SIMON’S spotty skin had bothered him since he was 13. With random purulent eruptions and the oily glow of perpetual inflammation, his face had been like a red traffic light at the intersection of Boy Road and Teen Street.

Around the time of his 15th birthday six months ago, Simon went with his mother to see a dermatologist and was prescribed the medication Isotane to treat his rampant acne.

“I was kind of sick of it after a while, and just wanted to get rid of it,” he says. “I had tried creams and stuff but they did not do anything. I also tried antibiotics, but they didn’t work very well either.”

The 2006 census counted more than 600,000 New Zealanders aged between 15 and 24. With some estimates putting the incidence of acne requiring treatment at 40% of older adolescents, there could be up to quarter of a million people seeking solutions for their spots at some point in their lives.

This month there is good news for sufferers like Simon. Pharmac says family doctors can now prescribe Isotane with full subsidy, meaning people no longer have to pay the high fees of about $150 per session to see a skin specialist.

However, the drug, a vitamin A derivative, has crossed ethical terrain as rugged as the skin ailment it aims to treat. Linked with depression and suicide, and confirmed as a teratogen causing birth defects, its use has been tightly monitored for the past 20 years.

Using a drug like Isotane (generic name isotretinoin, earlier called Roaccutane) isn’t necessary for most people with pimples. The simple solution for them is regular use of a soapy flannel. But for those plagued with severe acne, the anxiety of altered appearance can be overwhelmingly complex.

Louise is a stunning 22-year-old student, who models part-time and is aiming for a job in communications when her studies are over. She is the last person you could imagine staying at home on a Saturday night splattering the bathroom mirror with projectile pus. But just over a year ago her face staged an acne riot.

“For me it was bad. I had never had pimples before and then at 21, I suddenly had this massive outbreak. I wanted to deal with it because it affected my confidence. I definitely needed to treat it to feel better about myself.” She started a course of Isotane.

When asked about side effects, Louise feels, in balance, it was worth overcoming these for the benefits of clear skin. “First, I had very dry skin and my lips cracked. I actually had a split bottom lip for a while and that was pretty painful.

“I was a little bit concerned about the depressive tendencies, because I have had a little bit of a problem with that before, with the contraceptive pill. My family doctor said that the pill I was on worked in together with Isotane. I wanted to risk it to get better skin. Because I wasn’t trying to get pregnant at the time, I did not see it as a big issue. I didn’t really suffer any major side effects.”

Simon says he, too ,was made fully aware of the pitfalls of the medication.

“The specialist told me about the side effects. He mentioned dry skin, which was a bit of a problem, but nothing too major. He also talked about depression, but I wasn’t affected in any way. If anything, I felt better because my skin was clearing up.”

Wellington general practitioner Carol Shand says improving access to acne treatment for everyone will make the drug less exclusive. “One of the disadvantages of it only being available through a specialist is it is really only people with enough money who can afford to go private.”

Access to public hospital dermatology services in many areas means a long waiting time and acne is not a priority, she says. “It has become a drug which is only available really for the rich.”

Louise says it depends on how much you value the clarity of your skin. “I suppose I was lucky my mum paid for it. I know it sounds shallow, but I need to look good to feel good, and to actually function well. My mum understands that. If you feel it will help your self-esteem and your confidence, then it is worth every cent.”

Dr Shand says the drug has been around for a long time, and everyone is now very familiar with its side effects, of which she agrees there are many.

She believes many of the actual disadvantages are probably better dealt with by family doctors. “Pregnancy risk is something that GPs manage with skill. We prescribe contraception and monitor contraception regularly. Likewise, we manage depression and mood disorders. So in many ways the side effects and risks are more appropriately managed in general practice.”

Consultant dermatologist Bruce Taylor says family doctors need to be careful.

“It is a drug which is quite a complex drug to prescribe. There are some potentially nasty side effects. I don’t have a problem with GPs prescribing it, but I do have some concerns about the training they are going to get in how to manage it properly.”

There is a wide spectrum of acne, says Dr Taylor. People can have nodulocystic acne, a severe form of acne that is characterised by numerous deep, inflamed bumps (nodules) and large, pus-filled lesions that resemble boils (cysts), or it may cause scarring or be wide-spread covering a person’s chest and back. It can be a major psychological stress.

Dr Taylor says it takes more than five minutes to discuss use of the drug with a patient and often involves thorough discussion with parents and teenagers. “Every one gets drying of the skin. There are less common side effects of sore muscles, headaches and blurred vision. It can upset liver function. There are the increasingly controversial issues of pregnancy and perhaps mood swings and depression.”

There is no firm evidence to say that it does cause depression or teenage suicide, he says. Mood problems common enough with most adolescents can be unfairly blamed on the drug. He has an open mind about whether it does mess with emotions, but thinks people certainly should be warned about the possibility of depression.

“It does actually work very well. It has had its share of media beat-ups over the years, but it is by far the best treatment for severe acne. Roaccutane or Isotane has been in New Zealand since the 1980s, and nothing comes close to the drug in terms of treating severe acne. The results are very, very good for most people.”

Alice, a 40-year old mother of three, jumped on the Roaccutane bandwagon back in the 1980s, when her anxious mother took her along to a skin specialist with her pock-marked brother.

“It was like a miracle drug when it came out. My brother had terrible acne right down his back. The doctor looked at me through a microscopy thing, I did have some spots on my chest, but not much, and just about none on my face, and he said ‘yes, she is going to get acne too’, so they put me on the drug as well.

“I never really had bad acne, but I was on the drug for a number of months. I have since heard it can cause serious liver damage. It must be worthwhile for people who have shocking acne like my brother. His back looks like the moon surface now, it’s so scarred. But there is no acne, it certainly cleared it up.”

