42-Year-Old Female Beginning Isotretinoin (Accutane) for Persistent Acne
At Reena Jogi MD, Village Dermatology in Katy and Houston, Texas, we help patients of all ages manage acne that has not responded to standard therapies. This case features a 42-year-old female who presents for follow-up after persistent breakouts despite topical medications, oral antibiotics, and hormonal therapy—and who, after thorough discussion, elected to begin isotretinoin (Accutane).
Patient Background
The patient was last evaluated on February 5, 2025, and began the following regimen for acne vulgaris:
Gentle cleanser twice daily
Tretinoin 0.025% cream nightly
Doxycycline 100 mg twice daily
She has since stopped working and started Hailey 24 Fe oral contraceptive pills (OCP). She now presents for further management and evaluation of persistent acne.
Clinical Examination
A focused facial examination was performed, showing:
Comedonal papules
Inflammatory papules
Pustules
The patient appeared well-developed, well-nourished, alert, oriented, and in no distress. A dermatoscope was used during the exam. No other concerning findings were noted.
Assessment and Plan
1. Acne Vulgaris – Considering and Initiating Isotretinoin (Accutane)
(L70.0)
Given continued breakouts despite tretinoin, clindamycin/benzoyl peroxide, and oral antibiotics, we discussed isotretinoin (Accutane) as a next step. The patient expressed interest in moving forward.
What Was Reviewed With the Patient
We provided a comprehensive review of Accutane, including:
Effectiveness
Accutane can lead to long-term remission of acne.
About 1 in 5 patients require a second course.
Safety Requirements
Two forms of birth control required
Two negative pregnancy tests 30 days apart before starting
Monthly visits due to iPledge regulations
Lab monitoring for liver function and triglycerides
— Labs ordered today: CMP, Triglycerides, Urine pregnancy test
Side Effects Discussed
Common:
Dry skin, dry lips (cheilitis)
Photosensitivity
Joint/muscle aches
Mood changes
Serious but rare:
Elevated liver enzymes
Elevated triglycerides
Pseudotumor cerebri (increased brain pressure)
Severe depression
The patient verbalized understanding and elected to begin the Accutane initiation process today.
She will not receive medication today due to the required 30-day waiting period between pregnancy tests but will be eligible to start at her next follow-up.
Isotretinoin Initiation Plan
Indications
Persistent acne despite oral antibiotics and topical therapy
Scarring risk
Protocol
1 mg/kg with a goal cumulative dose of 220 mg/kg
Birth Control
Primary: OCP (Hailey 24 Fe)
Secondary: Male latex condoms
Pregnancy Test
Urine pregnancy test today: NEGATIVE
Next Steps
Begin spironolactone 50 mg twice daily for hormonal support during the waiting period
Complete labs after 2 weeks of spironolactone
Follow up in 2 months to start isotretinoin officially unless spironolactone alone provides adequate control
Prescription Provided:
Spironolactone 50 mg BID (60 tablets, 2 refills)
High-Risk Medication Monitoring
(Z79.899)
Patients on isotretinoin require ongoing monitoring due to its potential side effects. The patient was counseled to notify the office immediately for:
Abdominal pain
Vision changes
Severe headaches
Rash
Fever or chills
Fatigue
Signs of depression
Trouble breathing
Monthly visits and bloodwork will be required during the course.
Discussion
This case highlights the thoughtful progression from topical therapies and antibiotics to isotretinoin for patients with persistent adult acne. After years of recurring inflammation, this patient is well-positioned to benefit from Accutane’s long-term remission potential under careful monitoring.
At Reena Jogi MD, Village Dermatology, we provide individualized acne care for patients throughout Katy and Houston, Texas, integrating:
Medical therapies
Hormonal options
Procedural support
Comprehensive isotretinoin monitoring
Our goal is clear, healthy, confident skin—at every age.
