ACCUTANE-NONRESPONDERS ------------------------------------------ I have a 17 year old woman patient that has had three 5 month courses of Accutane @ the dose of 1mg/kg over the last 3 years. She had cystic acne which was completely cleared with Accutane, but she continues to have recurrences of milder acne that is resistant to Minocin, Retin-A, and Benzamyacin gel. The acne improves with each course and she tolerates it well. She would like to start another course of Accutane, but at this point I wonder if she would obtain any further lasting improvement following a fourth course. Any suggestions? Has anyone seen more improvement after two or three courses? Sally Moore PA-C ================= It may be time for Course #4 ,this time at 1.5mg/kg. 20 weeks. Daniel F Mitchell MD ==================== Four courses over 3 years starts to look pretty unrewarding. Have you checked androgen levels? Even in some Accutane non-responders I've had some success with spironolactone, usually with p.o. antibiotics. Mark R Ling MD PhD ================== I would add my opinion that serum androgens need checking and that spironolactone may be of some value but I have never found it to be good monotherapy, even at 200mg/day. I currently figure accutane courses using the 125mg/kg dose using the formula Wt. in kg x 125mg divided by the daily dose then divided by 7 to get the # of weeks. I also agree with the earlier writer that higher doses may be of value since when we started using accutane in the 80's I was using 2mg/kg and none of those patients relapsed that I know of. Cost , side effects and current package inserts and articles support the 125mg/kg total dose as providing the best balance, not necessarily the most long remissions. L.J. Gregg MD ============= I concur with others that it may be worthwhile to check free testosterone and DHEAS. In my experience, this patient has not been treated with enough accutane. On the first round, I generally use 1 mg per kg. On subsequent courses, I increase (as much as side effects will allow) to 1.5 to 2 mg/kg. Studies have clearly shown that the higher the total dosage in a treatment course, the more longlasting is the response. I've had the experience of seeing several patients who did not respond to accutane in doses as high as 2 mg/kg for 20 weeks. Although this may be regarded as anecdotal nonsense, I've controlled two of these patients on dapsone over the long term. All antibiotics known to man had previously failed. Alan Fleischer MD ================= Zithromax [azithromycin] 250 mg/d plys Naprosyn-SR 750 mg daily or bid works about as well as Accutane [Jim Rasmussen @ Ann Arbor published a good paper on NSAID/ABX for acne a number of years ago.]. Zithromax is my fave because of very high skin levels. KSmithDerm@aol.com ================== You could consider a longer-term low dose type treatment. I would guess that your patient may nevercompletely clear, and I would be a little concerned about more long-lasting occurrence of side effects, like dry eyes, skin fragility, etc. A dose I have sometimes used for desperate patients is 20 mg qod or 40 mg 2 times weekly for 8 months or more, but this usually only gives temporary treatment. Otherwise, maybe an aggressively dosed course, like 40mg bid. Heidi Cole, MD ============== It's my understanding that after the 5 day loading dose regimen for Zithromax, it is possible to maintain therapeutic serum levels with a single 250 mg dose per Week: therefore I'd be a bit concerned at the possibility (which I would guess is QUITE likely) that with a long-term 250 mg. QD dosing regimen one could rapidly build to potentially toxic levels. At the least, I'd like to check with Pfizer regarding any experience with extended dosing regimens before making this commitment. Mark Ling, MD, PhD ================== Have you tried a scan for policyclic ovaries? Cyproterone acetate would be a good choice in that case (perhaps available in Europe only). Enrico Ceccolini M.D. ---------------------