Samantha Robinson assumed her struggles with acne were through by the time she reached her late 20s. She had already done her time in high school, she thought, when benzoyl peroxide and sulfur masks were her best friends. And for more than a decade, her skin had been crystal clear.
Then, not long after her 27th birthday, Robinson got acne déjà vu. It started with some run-of-the-mill blemishes around her period, but within a few months had progressed to full-on acne, covering every inch of her face and neck. She made an appointment with her dermatologist, and the two came up with a plan of attack that included both topical treatments and a prescription for spironolactone, a diuretic used to treat hormonal acne.
But six months later, Robinson’s acne was unchanged. Feeling hopeless, she returned to her dermatologist and was met with an answer she’d long feared: It was time to go on Accutane. Having witnessed her friends take the oral medication during their teenage years, Robinson knew it came with some serious side effects, from immense dryness and nosebleeds to the required sacrifice of alcohol and even possible links to depression.
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She expressed her fears and concerns about Accutane, but her doctor quickly put them to rest; what she had in mind for the 27-year-old, she learned, was actually a low dose of the drug.
As it turns out, microdosing isn’t reserved solely for cannabis and mushrooms (although the term is most closely linked to psychoactive drugs). The practice can actually be applied to all kinds of drugs, including prescription medication. The rationale is simple: to capitalize on the benefits while minimizing undesirable side effects.
Low-dose or microdosed Accutane is an off-label use of isotretinoin (Accutane is just one of many brand names), by which patients take a smaller amount over a longer period of time. The approach has gained considerable traction in recent years, as it claims to offer the same impressive, acne-clearing benefits of a traditional dose without the severe side effects. Robinson is just one of many acne sufferers who has found a solution in the low dose, but microdosing the drug isn’t as straightforward as it seems. Read on to learn more about how low-dose Accutane works, what it can do for breakouts, and what those who take it should still be aware of.
What is Accutane, and how does it work?
First, it’s important to understand just what Accutane is and how it works. Although it was the first isotretinoin to come to market, there are now many brands of the drug available. That said, many dermatologists and patients alike still refer to the various options as Accutane (kind of like how people refer to all tissues as “Kleenex”).
Isotretinoin is, in simplest terms, a derivative of vitamin A that effectively shuts down the sebaceous (a.k.a. oil) glands in skin. The medication works by reaching a cumulative dose in your system, usually over the course of four to six months. The goal is to not only shrink the oil glands while you’re taking it, but also long after so that acne can’t return. “It’s typically used for patients with moderate—or more commonly, severe—acne who have not responded to other treatments or chronic use of antibiotics,” David Goldberg, a dermatologist at Schweiger Dermatology Group in New York City and New Jersey, explains.
In many ways, Accutane is the closest thing we have to a cure for acne. Although topical treatments and other oral medications can help to alleviate certain causes of breakouts, isotretinoin addresses—and stops—the physical pathways that allow acne to happen in the first place and usually does so permanently.
What is low-dose Accutane?
Low-dose or microdosed isotretinoin is, as the name suggests, a smaller dose of the oral medication. Although it’s technically an off-label use of the drug, many dermatologists recommend this approach for patients who would benefit from the results of Accutane without such harsh side effects (more on that in a minute).
“The best candidates for low-dose isotretinoin are patients who have mild-to-moderate acne that has not been controlled by more conventional therapy, like topicals, oral antibiotics, or other oral medications,” Melissa Levin, a dermatologist in New York City, explains. “I also like to give it to folks who have actually been proven to have a good response to isotretinoin in the past—so we have lots of patients who have been on traditional, full-course isotretinoin treatments or who have done multiple rounds of traditional Accutane courses, and the acne just keeps coming back.”
The best candidates for low-dose isotretinoin are patients who have mild-to-moderate acne that has not been controlled by more conventional therapy.
While a traditional dose of isotretinoin is often somewhere between 40 and 80 mg taken daily, the low-dose approach is less fixed. A patient might take 10 mg every day, 10 to 20 mg a few days a week, or even 10 to 40 mg taken just once a week. “There’s a lot of variability on how people do it, because there are no big, robust clinical trials that guide physicians on the way to prescribe low-dose,” Levin says. “There have been several studies that looked at the goal dose, basically how much medication needs to accumulate in the body by the end of the treatment course, and they found that long-term acne clearance is seen after 150 to 250 mg. So that could take four to six months to achieve, but if you’re doing low-dose, it can take much longer.”
Even so, there are some patients who stay on Accutane well beyond that goal-dose threshold. “The unfortunate thing is that acne is a chronic condition, and we want the patient to be clear, without any new acne lesions, before we take them off of isotretinoin,” Levin notes. “Studies show that even 12 months after treatment, there’s still a 30 to 40 percent relapse, which is pretty high. So there are people who end up staying on a low dose for many years.”
What are the side effects of Accutane?
