Isotretinoin Explained
The only acne treatment that can end acne rather than control it — and the most tightly regulated. Who it is for, how UK referral works, and what a course actually involves.
Part of the Complete Acne Guide.
Key fact: Isotretinoin is the only acne treatment that can produce lasting remission rather than control. It is also the most tightly regulated, and in the UK it can only be prescribed and supervised by a consultant dermatologist — not by a GP, and not by an online pharmacy.
What isotretinoin is
Isotretinoin — still widely known by the discontinued brand name Roaccutane — is an oral retinoid, a vitamin A derivative. It is the only acne treatment that acts on all four processes behind acne at once: it shrinks the sebaceous glands and dramatically reduces oil production, normalises the shedding of cells that block the follicle, reduces the bacterial population that depends on that oil, and dampens the inflammation.
Because it shrinks the glands themselves, its effect can persist after the course finishes. That is what separates it from everything else: other treatments control acne while they are being taken, and this one can end it.
We do not prescribe isotretinoin, and neither does any online pharmacy in the UK. It is a hospital-only medicine. This guide exists so that you know what it involves, whether you might be a candidate, and how to get to the people who can prescribe it.
Who it is for
Isotretinoin is not a first step. UK guidance reserves it for specific situations:
- Severe acne — nodules or cysts, or acne covering large areas of the face, chest and back.
- Acne that is scarring, at any severity. Visible scarring is a reason to escalate early rather than wait, because scars are permanent and the acne is not.
- Acne that has not responded to a proper course of standard treatment — which means a topical retinoid or combination topical plus an appropriate oral antibiotic, each given long enough to work.
- Acne causing significant psychological distress, which is a recognised reason in its own right regardless of how it looks to someone else.
- Acne that relapses quickly each time treatment stops.
“Long enough to work” is the phrase that trips people up. Standard treatments need at least eight to twelve weeks before being judged, and a fortnight of a cream does not count as having tried.
How referral works in the UK
| Stage | What happens |
|---|---|
| Standard treatment first | A GP or prescriber treats with topical and usually oral treatment for a defined period. This is a prerequisite, not a delaying tactic — a dermatologist will ask what has been tried and for how long |
| Referral | Your GP refers to dermatology. NHS waiting times vary considerably by area; private dermatology is an option and the same prescribing rules apply |
| Dermatology assessment | Severity, scarring, previous treatment, medical history, mood, and pregnancy risk are all assessed |
| Baseline tests | Blood tests before starting, and a pregnancy test for anyone who could become pregnant |
| Ongoing supervision | Monthly review throughout the course, with repeat blood tests and, where applicable, monthly pregnancy testing |
Keeping a record of what you have taken and for how long genuinely shortens this. “Three months of lymecycline with adapalene, then three months of doxycycline with benzoyl peroxide” is a referral; “I've tried everything” is not.
What a course involves
A course usually runs four to eight months, dosed by body weight, with the aim of reaching a cumulative total dose associated with lasting remission. Dose is often started low and increased.
Acne commonly worsens in the first few weeks before it improves. This is expected, it is not a sign of failure, and being told in advance is most of what gets people through it. Meaningful improvement typically begins at one to two months, and skin often continues improving for months after the course ends.
Pregnancy prevention
Isotretinoin causes severe birth defects. The risk is very high and affects the brain, face, heart and other organs, and it applies to any pregnancy during treatment or in the month after stopping. This is not a precaution — it is the single most important fact about the drug.
Anyone who could become pregnant is enrolled in a formal Pregnancy Prevention Programme, which requires medically supervised pregnancy testing before, monthly during and after the course; highly effective contraception from one month before until one month after; and monthly prescriptions dispensed within a short window.
Isotretinoin does not affect future fertility, and pregnancy after the drug has cleared — one month after the last dose — is not affected by it. Blood donation is not permitted during a course or for a month afterwards, for the same reason.
Side effects, and what is monitored
Side effects are near-universal, mostly dose-related, and almost all reversible.
| Effect | What to know |
|---|---|
| Dry lips | Affects essentially everyone. Lip balm constantly, from day one rather than once it starts |
| Dry skin, eyes and nose | Common. Nosebleeds are frequent. Contact lenses often become uncomfortable |
| Sun sensitivity | Skin burns more readily. Daily sunscreen throughout |
| Muscle and joint aches | Common, particularly with heavy exercise. Worth discussing before a training block |
| Blood changes | Liver enzymes and blood fats can rise, which is why blood tests are repeated. Usually manageable with dose adjustment |
| Alcohol | Restricted, because both alcohol and isotretinoin affect the liver |
| Hair thinning | Uncommon and generally reverses after the course |
| Skin procedures | Waxing, laser and dermabrasion are avoided during and for some months after, as the skin is fragile |
Mood and mental health
This deserves a straight answer rather than either reassurance or alarm. Reports of depression, anxiety and suicidal thoughts in people taking isotretinoin have been investigated extensively, including a major UK regulatory review. A definite causal link has not been established, and severe acne independently raises the risk of depression — which makes the two very difficult to separate.
