Severe acne has become increasingly common in adult men and women. In skin of color, severe acne results in postinflammatory hyperpigmentation and hyperpigmented scars that are difficult to treat and often cause more distress to the patient than does the acne itself.
Scarring, refractory acne, or nodulo-cystic acne may not respond to traditional therapies and thus may require isotretinoin therapy.
However, many clinicians are rightfully concerned about the legal implications of isotretinoin, particularly the potential for suicide in patients with a history of depression. Clinicians will often not prescribe isotretinoin given these risks, even though their patients may have failed a myriad of topical and oral treatments.
In our clinical experience, severe depression is an underrecognized yet prevalent finding in patients with severe acne. The hyperpigmented scarring is difficult to cover with make-up, particularly for patients with skin types IV-VI. Other cosmetic options are limited.
Patients can develop depression and a lack of self-confidence, particularly if they have been dealing with acne and acne scarring without much relief. It is important to treat these patients aggressively to prevent severe scarring. Often the most effective medication is isotretinoin.
In two well-designed retrospective studies, depression was found to be linked to severe acne, and not to isotretinoin therapy.
In the most recent study, researchers evaluated data from 5,756 patients aged 15-49 years who were prescribed isotretinoin for severe acne between 1980 and 1989. The data were interpreted along with data from hospital discharge and cause-of-death registers from 1980 to 2001 (BMJ 2010;341:c5812).
In this study, 128 patients were admitted to the hospital for attempted suicide. During the year before treatment with isotretinoin, the incidence ratio for attempted suicide was increased 1.57 (95% confidence interval [CI], 0.86–2.63) for all suicide attempts, including repeat attempts, and 1.36 for first attempts only (95% CI, 0.65–2.50), compared to the general population.
The incidence ratio during and up to 6 months after treatment was 1.78 (95% CI, 1.04–2.85) for all attempts and 1.93 (95% CI, 1.08–3.18) for first attempts. Finally, 3 years after treatment the standardized incidence ratio declined to the expected level, 1.04, and remained the same throughout the 15 years of follow-up (95% CI, 0.74–1.43) for all attempts. The ratio for first attempts declined to 0.97 (95% CI, 0.64–1.40).
The authors concluded that suicidal ideation reflects the burden of the disease, rather than treatment with isotretinoin. They suggest that physicians know the psychiatric history of each patient they want to begin on isotretinoin therapy, and follow them closely both throughout the treatment and for up to 1 year after. However, in many patients, the psychiatric morbidity may be related to the acne itself.
Dark-skinned patients develop severe dyschromia from acne lesions which are often difficult to treat. Given the pigmentation of their skin, the severe dyschromia associated with acne, and the lack of cosmetic options for camouflage, these patients may present with signs and symptoms of depression related to their underlying disease. It is imperative that the treating clinician understand each patient's concerns because NOT treating the patient appropriately can be more detrimental to their psychiatric health than treating them with isotretinoin.