Oral Isotretinoin for Acne in the US Military: How Accelerated Courses and Teledermatology Can Minimize the Duty-Limiting Impacts of Treatment
Acne vulgaris is a common dermatologic disease affecting 40 to 50 million individuals in the United States each year. It has a peak incidence in adolescents and young adults; however, for some patients, the disease may persist well into adulthood. These incidence peaks coincide with the age demographic of a large proportion of military service members. Although there are many approaches to treating acne, active-duty service members and military dermatologists must weigh multiple additional challenging factors when selecting a therapy. Untreated acne itself may hinder a military service member’s ability to perform, and many of the available therapies also can limit their medical readiness or fitness for full duty. Herein, we review operational restrictions to acne-specific therapeutics and discuss an accelerated course of oral isotretinoin as a safe and effective option for military service members bound by duty restrictions and operational timelines. In addition, we explore the role of teledermatology for the treatment of acne in military service members.
Practice Points
- Acne is a common skin disease with a high prevalence in the active-duty US Military population.
- Oral isotretinoin is a commonly utilized acne medication that can limit the ability for military service members to deploy and is considered disqualifying for some special duty assignments.
- High daily- and cumulative-dose oral isotretinoin therapy as well as teledermatology can minimize the duty-limiting impact of isotretinoin therapy for military service members.
High-Dose Isotretinoin
An optimal isotretinoin dosing regimen would achieve swift resolution of acne lesions and reduce the overall relapse rate requiring retrial of isotretinoin, thereby minimizing the operational- and duty-limiting impacts of the medication. Cyrulnik et al13 studied treatment outcomes of high-dose isotretinoin for acne vulgaris using a mean dosage of 1.6 mg/kg daily with an average cumulative dosage of 290 mg/kg. They demonstrated 100% clearance of lesions over 6 months, with a 12.5% relapse rate at 3 years. Aside from an increased rate of elevated transaminases, incidence of adverse effects and laboratory abnormalities were not significantly increased compared to conventional dosing regimens.13 The goal cumulative dosing of 120 to 150 mg/kg can be achieved 1 to 2 months earlier using a dosage of 1.6 mg/kg daily vs a conventional dosage of 1 mg/kg daily.
It has been hypothesized that higher cumulative doses of oral isotretinoin reduce the risk for relapse of acne and retrial of oral isotretinoin.14 Blasiak et al15 studied relapse and retrial of oral isotretinoin in acne patients who received cumulative dosing higher or lower than 220 mg/kg. A clinically but not statistically significant reduced relapse rate was observed in the cohort that received cumulative dosing higher than 220 mg/kg. No statistically significant difference in rates of adverse advents was observed aside from an increase in retinoid dermatitis in the cohort that received cumulative dosing higher than 220 mg/kg. Higher but not statistically significant rates of adverse events were seen in the group that received dosing higher than 220 mg/kg.15 Cumulative doses of oral isotretinoin higher than the 120 to 150 mg/kg range may decrease the risk for acne relapse and the need for an additional course of oral isotretinoin, which would reduce a service member’s total time away from deployment and full duty.
Relapse requiring a retrial of oral isotretinoin not only increases the operational cost of acne treatment but also considerably increases the monetary cost to the health care system. In a cost-analysis model, cumulative doses of oral isotretinoin higher than 230 mg/kg have a decreased overall cost compared to traditional cumulative dosing of less than 150 mg/kg due to the cost of relapse.16
Limitations of high daily and cumulative dosing regimens of oral isotretinoin are chiefly the dose-dependent rate of adverse effects. Low-dose regimens are associated with a reduced risk of isotretinoin-related side effects.6,17 Acute acne flares may be seen following initial administration of oral isotretinoin and are aggravated by increases in dosage.18 Isotretinoin-induced acne fulminans is a rare but devastating complication observed with high initial doses of oral isotretinoin in patients with severe acne.19 The risks and benefits of high daily and cumulatively dosed isotretinoin must be carefully considered in patients with severe acne.
Teledermatology: A Force for Readiness
The COVID-19 pandemic drastically changed the dermatology practice landscape with recommendations to cancel all elective outpatient visits in favor of teledermatology encounters.20 This decreased access to care, which resulted in an increase in drug interruption for dermatology patients, including patients on oral isotretinoin.21 Teledermatology has been increasingly utilized to maintain continuity of care for the management of patients taking isotretinoin.5 Routine utilization of teledermatology evaluation in military practices could expedite care, decrease patient travel time, and allow for in-clinic visits to be utilized for higher-acuity concerns.22