What UK regulators concluded is that a possible association cannot be excluded, and that psychiatric monitoring should be part of every course. In practice that means mood is asked about before starting and at every review, and anyone with a history of mental health difficulty can still be treated but is monitored more closely.
What to do: tell the dermatologist about any history of depression or anxiety — it is not a bar to treatment. Ask someone close to you to mention it if they notice a change. If your mood changes during a course, contact the team rather than stopping on your own. Isotretinoin is also associated with sexual side effects in a small number of people, which should be reported in the same way.
Afterwards, and relapse
Most people are clear or nearly clear at the end of a course, and skin frequently continues to improve for several months afterwards. Somewhere around a fifth to a third need a second course, more often those who were younger at the first course, had acne mainly on the trunk, or received a lower cumulative dose.
A second course is a normal outcome rather than a failure. Between courses, or where acne returns mildly, maintenance with a topical retinoid is commonly used.
What to do in the meantime
Referral takes time, and untreated acne scars while you wait. The productive use of that period is to complete a proper course of standard treatment — which both improves the acne and is the prerequisite for referral.
That means a topical retinoid or combination topical used consistently for at least twelve weeks, with an oral antibiotic where the acne is inflammatory, and photographs taken along the way so the response can be judged rather than remembered. What is available without an in-person appointment is set out on our acne treatment page, and if scarring is already appearing, say so — it changes the urgency.
Frequently Asked Questions
Can I get isotretinoin online in the UK?
No. Isotretinoin is a hospital-only medicine in the UK and can only be prescribed and supervised by a consultant dermatologist. No online pharmacy and no GP can prescribe it, and any service offering it without dermatology supervision is not operating legally. The route is a GP referral to dermatology, NHS or private, after a proper course of standard treatment.
What do I need to have tried before I can be referred for isotretinoin?
Generally a topical retinoid or combination topical together with an appropriate oral antibiotic, each used long enough to be judged — at least eight to twelve weeks, not a fortnight. A dermatologist will ask specifically what was used and for how long, so keeping a record helps considerably. Severe scarring acne, or acne causing significant psychological distress, can justify earlier referral.
Does isotretinoin cause depression?
The question has been investigated extensively, including by UK regulators, and a definite causal link has not been established. Severe acne itself raises the risk of depression, which makes the two hard to separate. Regulators concluded that a possible association cannot be excluded and that psychiatric monitoring should form part of every course. Tell the dermatologist about any history of depression or anxiety — it is not a bar to treatment, and it means you will be monitored more closely.
Why does acne get worse when you start isotretinoin?
An initial flare in the first few weeks is common and expected as the treatment begins acting on existing blocked follicles. It is not a sign that the drug is not working. Meaningful improvement usually begins at one to two months, and skin often continues to improve for several months after the course has finished. Dermatologists sometimes start at a lower dose to reduce the severity of the initial flare.
Will my acne come back after isotretinoin?
For most people the improvement lasts, which is what distinguishes isotretinoin from treatments that control acne only while being taken. Roughly a fifth to a third of people need a second course, more often those treated younger, those with acne mainly on the trunk, and those who received a lower total dose. A second course is a normal outcome rather than a failure, and maintenance with a topical retinoid is commonly used afterwards.
References
- National Institute for Health and Care Excellence. Acne vulgaris: management (NG198). nice.org.uk
- National Institute for Health and Care Excellence. Clinical Knowledge Summary: Acne vulgaris. cks.nice.org.uk
- NHS. Acne. nhs.uk
- British Association of Dermatologists. Patient information leaflets and isotretinoin guidance. bad.org.uk
- Medicines and Healthcare products Regulatory Agency. Isotretinoin: Pregnancy Prevention Programme and safety review. gov.uk
- DermNet. Acne and acneiform eruptions. dermnetnz.org
Medical disclaimer: This article is for informational purposes only and does not constitute medical advice. Several acne treatments, including oral retinoids and the tetracycline antibiotics, must not be used in pregnancy or when there is any chance of becoming pregnant. Acne treatment takes weeks to months to work and a short-lived worsening at the start is common. Always consult a qualified healthcare professional for diagnosis and treatment. In a medical emergency, call 999.