:

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Low dose accutane is pretty much just like taking a vitamin A tablet. I'm starting to see a pattern:

This research says that smoking seems to cause acne:

http://www.hindu.com/thehindu/holnus/008200709181141.htm

Smoking lowers the level of vitamin C in the body (that's why people get more wrinkles- vit C is involved in collagen production).

Also I read somewhere that people with acne have low levels of beta carotene, zinc and vitamin C.

The connection could be the fact that there's an enzyme in the body that converts beta carotene into the retinoid form (which is the active form in the body). That enzyme needs zinc and vitamin C to work. It's known that retinoids trigger differentiation of the cells in the pores and help unblock the pores, so if you don't have enough retinoids for any reason, acne would seem to be a likely outcome.

Maybe in at least some people, acne is simply the end point of weeks or months of deficiencies in vitamin C, zinc and/or beta carotene causing a deficiency of retinoids in the skin. That would at least be consistent with the smoking findings.

I've recently upped my beta carotene intake (eating more carrots and kale) and my skin is now significantly dryer, particularly if I also eat normal amounts foods like egg (even one per day), which contains small amounts of retinoid form of Vitamin A.

Its very early days but it may be that my acne is a dietary deficiency. Here's hoping.

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Great info. The bone issue is a consideration so they should

study it more. I've had a diet rich in healthy vitamins and

carotenoids and zinc and it had no bearing on oil output.

Being / eating healthier and getting enough of nutrients

mentioned as well as C in generally may help, it did for

me, but just the RDA amount. Extra doesn't 'medicate'

or help. Accutane's action is still pretty unique in this.

My anger is that they made a topical 'Isotrex' gel at this

incredibly low dose that is said to work like a very weak

Retin-A. I tried it, it was totally useless. They need to go

find a way to make Accutane topically applied with really

a very low absorption rate (probably the equivalent of a

1mg dose a month or less) that you could just rub on to

reduce oiliness and acne. That's a potential cure I think.

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Would High doseage vit A capsules from Holland n Barratt be the equivalent of taking low dose tane? Say 3 or 4 vit A capsules daily.

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Does anyone know whether a low-dose (10 mg/day or lower) Accutane regimen still makes your skin highly photosensitive?

I have been seriously considering this idea, but have just started a year of laser hair removal treatments, which you are not supposed to do while on Accutane. I decided not to risk it .... but I am curious.

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Lionqueen,

Just joined this forum as I felt compelled to post a response to your comment regarding Accutane and hair removal.

This link should take you to a link that you would appreciate. It is an abstract of a study on that very thing. The study participants were on regular dose so one would like to think it is even safer for low-dose.

http://www.blackwell-synergy.com/doi/abs/1...journalCode=dsu

Good luck.

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Now, that is some good news, and very interesting. :D

Thank you so much for posting it! I think that abstract deserves its own thread.

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Let me put it this way, I have dealt with acne and oily skin for almost 30 years now. Finally in this last year the acne has subsided. I still have extremely oily skin. I know I will have this oily skin probably into my 60s. These are the facts.

I avoided accutane for all these years with the same concerns you think about. I struggled with this disease and living life telling myself, 'I will tough it out', 'I'm not going to sell my soul to the devil by taking accutane', 'It's just a matter of time before it clears up' .... well, when it finally happened I was an older man with wrinkles to show and gravity starting to take over my body.

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As far as i understand it... Accutane is basically a mega-dose of vitamin a. If it isn't exactly that, then it is something that has very similar effects to it. So i guess what I'm suggesting is that an extremely low dose therapeutic regimen of Accutane (as in a lower dose than is currently in existence) may in fact be nothing more than the equivalent of taking the highest over the counter dose of vitamin a supplement with zinc. Anyone that can expand on that more please do so.

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So i guess what I'm suggesting is that an extremely low dose therapeutic regimen of Accutane (as in a lower dose than is currently in existence) may in fact be nothing more than the equivalent of taking the highest over the counter dose of vitamin a supplement with zinc. Anyone that can expand on that more please do so.

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So i guess what I'm suggesting is that an extremely low dose therapeutic regimen of Accutane (as in a lower dose than is currently in existence) may in fact be nothing more than the equivalent of taking the highest over the counter dose of vitamin a supplement with zinc. Anyone that can expand on that more please do so.

Accutane is isotretinoin, which is slightly different than the chemicals like Retinyl palmitate that you get in vitamin pills. Isotretinoin is chosen because it's a lot less toxic but shares many of the same properties.

High dose vitamin A was tried for a while before isotretinoin, but it was much more toxic and only modestly effective.

The question to me remains whether acne is or can be caused by marginal vitamin A status. It seems likely that many people in the modern world would not get enough vitamin A, and hence will live for long periods in that state. If that messed up the growth in the pores then acne could be the end product. I also note that children often dislike many of the foods that are rich in vitamin A... but the effects would tend to not be noticed till late in puberty when the sebum output is at its highest.

Anyway, you wouldn't want to OD on ordinary vitamin A (retinoid form) as this gives liver toxicity and other bad side-effects but lots of beta carotene and only a bit in retinoid form should be fine.

I've been on an ultra-low dose for a long time and it works great with almost no side effects, 10mg every other day or twice a week, I have more than 100 of the 10mg brand name capsules left in their packaging, I bought them in December 2007, so I don't think I'll use all of them before they expire this summer. I paid about 1.50 a pill since I don't have insurance, but it has been worth every penny, comes out to about $3-5 dollars a week at my dose.

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I was just about to start a thread about low and ultra-low Accutane doses when I saw this one. It seems so many others are on exactly the same wavelength (i.e., "I hate my acne and the potential it has to scar, but am also very concerned about Accutane side effects; therefore, what is the absolute least amount of Accutane I can take and get still results, and how long will those results last?") I had just read the "Dermatology Times" article entitled "Low Dose, High Rates of Success" (shared in this thread by an earlier commenter) where a Dr. Plewig argues that low and ultra-low doses of Accutane should be the preferred way Accutane dosage for many people... that's what got me wondering about this. It seems most people agree that lower doses of Accutane reduce the chance of side effects.

My question is: Is anyone aware of any studies that test the effectiveness/side effects of low (10-20mg/day) and ultra-low doses (1.5mg-5mg/day) of Accutane in treating cystic acne? It would be great to have a compilation of links to such studies, if there are any that have been done.

So i guess what I'm suggesting is that an extremely low dose therapeutic regimen of Accutane (as in a lower dose than is currently in existence) may in fact be nothing more than the equivalent of taking the highest over the counter dose of vitamin a supplement with zinc. Anyone that can expand on that more please do so.

Accutane is isotretinoin, which is slightly different than the chemicals like Retinyl palmitate that you get in vitamin pills. Isotretinoin is chosen because it's a lot less toxic but shares many of the same properties.

High dose vitamin A was tried for a while before isotretinoin, but it was much more toxic and only modestly effective.

The question to me remains whether acne is or can be caused by marginal vitamin A status. It seems likely that many people in the modern world would not get enough vitamin A, and hence will live for long periods in that state. If that messed up the growth in the pores then acne could be the end product. I also note that children often dislike many of the foods that are rich in vitamin A... but the effects would tend to not be noticed till late in puberty when the sebum output is at its highest.

Anyway, you wouldn't want to OD on ordinary vitamin A (retinoid form) as this gives liver toxicity and other bad side-effects but lots of beta carotene and only a bit in retinoid form should be fine.

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