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Initial Breakout

I believe that the severity of your initial breakout is predetermined by the severity of your condition before going on Accutane. Let me explain:

Accutane brings up existing pimples(cysts, nodules etc) to the surface.

Accutane forces pimples to surface faster then they would naturally.

Someone with severe acne would have numerous pimples under the surface.

Someone with less severe acne would have less pimples under the surface.

Therefore, during the "initial breakout", when Accutane surfaces pimples, the person with severe acne clearly has more pimples to be surfaced and therefore has a worse initial breakout.

This is for those new starters of Accutane who are stressed about the initial breakout, because if what I'm saying is indeed true, then you'll have some sort of idea of what to expect during your initial breakout.

Just my view. Any opinions?

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The body needs to get accustomed to the drug, so in order for your body to cope, it produces more sebum and therefore more acne. Now, I think that it doesn't matter how much acne you have under your skin (sounds wrong to me). It matters upon how your body reacts to the drug as a whole (stress? hormonal imbalance? - these are probably caused by accutane which evidently, do lead to acne). I think your theory is wrong anyhow, from my past experiences with this drug.

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From everything I've read, I think you are on the right track. The more closed comedones one has when starting Accutane, and the larger they are ("macrocomedones"), the higher the risk of a "devastating" flare-up, according to several leading acne reseachers/dermatologists.

This is from W. Cunliffe: Comedogenesis

Suboptimal therapy can often result from inappropriate assessments of comedones, especially microcomedones, sandpaper comedones, submarine comedones and macrocomedones. Macrocomedones can produce devastating acne flares, particularly if patients are inappropriately prescribed oral isotretinoin.

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I've read that research and it's made me consider some crazy things...

I've thought of prescribing differin prior to accutane usage in patients that tolerated it very well but had little true acne relief from it (would clear "blackheads" etc but did little for the actual eruptions)...I find that if differin wasn't very irritating to begin with...a 2 month period of it will help clear blackheads etc and lessen the severity of the initial breakout...this is assuming that research is valid...

however, most of my patients have unpredictable initial outbreaks...those with severe acne do not always end up with a severe breakout...and vice versa...

There appears to be little linking the severity of acne going into treatment w/the severity of the initial outbreak (in my real life experience)...it does appear to be more related to the body's reaction to the drug...

keep in mind that I don't start out with high dosing...I find that most reports of initial high dose treatment lead to severe outbreaks and I blame this on the body's reaction to the drug...let's not forget it does influence the liver and that has an influence on your acne (toxins and such)...I tend to gradually up the dosage...or keep it the same depending on results/side effects...and the course usually runs 5 or 6 months (if needed)...

with this strategy many of my patients suffer a very mild initial outbreak if they have one at all...and I've seen several patients with nodular acne covering 60% or more of facial area...

best of luck...

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I support croft's theory of randomness. The first time I started Tane it was straight into 80mg a day. I didn't have an intial breakout. This second time, I'm at 40mg, and at about 2-3 weeks in, mild breakout! weird.

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