Dermsquared PA&NP Hub

Should we consider recommending oral omega 3 supplementation to our patients on isotretinoin for acne vulgaris?

Isotretinoin for acne vulgaris is arguably the most efficacious treatment for our patients suffering from recalcitrant acne. The most commonly encountered side effects in our daily practice are mucocutaneous in nature. Dry eyes, lips, skin, and nasal mucosa are to be expected on therapy provided optimal drug absorption and patient compliance. Therefore, it is imperative that we know how to manage these side effects in order to enhance patient adherence and achieve the desired clinical outcome of clear skin. Omega-3 supplementation has been investigated to this end due to its ability to provide many benefits.1 Not only has omega-3 supplementation been shown to help alleviate dry eye syndrome,2 especially in contact lens wearers,3 it also exerts anti-inflammatory benefits that could improve eczema which may be encountered on isotretinoin.4 Additionally, administration of omega-3 fatty acids was shown to reduce trans epidermal water loss thereby reducing skin xerosis in rats.5 This supplement also exerts cardioprotective effects by way of reducing serum triglyceride and total cholesterol levels, while increasing high-density lipoprotein concentration.6 Omega-3 fatty acid supplements are readily accessible, affordable, and generally regarded as safe. It would be reasonable to consider adding this to our treatment paradigm for patients on isotretinoin, particularly those with abnormal lipid parameters, dry eye syndrome, and those prone to dry skin, eczema, and nose bleeds. Patients that wear contact lenses can also benefit from oral administration of omega-3 fatty acids. This is a relatively easy measure to implement into our isotretinoin treatment protocol to help to reduce the well-known mucocutaneous side effects of isotretinoin, thereby optimizing patient adherence and clinical outcomes. References: Mirnezami M, Rahimi H. Is Oral Omega-3 Effective in Reducing Mucocutaneous Side Effects of Isotretinoin in Patients with Acne Vulgaris?. Dermatol Res Pract. 2018;2018:6974045. Published 2018 May 29. doi:10.1155/2018/6974045 Kangari H., Eftekhari M. H., Sardari S., et al. Short-term consumption of oral omega-3 and dry eye syndrome. Ophthalmology. 2013;120(11):2191–2196. doi: 10.1016/j.ophtha.2013.04.006 Bhargava R, Kumar P. Oral Omega-3 Fatty Acid Treatment for Dry Eye in Contact Lens Wearers. Cornea. 2015;34(4):413-420. doi:https://doi.org/10.1097/ico.0000000000000386

The Intersection of Dermatology and Psychiatry (Part Two)

HAccutane: Top 10 Hacks to Make YOU a More Confident Accutane Prescriber

What is the “dilutional effect” as it pertains to SPF?

Judicious use of broad spectrum sun protection factor (SPF) is imperative to reduce signs of accelerated skin aging, pigmentation, and cancer risk. Therefore, it is essential that we as dermatology clinicians counsel our patients on the regular and appropriate use of SPF. When speaking with my patients about sunscreen, I discuss the “dilutional effect.” I tell patients that one ounce of SPF, or one shot glass, is necessary to cover the entire body surface area. I proceed to tell them that consumers apply anywhere from 20-50% of the recommended allotment, let alone apply sunscreen at the recommended frequency.1 With this said, I instruct patients to select an SPF of 50 or greater despite the American Academy of Dermatology’s recommendation to select an SPF of 30 or greater. The rationale behind using a higher SPF is logical when framed appropriately to patients. The “dilutional effect” refers to the concept that despite using a higher SPF, one will not ultimately derive the benefit of the SPF indicated on the packaging due to inadequate application.1 Consumers are thus effectively “diluting” the protective power of their sunscreen, let’s say from an SPF of 50 to 30, for instance. This is when patients have that rewarding “light bulb moment.” Rather than waiting for patients to inquire about SPF, I initiate the conversation. My very astute patients ask me if there is really a difference in protection between an SPF of 15, 30, and 50. What I tell them is that in a lab setting, there is a marginal difference in protection afforded at each level. However, in real life, due to the improper dosage and frequency by which sunscreen is applied, there is a meaningful difference and this is key. I like to reference a study conducted by Williams et al2 that demonstrated that the use of higher level SPFs in real life were more effective than lower value SPFs in protecting against sunburns. The concept of the “dilutional effect” highlights the need to understand the real-world application of sunscreens in order to better inform our patients and improve their understanding of sun protection. References: Petersen B, Wulf HC. Application of sunscreen− theory and reality. Photodermatology, photoimmunology & photomedicine. 2014 Apr;30(2-3):96-101. Williams JD, Maitra P, Atillasoy E, Wu MM, Farberg AS, Rigel DS. SPF 100+ sunscreen is more protective against sunburn than SPF 50+ in actual use: Results of a randomized, double-blind, split-face, natural sunlight exposure clinical trial. J Am Acad Dermatol. 2018;78(5):902-910.e2. doi:10.1016/j.jaad.2017.12.062

