TABLE 1: Oral Contraceptives Containing Low Doses of Estrogen

Ethinyl estradiol 20 mg/Levonorgestrel 0.1 mg (AlesseTM)
Ethinyl estradiol 20, 10 mg/Desogestrel 0.15 mg (MircetteTM)
Ethinyl estradiol 20, 30, 35 mg/norethindrone 1.0 mg (Estrostepw)
Ethinyl estradiol 20 mg/norethindrone acetate 1.0 mg (Lo-Estrinw 1/20)
Ethinyl estradiol 20 mg/drospirenone 3.0 mg (YazTM)

Many oral contraceptives have been studied in the treatment of acne (Table2 ). These include those containing ethinyl estradiol in combination with cyproterone acetate (Diane, Dianette), ethynodiol diacetate (Demulen), levonorgestrel (TriPhasil, Alesse), norgestimate (Ortho Tri-Cyclenw), desogesterel (Desogen), and drosperinone (Yasmin, Yaz). Numerous studies point to the efficacy of ethinyl estradiol/cyproterone acetate oral contraceptives (Diane and Dianette) in the treatment of acne. Reductions in inflammatory lesion count on the order of 50% to 75% have been reported. Two large studies involving a total of approximately 500 women with moderate acne were conducted with ethinyl estradiol 35 mg/norgestimate (Ortho Tri-Cyclen). Improvement in inflammatory lesions, total lesions, and global assessment was noted with this oral contraceptive after six months of treatment (46,47). There was a 50% to 60% improvement in inflammatory lesions. Decreases in serum free testosterone and an increase in sex hormone-binding globulin were noted in the active group. Two large, six-month, placebo-controlled trials (350 and 371 women, respectively) were conducted

TABLE 2 Oral Contraceptives Studied in Acne

Demulen (ethinyl estradiol 35 mg/ethynodiol diacetate)
Diane, Dianette (ethinyl estradiol 50, 35 mg/cyproterone acetate)
Estrostep (ethinyl estradiol 20, 25, 30 mg/norethindrone)
Alesse (ethinyl estradiol 20 mg/levonorgestrel)
Ortho Tri-Cyclen (ethinyl estradiol 35 mg/norgestimate)
Desogen (ethinyl estradiol 30 mg/desogestrel)
Yasmin (ethinyl estradiol 30 mg/drospirenone)
Yaz (ethinyl estradiol 20 mg/drospirenone)
Triphasil (ethinyl estradiol 30 mg, 40 mg/levonorgestrel)

using ethinyl estradiol 20 mg/levonorgestrel (Alesse) in the treatment of acne. In each study, the oral contraceptive demonstrated significantly greater reduction in acne lesion counts and improvement in global assessment scores compared with placebo. The reduction in inflammatory lesion count was on the order of 47%. A study of 128 women with mild-to-moderate acne compared the efficacy of ethinyl estradiol 30 mg/drospirenone (Yasmin) and ethinyl estradiol 35 mg/cyproterone acetate (Diane-35) in the treatment of acne for nine cycles (50). Both treatments produced comparable reductions in acne lesion counts, with an approximate 60% reduction in inflammatory lesion count. Both treatments also reduced sebum production and yielded comparable increases in sex hormone-binding globulin. Two large placebo-controlled studies involving a total of approximately 593 women with moderate acne, found improvement in inflammatory lesions, total lesions, global assessment, and quality of life in women who were treated for six months with a triphasic oral contraceptive that contains doses of 20 to 35 mg of ethinyl estradiol in combination with 1.0 mg norethindrone acetate (Estrostep). In these studies, inflammatory lesion counts were reduced by approximately 47% .

Oral contraceptives that have been approved for the treatment of acne in the United States include ethinyl estradiol 35 mg/norgestimate (Ortho Tri-Cyclen) ethinyl estradiol 20 to 35 mg/norethindrone acetate (Estrostep), and ethinyl estradiol 20 mg/drospirenone (Yaz).

Often there is an observable improvement over the first month that continues over the course of treatment. In the vast majority of isotretinoin (Accutane) users, complexions smooth out, marks fade, and acne improves dramatically. Some lesions may still remain after you have stopped treatment, but many individuals notice that their acne continues to improve even in the weeks after treatment has stopped.

Shortly after starting isotretinoin (Accutane) therapy, some people may initially get worse before they get better. Often that’s because they stopped all of the other acne medications that they were using up until then. A minority of isotretinoin (Accutane) users have a more serious flare at the beginning of treatment. Your dermatologist can manage this by adjusting the dosage or by adding other medications to calm things down.

Most people don’t require a second course of treatment; when needed, it should be resumed only after the drug has been stopped for four months.

