Approved Indications

FDA approved in 1982. Approved for severe, recalcitrant nodular cystic acne unresponsive to other first line therapies.

Physician Initiated (Off-Label) Use

  • Other Acne Use:
    • Moderate acne
    • Unresponsive Mild inflammatory acne scarring
    • Acne resulting insignificant emotional sequelae
    • Patients unwilling to use long term medication for the control of their acne
  • Acne keloidalis nuchae
  • Dissecting cellulitis of the scalp
  • Hidradenitis suppurativa
  • Pyoderma faciale
  • Rosacea
  • Grovers disease
  • Follicular mucinosis

Severe non-cystic acne

  • Severe unresponsive acne without cysts.
  • Scars often present

Moderate acne

  • Inflammatory acne causing scars or psychological harm.
  • In some the degree of acne may be mild.

Occasional or few cysts

  • Adult onset acne characterized by occasional large painful cysts that are often unresponsive to other therapy.

Excoriated acne

  • Those with compulsive disorders resulting in picking of their acne lesions producing significant scars.

Failure of, or unwilling to take long term therapy

  • Many patients do not want to continue with long term oral antibiotics which may be required for control.. Acne tends to relapse after stopping antibiotics.

Use of Isotretinoin in Rosacea

  • Unresponsive to typical rosacea therapy
  • Rosacea fulminans
  • Granulomatous rosacea
  • Localised rosacea lymphoedema


  • 0.2 to 1mg /kg/day or 10 to 60 mg a day.
  • Duration of therapy ranging from 6 weeks to 6 months
  • Higher total doses trend to better long term results
  • Start with low dose for first month makes patients tolerate the drug better.
  • 120mg/kg total dose is minimum for all patient
  • Multiple treatment acceptable
  • Long term low dose regimen is favoured by some clinicians
  • Good results in some to mini dose of 10mg daily
  • Some respond well in 2 weeks when acne like doses used
  • Reports of long term responses seen

Rosacea Variants:

    • Pyoderma Faciale
      • Severe sudden onset of pustules and abscesses.
      • Isotretinoin 1 mg /kg/day usually required for 4-5 months. Early short course of systemic steroids desirable starting at around 30mg and reducing by 5-10mg per week.This can be combined with oral anti-inflammatory antibiotics.

[Euro J Dermatol 1996;6:94-6.]

  • Lymphodema
    • Rosacea may on rare occasion present with a localized fixed plaque of erythematous swelling particularly on the forehead or cheek.
    • Low dose 0.1-0.2mg/kg/day for 2-4 months may be adequate. The dose can be increased if a poor response is achieved.