Hidradenitis Suppurativa: An In-Depth Review of Pathophysiology, Clinical Presentation, and Therapeutics

Should we consider recommending antihistamines when prescribing isotretinoin for acne vulgaris?

Medically reviewed on 5.15.25 by Nicholas Brownstone, MD Isotretinoin is undoubtedly the most efficacious treatment for moderate to severe recalcitrant acne vulgaris. Those that prescribe this drug see the powerful results it can achieve, yet many patients hesitate to pursue this treatment option despite failing to improve on other medications. Patients and their families have certain reservations about starting this drug. One of which is the fear of an initial “purge” or “flare” of their acne. It is imperative for clinicians to understand this phenomenon and of equal importance, how to prevent it. To this end, several studies have surfaced investigating the role of combination therapies with isotretinoin. One of these combinations is the administration of antihistamines concurrent with isotretinoin. A small study conducted by Lee et al1 demonstrated a reduction in acne flares, lesion count, erythema, and sebum in those patients treated with combination therapy when compared to those on isotretinoin alone. Two more studies demonstrated similar results, showing a reduction in acne lesion count, acne flaring, and pruritus induced by isotretinoin in those receiving isotretinoin plus desloratadine.2,3  Pandey and Agrawal4 also assert that patients taking isotretinoin and levocetirizine compared to isotretinoin alone had a statistically significant decrease in both inflammatory and non-inflammatory lesion count and less flaring of acne. Although these are relatively small studies, the results are promising. Antihistamines are readily accessible, affordable, and generally regarded as safe. It would be reasonable to consider adding this to our treatment paradigm for patients on isotretinoin. In my own clinical practice, I have elected to add either omega 3 fatty acid supplementation or antihistamines concurrent with isotretinoin based on individual patient risk factors. Both have proven to be effective and have increased patient satisfaction and clinical outcomes. References: Lee HE, Chang IK, Lee Y, et al. Effect of antihistamine as an adjuvant treatment of isotretinoin in acne: a randomized, controlled comparative study. J Eur Acad Dermatol Venereol. 2014;28(12):1654-1660. doi:10.1111/jdv.12403 Hazarika N, Yadav P, Bagri M, Chandrasekaran D, Bhatia R. Oral isotretinoin with desloratadine compared with oral isotretinoin alone in the treatment of moderate to severe acne: a randomized, assessor-blinded study. Int J Dermatol. 2024;63(7):929-935. doi:10.1111/ijd.17129 Van TN, Thi LD, Trong HN, et al. Efficacy of Oral Isotretinoin in Combination with Desloratadine in the Treatment of Common Vulgaris Acne in Vietnamese Patients. Open Access Maced J Med Sci. 2019;7(2):217-220. Published 2019 Jan 25. doi:10.3889/oamjms.2019.054 Pandey D , Agrawal S . Efficacy of Isotretinoin and Antihistamine versus Isotretinoin Alone in the Treatment of Moderate to Severe Acne: A Randomised Control Trial. Kathmandu Univ Med J (KUMJ). 2019;17(65):14-19.