Now, Alice is faced with a new generation of spotty bother. Her 16-year-old son has taken after his uncle and is plagued by pimples. However, she has taken a different path to her own mother and believes there are other roads through the valley of adolescent angst about acne.

“There are alternatives that people can use instead of going on a radical drug. Food intolerance and allergy is absolutely rife and completely under-diagnosed. It is amazing what happens to my son’s skin when he stops eating chocolate and eggs.

“I know that kids can get depressed if they think they are looking awful because of their skin. But I certainly wouldn’t give a teenage kid a drug that might give them depression. No way, under no circumstances whatsoever. Acne does go away. He will grow out of it.”

Government drug buying agency Pharmac has consulted with both specialists and family doctors, and medical director Dr Peter Moodie says widening access to the medication has been made with full awareness of patient safety issues.

“Our prescribing data shows this drug is less used in deprived areas than it is in well-off areas of New Zealand, so there is clearly an equity issue. Widening access would remove this.

“At the same time, we have confidence that general practitioners who prescribe this drug will be well trained and aware of the need to prescribe this medicine carefully, and monitor patients closely. We are confident that patient safety will be maintained while the equity issue is resolved.”

Some doctors are worried that if more people take the drug there will be a risk of increased numbers of pregnancies being exposed to birth defects from Isotane.

According to Wikipedia more than 2000 American women became pregnant while taking the drug between 1982 and 2003, with most of those pregnancies ending in abortion or miscarriage. About 160 babies were born with birth defects such as hearing and visual impairment, missing earlobes, facial dysmorphism, and mental retardation.

Pharmac believes that close and ongoing contact between individuals and family doctors is the best way to reduce the risk of accidental pregnancy, especially with the doctor also providing contraception advice.

The other key concern about the drug is increased risk of suicide. Pharmac, like dermatologist Dr Taylor, notes a lot of emotive debate, but little evidence confirming a link to Isotane.

The agency affirms family doctor Carol Shand’s view that general practitioners are well placed to know a patient’s medical history, and better positioned to detect symptoms of mental ill-health, including depression and suicidal thoughts.

Dr Shand says she feels reasonably comfortable now that Isotane is becoming available in general practice and hopes her colleagues will be sensible in prescribing it. “GPs should be cautious. It does have problems. It is not a particularly nice drug. It would be sad if it were in wholesale use. There is no reason why GPs should do that, any more than would happen now, by writing a specialist referral.”

Specialist Dr Taylor says he still expects to see some referrals from family doctors, especially for those people with complex and severe acne. “I would like to see, now this is happening, that the people who are prescribing the drug are well trained, otherwise there will be problems.”

Pharmac’s Dr Moodie says information will be provided to doctors through the Otago University-based Best Practice Advocacy Centre, and through its own seminar series. The Royal NZ College of General Practitioners is asking its members to update their knowledge about the drug and has commissioned a new British Medical Journal learning module on Isotane, which it hopes will be available in early April.

Dr Moodie says the decision to widen access will probably lead to a 5% to 10% increase in the use of Isotane. Pharmac estimates this will cost it between $55,000 and $100,000 more a year. 

Meanwhile Louise thinks the improved availability of the acne treatment is a bonus.

“If it is more accessible through family doctors, then it will be less embarrassing and less awkward for young people to get help. If you feel good and look good then you usually show that in your personality, and the way you project yourself.

“I think being comfortable in your own skin is really important.”

Fifteen-year old Simon agrees. “Now that my skin has cleared up, it has made a massive difference, I feel a lot more confident, with like talking to girls, and stuff.”

“I would highly recommend it,” he says with a genuine wide grin from a face with a clean and clear complexion.

 
Do not take Isotane if you:
1. Are pregnant, or you intend to become pregnant. If you become pregnant while taking ISOTANE, there is an extremely high risk that your baby will be severely deformed. Effective birth control must be used one month prior to starting ISOTANE treatment, during treatment and for at least one month after treatment has finished.
2. Are breastfeeding. You must not breastfeed while taking ISOTANE. Isotretinoin is likely to pass into the breast milk and may harm your baby.
3. Have liver disease.
4. Have very high cholesterol.
5. Are allergic to vitamin A

Before you start, tell your doctor if you:
1. Are depressed, have a mental illness, have thoughts about suicide, or you have had them in the past.
2. Have any other health problems, especially the following:
• you are considerably overweight
• diabetes, or a history of diabetes in your family
• a history of pancreatitis (inflamed pancreas)
• kidney disease
• high fat levels (cholesterol, triglycerides) in your blood.
3. Drink large amounts of alcohol.
4. Are on the “mini-pill”.
5. Undertake regular vigorous exercise.

Possible side effects

   Mild signs that can be managed:
• dryness of the lips, mouth, throat, nose, eyes or skin
• skin eruptions, rashes, itching, inflammation, redness, sweating or changes in skin colour
• nail inflammation, infection or altered appearance
• nosebleeds
• tenderness, soreness or stiffness in your bones, joints or muscles
• headache
• an increased sensitivity to sunlight
• hair loss, thinning or increased growth.
Serious symptoms needing immediate medical attention:
• you feel depressed (have feelings of deep sadness and unworthiness or feel “down”)
• changes in your normal behaviour
• suspected pregnancy
• nausea, vomiting, diarrhoea with blood and mucous, stomach pain or fever
• persistent headache, severe headache or seizure
• blurred vision or visual disturbances, including decreased vision at night
• severe stomach pain which passes straight through to your back (infected pancreas)
• blood in your urine
• tiredness, signs of bruising or bleeding easily
• signs of infection such as swelling, tenderness, redness and increased temperature
• sudden signs of allergy such as a skin rash, itching or hives; swelling of the face, lips, tongue or other parts of the body; shortness of breath, wheezing or trouble breathing.