What not to do when you’re taking isotretinoin (Accutane)

You must avoid certain things while taking isotretinoin (Accutane), including the following:

• If you’re a woman, don’t even consider having unprotected sex while you’re taking isotretinoin (Accutane).
• Don’t breastfeed while taking isotretinoin (Accutane) and for one month after stopping.
• Don’t donate blood during treatment or for one month after stopping treatment. If someone who is pregnant gets your donated blood, her baby may develop severe birth defects.
• Treatment with tetracycline and isotretinoin (Accutane) shouldn’t be given at the same time because the combination has been associated with brain swelling (pseudotumor cerebri).
• Vitamin A should be strictly avoided while undertaking therapy with isotretinoin (Accutane) because they’re closely related to one another. The use of both vitamin A and isotretinoin (Accutane) at the same time may lead to added side effects.
• If you’re taking birth control pills, the herbal supplement St. John’s Wort may make the birth control pills work less effectively.

Sizing up side effects of isotretinoin (Accutane)

Although they’re common, side effects with isotretinoin (Accutane) are usually tolerable. In general, most folks work through many of the reactions because the drug is so effective that people with severe acne want to continue taking it despite some of the bothersome side effects. Side effects of isotretinoin (Accutane) are dose-related. That means that the higher the dosage, the greater chance of having side effects. One way around this problem is for your dermatologist to put you on a low dosage for a longer period of time. However, females will then have to continue monitoring pregnancy tests and continue birth control for a longer period of time.

Mild side effects of isotretinoin (Accutane)

isotretinoin (Accutane) is effective, in part, because it can shut down the oil production in the body, but this action accounts for some of its side effects. Because of the great decrease in oil production, even your mucous membranes, such as the inside of your nose, eyelids, and mouth, lose oil and become very dry. In fact, dryness is the most common side effect of isotretinoin (Accutane). This reduction of oil can result in some of the less serious side effects, such as:

• Dry lips: Dry, chapped, and sometimes cracked lips are the most common and persistent annoyances from isotretinoin (Accutane).These irritating problems occur in just about everybody who takes the drug. You can deal with them by gobbing on lipbalm. I recommend Vaseline Petroleum Jelly, Chapstick, or Bag Balm.
• Dry eyes: You may find dry eyes to be a problem, particularly if you wear contact lenses. You may need to stop wearing them temporarily, but the frequent use of artificial tears such as Tears Naturale or Visine True Tears may allow you to continue using contacts. Artificial tears are used as one or two drops placed in the affected eye(s), as needed.
• Mild nosebleeds: Nosebleeds occur when the nasal lining dries out. They’re usually short-lived and can be stopped with direct pressure. Nosebleeds can be prevented by coating nasal surfaces with lubricants, such as Vaseline Petroleum Jelly or Aquaphor ointment.
• Dry skin: You may notice peeling of your palms and soles, or scaly skin on the backs of your hands and forearms. Helpful moisturizers such as Eucerin cream, Moisturel, Cutemol, and Am-Lactin, are all available over the counter.

However, reduction in oil isn’t the only annoying problem you face.
You may also experience:

• Aches and pains: Musculoskeletal symptoms such as pain or stiffness of large joints or of the lower back occur and are usually very mild and disappear after a month or so. Try Tylenol
  (acetaminophen) if you experience ongoing pain.
• Increased sensitivity to the sun: I know you’re all wearing sunscreen daily anyway (hint, hint), so apply it more often and use a higher SPF than you might normally.
• Thinning hair: Less common, but still annoying; some people have reported thinning hair during treatment. Rarely has this been a persistent or a permanent problem — the hair generally grows back when the treatment regimen is over.

More serious problems

More serious unwanted events have also been reported and you should stop taking isotretinoin (Accutane) and call your dermatologist if you experience any of the following side effects. Most, if not all, of these side effects disappear after treatment is stopped, however, some have persisted after therapy:

• Changes in mood, depression, or suicidal thoughts or attempts: Depression is unfortunately a common problem in the age group that needs isotretinoin most frequently — the adolescent group.
• Allergic reactions such as an itchy red rash or difficulty breathing: In some people, isotretinoin (Accutane) can cause serious allergic reactions. Stop taking it and get emergency care right away if you develop hives, a swollen face or mouth, or have trouble breathing. Also stop taking isotretinoin (Accutane) and call your prescriber if you develop a fever, rash, or red patches.
• Changes in vision: You may experience decreased night vision. You should be particularly careful when driving at  night. Rarely has this persisted following treatment.
• Persistent headaches: A rare side effect of this drug is benign intracranial hypertension, which is an increase in pressure of the fluid surrounding your brain. If you have continual headaches that are present in the morning on waking and wear off through the day, you should be evaluated by your doctor.
• Hearing impairment: This problem has rarely persisted following treatment.
• Skeletal hyperostosis: This condition is typified by excessive bone growth along the sides of the vertebrae of the spine. It is diagnosed by X-ray studies. This problem is limited to those who take a high dosage and long-term therapy with isotretinoin (Accutane), a dosage much higher than is used to treat acne.