Isotretinoin (Accutane) Therapy for Adult Female Acne: A 36-Year-Old Patient Case
Case Overview
A 36-year-old woman presented to Reena Jogi MD Dermatology in Houston, Texas, for follow-up management of moderate to severe facial acne. She had been treated previously with tretinoin 0.1% cream, topical clindamycin, and a comprehensive skincare regimen.
Despite good compliance, she continued to experience persistent inflammatory papules and cystic lesions, primarily on the chin, lower cheeks, and perioral region, leading to scarring and emotional distress. The patient expressed readiness to begin isotretinoin (Accutane) for long-term control.
Clinical Findings
On examination, the patient exhibited:
Multiple inflammatory papules, pustules, and comedones on the lower face and jawline
Cystic nodules on the chin and perioral areas
Early post-inflammatory hyperpigmentation and mild scarring
No active infection, scaling, or erythema beyond lesion borders
Her general health was excellent, and she appeared well-nourished, alert, and in no distress.
Diagnosis
Acne Vulgaris (L70.0) — moderate to severe, inflammatory and comedonal
Inflammatory Acne Cysts (L72.8) — localized papules and nodules on the lower face
Treatment Plan
1. Isotretinoin (Accutane) Initiation
After thorough evaluation and laboratory review, the patient was started on oral isotretinoin, an FDA-approved systemic therapy for severe, recalcitrant acne.
Treatment Protocol:
Dose: Approximately 1 mg/kg daily
Goal: Cumulative dose of 120–150 mg/kg over 6–8 months
Monitoring: Monthly follow-ups per iPledge program regulations
Counseling Summary:
Common side effects include dry lips, dry skin, joint aches, and photosensitivity
Rare risks: elevated cholesterol, abnormal liver function, pseudotumor cerebri, mood changes
Monthly liver function tests (LFTs) and triglycerides ordered for monitoring
Strict birth control emphasized due to high teratogenic risk
Advised no blood donation, cosmetic procedures, or waxing during and 6 months after treatment
The patient’s urine pregnancy test was negative prior to initiation, and she was counseled on dual contraception use throughout therapy.
2. Intralesional Kenalog for Active Inflammatory Lesions
To manage a few deep inflammatory cysts on the chin and lower lip area, the patient underwent intralesional Kenalog (triamcinolone) injections at 2.5 mg/cc concentration.
Total of 4 lesions injected (1 cc total volume)
Discussed risk of localized skin atrophy and expected resolution in 1–2 weeks
3. Supportive Skincare Routine
To minimize irritation and dryness during isotretinoin therapy, the following skincare regimen was reinforced:
Morning (AM):
Cleanse with a gentle cleanser (CeraVe, Cetaphil, or La Roche-Posay).
Apply non-comedogenic moisturizer with SPF 30+.
Use clindamycin lotion for spot treatment as needed.
Evening (PM):
Cleanse with mild, fragrance-free cleanser.
Apply tretinoin 0.1% cream (if tolerated during transition).
Follow with hydrating moisturizer (CeraVe or Vanicream).
Patient Counseling
The patient received detailed counseling on the importance of consistency, sun protection, and hydration while on Accutane.
She was informed that visible improvement typically begins after 8–12 weeks, with maximum clearance by 5–7 months.
Additional education included:
Do not share medication or undergo cosmetic treatments (e.g., waxing, peels).
Report symptoms such as persistent headache, mood changes, visual disturbances, or abdominal pain immediately.
Avoid alcohol and vitamin A supplements to reduce liver strain.
Follow-Up and Monitoring
The patient will follow up monthly for:
Pregnancy testing
Laboratory monitoring (LFTs, triglycerides)
Mood assessment and dryness evaluation
Dose adjustments as tolerated
A 6–8 month treatment course is anticipated, with expectations of long-term remission and scar prevention.
Discussion
This case underscores the role of isotretinoin (Accutane) as a transformative therapy for adult female acne unresponsive to topical and oral antibiotics.
Unlike short-term antibiotic regimens, isotretinoin targets all four major acne mechanisms:
Sebum reduction
Comedolysis
Anti-inflammatory action
Suppression of Cutibacterium acnes proliferation
When used responsibly under expert dermatologic supervision, Accutane achieves lasting clearance in 70–90% of patients, improving both skin appearance and self-confidence.
Key Takeaways
Isotretinoin offers the highest efficacy for resistant or scarring acne.
Monthly lab testing and pregnancy monitoring are essential for safety.
Dryness and mild irritation are expected and manageable with proper skincare.
Combining Accutane with intralesional Kenalog speeds recovery from active cysts.
About Our Clinic
At Reena Jogi MD Dermatology, we provide comprehensive acne management for teens and adults in Houston and Katy, Texas.
Our practice offers Accutane therapy, advanced topical regimens, light-based treatments, and acne scar management—all guided by board-certified dermatologic expertise.
