Isotretinoin — still widely known by the original brand name Roaccutane — is an oral retinoid. It is the most effective treatment available for severe acne, and unlike antibiotics or topical treatments it can produce long-term remission after a finite course rather than requiring indefinite use.
It is also the most restricted acne treatment in the UK, and the restrictions are proportionate to the risks.
Who Can Prescribe It
In the UK, isotretinoin is prescribed under the supervision of a consultant dermatologist. A GP cannot start it. That means a referral, and in most areas a wait.
It is generally reserved for severe acne, acne that has not responded to adequate courses of other treatments, or acne that is causing scarring or significant psychological distress. Failing to respond to a proper trial of topical treatment plus oral antibiotics is the usual route to it.
How It Works
It reduces sebum production dramatically, shrinks sebaceous glands, normalises the shedding of skin cells inside the follicle and reduces inflammation. It attacks every part of the process that produces acne, which is why it works when single-mechanism treatments have not.
What a Course Looks Like
Typically several months, with dosing based on body weight and a target cumulative dose. Most people take it daily with food — absorption is much better with a fatty meal, and taking it on an empty stomach wastes part of the dose.
Acne frequently gets worse before it gets better, often around weeks two to six. This is expected and is not a reason to stop, though it is worth being warned about rather than discovering it.
Side Effects
Effectively everyone gets the predictable ones:
- Dry lips — universal, and worth buying good lip balm in bulk before you start
- Dry skin, dry eyes, dry nasal passages and nosebleeds
- Increased sun sensitivity
- Muscle and joint aches, particularly with exercise
Less common but monitored: raised liver enzymes and raised blood lipids, which is why blood tests are part of the course.
Pregnancy: the Non-Negotiable Part
Isotretinoin causes severe birth defects. The pregnancy prevention programme is not a formality:
- Pregnancy tests before, during and after treatment
- Reliable contraception — usually two methods — from a month before until a month after
- Prescriptions limited in duration and dispensed within a short window
There is no version of this that can be safely relaxed.
Mental Health
Psychiatric side effects, including depression and suicidal thoughts, have been reported. The relationship is genuinely difficult to untangle, because severe acne itself causes significant psychological distress and the age group treated is one in which mental illness commonly first appears.
The MHRA's position is that patients should be asked about mental health at follow-up appointments, and that patients and those around them should be alert to changes in mood. If mood changes occur, they should be reported promptly rather than waited out. Anyone with a history of mental illness should discuss it before starting — it is not automatically a barrier, but it changes the monitoring.
Sexual Side Effects
Sexual dysfunction has also been reported, and prescribers are now expected to ask about it at follow-up. It is a legitimate thing to raise, and being asked is intended to make raising it easier.
What to Expect Afterwards
Many people achieve long-term clearance from a single course. Some need a second. Skin often remains drier than before for a period, and the sun sensitivity resolves after treatment ends.
Cost
Through the NHS, you pay standard prescription charges where applicable, plus the wait for dermatology. Privately, you are paying for consultant appointments, monitoring blood tests and the medicine itself, so the total is considerably more than the drug cost alone. Anyone quoting a price for isotretinoin without specifying what monitoring is included is quoting an incomplete number.