In the four decades since Accutane first hit the market, the drug has garnered quite a bit of notoriety for its side effects, but in truth, they differ greatly from person to person. The one thing that’s inevitable, though, Hadley King, a dermatologist in New York City, says, is the side effect isotretinoin is best known for: dryness. “Everyone will experience dry skin and lips,” she warns. “This can be dramatic and can cause severely chapped lips, dry or irritated eyes, dry mouth, and nosebleeds.”
But reactions can also be far more severe. “Other side effects that may be seen include hair thinning, decreased night vision, and joint and muscle aches and pains,” King says, though she notes that these effects are all temporary and should return to normal after the course of Accutane. Additionally, taking isotretinoin can affect triglyceride levels, cause liver damage, lead to increased pressure in the brain, and cause inflammatory bowel disease. And some studies have even found that the drug could have a link to depression and suicidal ideation, but further research is needed.
It’s also hugely important that patients on Accutane—even low doses—do not become pregnant, as it can lead to serious birth defects. To ensure safety, patients are required to have two negative pregnancy tests before going on the medication and must submit to monthly pregnancy tests throughout the course of treatment. While this has always been a concern for dermatologists when prescribing isotretinoin, it’s given them even more pause in recent months following the landmark Supreme Court decision to overturn Roe v. Wade. With access to abortion—and even birth control—increasingly under attack across America, providers and patients alike are concerned about accidental pregnancy while on Accutane. Many states have already implemented laws that ban abortion entirely, even in cases where there are established risks to the fetus and known birth defects, as with teratogenic drugs like Accutane.
Are there still side effects when taking low-dose Accutane?
At the end of the day, low-dose Accutane is still Accutane. It’s not without some side effects—but for many, the dose does indeed make the poison. “Side effects that are dose related, like dry skin and dry lips, will be decreased,” King says, although they are still likely to happen in some capacity. “Other side effects may be what we call idiosyncratic—not related to dose—so the risk of these effects won’t be decreased.” That’s why, even on a low dose, it’s still very important that patients not become pregnant and that they drink sparingly and only on days when they’re not taking the medication, if at all.
Overall, though, studies have shown that low-dose isotretinoin is actually pretty well tolerated. “There’s sometimes a little cheilitis, which is chapped lips, or there’s dry skin, but we’re not seeing elevated triglyceride levels or liver anomalies, which are the scarier things that we worry about with isotretinoin,” Levin adds.
Are there any other downsides to taking low-dose Accutane?
Because low-dose isotretinoin is taken over a much longer period of time than the traditional four-to-six-month course, the side effects and risks last far longer. This means, at the very least, that you’ll have chapped lips and dry skin for years instead of months, even if it is to a lesser degree. The more serious risks last longer as well, as does the agreement to remain on strict birth control; for those thinking of building a family, this could be a reason to skip Accutane in any dosage altogether.
It’s also important to note some of the insurance limitations surrounding low-dose isotretinoin. “Typically, Accutane is a four-to-six-month treatment course, and your insurance covers that if you meet certain criteria, but low-dose could be years, and it’s not your standard dosing, so it’s difficult to have insurance cover it,” Levin explains. “As dermatologists, we want to give our patients what they need for their skin, and there are some patients who are actually great candidates for low-dose isotretinoin, but it can get a little sticky with the insurance coverage.”
For this reason, some dermatologists have started writing prescriptions for full-dose isotretinoin and instructing their patients to microdose themselves by taking the medication only on certain days. But for obvious reasons, many providers don’t feel comfortable prescribing one thing, and then telling patients to do something else, and it’s far more challenging to monitor treatment, so this practice remains fairly uncommon.
Do the results of low-dose Accutane last long-term?
There are a lot of advantages to low-dose isotretinoin, and it’s easy to see why more dermatologists are taking this approach with their patients. But there remain some questions about the permanence of the treatment too. “While you’re on low-dose isotretinoin, chances are, it will get you clear and you’ll have completely clear skin,” Levin says. “But there’s anywhere between a 30 and 40 percent—and sometimes, people quote as much as 60 percent—chance that the acne is going to come back, so some patients may go on a low dose once again.”
There’s anywhere between a 30 and 40 percent chance that the acne is going to come back.
But even if acne does return, it may be much more mild and respond well to topicals, in-office treatments, or other oral medications. “I find that a lot of patients would prefer to not need an oral medication,” Levin explains. “And sometimes, going on low-dose isotretinoin minimizes their acne enough for them to rely on more conventional therapies down the line.”
The Takeaway
There’s no denying that Accutane has been a true game changer for acne. But in general, dermatologists still see Accutane, at any dose, as a last course of action. If you want to reap the benefits of the medication with lower-grade side effects, a low dose may be the way to go, but it isn’t a silver bullet. The side effects are still there—but may only last longer—and with added insurance obstacles, it may not be worth the headache.
Gabby Shacknai is a New York-based journalist and editor who produces high-quality content for a wide variety of outlets and brands across various industries.
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