My derm won't prescribe another course of accutane, what can I do?

[preludesi88]

Hi.  I'm 22 years old and have been through two full courses of
accutane.  I still have mild to moderate acne, especially on my back and shoulders.  Last year my derm prescribed minicycline along with tazorac gel and brevoxyl 8.  I knew that none of this stuff wouldn't really do much and it didn't.  I figured I'd bite the bullet and give accutane one last shot.  After all, after all the creams and pills, it was the only method that actually cleared my skin, at least temporarily.  Anyway, I figured I'd go back to the derm and demand accutane.  Now I've been going to him since 1997 and he has been a long term supporter of accutane so I thought no problem.  He checked me out and asked me if I would try doxycycline along with avar cleanser.  I thought to myself this is another waste of time appointment.  Finally I just asked him straight out why not accutane. He said he'd love to do accutane again but he can't.  He said that the FDA has been very strict and he would have to sign a consent form that
states that I have severe acne. He said they came up with this form because their initial plan was to take it off the market. He said by signing this form he would be commiting perjury.  He just wants me to try this treatment because he figures I'll grow out of this soon.  I'm not so sure about that.  I think he is just trying to pasify me by prescribing these meds.  So now it seems as though I'm stuck.  Should I try to go to somebody else?  I don't want to waste more money on office visits if what he is saying is true and that no derm willprescribe it for moderate acne.  All I know is I have a million different prescriptions for products that just don't work for me.  Go figure that the one that could actually help isn't available to me.   figure I wasted my money with that appointment.  In fact, I don't even
know if its worth getting the prescriptions filled.  I am trying thesamples now but nothing doing yet.  

a brief timeline of what i've been on, Oct 97-Feb 97 Doxycycline 100mg/day with retin-a and differin gel, March 97-July 97 Accutane 80mg/day, March 98 Brevoxyl 8%, March 2000-July 2000 Accutane 80mg/day, Apr 02-Apr 03 Minocycline 100mg/day tazorac gel .1% and brevoxyl 8%, Latest prescription for 100mg doxycycline and Avar cleanser

In fact I asked for accutane last year and he told me I wouldn't need it.  In both cases where I took accutane I was clear for about a year until it came back again.  I suppose the good thing is that my face hasn't really gotten worse.  Maybe the treatments helped in that regard but my back continues to get progressively worse.  I even have some cysts.  To me that seems severe enough. My skin is still relatively oily.  In fact I still get acne in my scalp.  I was thinking that since it did help my face to a certain extent, maybe one more good treatment would help my back. I agree.  I'd much rather avoid the stuff but on the same note, taking oral antibiotics in an effort to control it isn't exactly a good idea either.

[Alan Rockoff, MD]

I don't know about the perjru part, but I am inclined to agree with your dermatologist that if Accutane has failed to give you a long-term remission over two courses, a thrid course will probably result in another relapse.  Also, treatments like doxycycline that don't work before Accutane often work afterwards.

I guess you can always get another opinion, but here's a tip: professionals like physicians have a bit of a problem with patients/clients who come in "demanding" a certain treatment, who are intolerant of alternate suggestions, however patientlt explained, and who consider a visit in which they didn't get what they demanded a "waste of time."

Medical treatment is a partnerhsip that requires mutual patience and trust.  It sounds as though your current dermatologist took the time to explain his position.  Still, if you've lost confidence in his judgment, you ought to look elsewhere.

Take care.

Dr. Rockoff

[preludesi88]

Thanks for the tip.  I think you may have miss understood me in a sense.  I never demanded anything.  I went in and he gave me a two minute evaluation and then decided to go with the doxycycline.  He told me that I'll probably grow out of it soon so it shouldn't be a problem.  I agree that sometimes you will get a better response from antibiotics after a few courses of accutane.  But I suppose I felt that a year on minocycline with virtually no result might account for something.

I'm a professional myself, and I have to deal with my clients demanding things on a daily basis.  Here's my point.  I'm not a doctor, and I respect all the individuals that work in your profession.  However on the same note, I respect when my clients inquire about certain things as long as they educated themselves before hand.  In my case I educated myself as much as I could and from my research, a third course of accutane *may* be beneficial.  Is that a definate?  Of course not and I understand that it may fail  The second course cleared my face fairly well.

Besides, he really is a good doctor.  It's not that I don't trust his judgement.  It's more about how people are sue crazy in this country, and they can cause restrictions on certain drugs as well as doctors' treatment methods.  I could almost detect the reluctance in his voice.  Hey I can't blame him or any other doctor for that.  I wouldn't want to risk losing everything either.  Anyway thanks for the advice.  I'll probably get another opinion, and if it doesn't work out then I'll accept it.  

Thanks again,
Josh

[Alan Rockoff, MD]

Thanks for your response.  It's of course hard to gauge tone from an e-mail.

I don't think that at 22 you're likely to grow out of acne soon, or at least you can't count on it.  I also am unaware that your doctor would be in any legal jeopardy if he prescribed it to you.  Basically, it's a judgment call.

Bottom line, I'd get another opinion.

Dr. Rockoff

[preludesi88]

Hi Dr. Rockoff

Well I took your advice and got another opinion.  I gave this derm a list of meds I was on and he took a look at my back.  I asked him about one last try with accutane since nothing else seemed to help.  Without hesitation he said ok to it.  He didn't object or question it and I didn't push the issue either. If he would have said no, I would have complied. Seems to me that he must have felt it was "severe" enough to warrant accutane.

Anyway I wanted to know your suggestions on treating the dry lip side effect.  In the past I've used Aquaphor which works great but my lips tend to get a red tint around them.  Is there anything I can use to help reduce this.  I'd rather not look like I'm wearing lipstick if I can avoid it, haha  This dry/chapped lip side effect is the only one that ever annoyed me so I could at least control it somewhat, this last course might not be so bad.

Thanks in advance,
Josh

[Alan Rockoff, MD]

2 capsules of Vitamin E 400IU may help, along with the Aquaphor.

Dr. Rockoff

[preludesi88]

Hello again Dr. Rockoff

A few questions about the vitamin E if you don't mind.  What kind should I take? I've seen the regular d-alpha Tocopherol and the mixed version.  Does it make a difference?  Also from what I understand vitamin E is fat soluble so I should take it with food, correct?  Would it hurt to take both the Accutane and vitamin E at the same time, say after a meal for example?  Finally,since Accutane is a derivative of vitamin A, is there any harm with taking two fat soluble vitamins (A and E) simultaneously?

Sorry for the abundance of questions.  I have researched the dry lip condition as much as I could before asking you my previous question.  In fact I have read elsewhere about the vitamin E so I had already picked up a bottle, but I didn't want to start using it until I consulted a professional.  You know how information on the internet can be...not_always_reliable

Thanks in advance,
Josh

[Alan Rockoff, MD]

None of these factors (type of pill, time of taking) matters.

Dr. Rockoff

[preludesi88]

Hi Dr. Rockoff,

Can you recommend anything for the minor swelling of the lips?

Thanks again,
Josh

[kvnmc07]

A related discussion, After 3rd course of accutane now what? was started.