October 18, 2021
When under the care of your dermatologist or doctor, Isotretinoin or Accutane is mostly considered safe and one of the most effective treatments for severe acne.
Most patients are free of acne after 4 to 6 months of treatment. But can acne come back after accutane? The unfortunate answer is yes, some people will have a relapse after taking Accutane and the long term cure rate is actually a lot lower than what people expect.
Can you relapse after Accutane?
Yes, The relapse rate for Accutane can be as low as 10% to as high as 60% depending on dosage and length of treatment.
In a 2021 study, patients had a 69.5% relapse rate 2 years after their isotretinoin ( accutane ) course.
The factors that determine if you will relapse after Accutane:
Accutane (isotretinoin, Roaccutane, Claravis, etc) is one of the world’s most commonly prescribed acne treatments.
A lot of people have turned to Accutane to clear their severe acne or acne that has been resistant to other treatment methods. This is often people's last resort, not only because doctors aren't "supposed" to prescribe it as a first-line treatment (they would rather jump right to harmful antibiotics), but also because there is a lot of fear-mongering surrounding it as a treatment. People are worried that they're going to cause serious damage to their bodies by using it, even though side effects like that are very rare. Thankfully, isotretinoin is considered safe.
Regardless of the stigma surrounding it, Isotretinoin remains the most effective treatment for severe acne, as well as cases of more moderate acne that is unresponsive to other treatment modalities. Accutane however is not always a permanent cure for acne. Anywhere from 10% to 60% of patients may experience acne again in the future.
To date, the efficacy of isotretinoin has not been superseded by any other treatment, and over two decades later isotretinoin remains the most clinically effective anti-acne therapy, producing long-term remission and/or significant improvement in many patients. This is why people opt for it - it's almost a sure thing. For example, here's some before and afters of Accutane:
Most patients who receive oral isotretinoin or Accutane will be free of acne by the end of 4–6 months of treatment depending on the dose.
However, recent clinical experience suggests that the long-term cure rate may be lower than was initially thought, and Accutane relapse rates may be higher, depending on a variety of variables (1)(2)(3)(4).
For some, it may be a permanent cure to acne, but acne can come back after Accutane for 10% and 60% of patients.
One explanation might be due to the fact that isotretinoin is now used to treat patients with less severe acne. These cases respond extremely well, and then patients expect to remain clear, whereas the initial cohorts of patients had severe disease and were less concerned by the resurgence of a few spots. This means that people with severe acne who used Accutane wouldn't consider the development of a few pimples after treatment to be a relapse, whereas people with mild acne who used Accutane would.
Some patients will not accept even minimal disease; however, this speaks more to a patient's own reservations, and not necessarily the efficacy of the product. So if you took Accutane and your skin cleared up, but then you still get regular pimples afterward - don't panic - it's probably just something in your diet or lifestyle that needs to be tweaked. You likely don't need a second course.
There is increasing evidence that younger patients relapse more readily than older ones. This is likely due to the fact that older patients generally experience fewer changes and shifts in hormones as they age, while younger patients have many years of hormonal changes before them.
This is not to suggest that young patients should avoid Accutane - just that they should be aware that they are at risk of a higher relapse rate. With that being said, using isotretinoin early on in the development of severe acne may lessen scarring, both emotional and physical, and relapse later in life may be less damaging than hard-to-clear scarring.
Early studies with isotretinoin found that it was 1.5 - 2 times more bioavailable with food ingested one hour before, with, or one hour after dosing than when given during a complete fast.
Having a meal with a larger percentage of fat can increase the absorption of isotretinoin. As the oral bioavailability of oral isotretinoin is variable and highly dependent on administration with food, it's likely that earlier relapse may occur if patients often took isotretinoin on an empty stomach, thus leading to lesser actual cumulative drug exposure despite the daily dose administered.
When taken without food, fasted isotretinoin plasma levels can be nearly 70% lower than levels measured when taken with food. Alarmingly, peak plasma concentrations between fed and fasted conditions can vary by a factor of nearly threefold, which may potentially affect both efficacy and safety.
To ensure more consistent gastrointestinal absorption and maintenance of therapeutic blood concentrations, all conventional formulations of oral Isotretinoin should be taken with food, preferably with a high-fat meal (at least 30-35% of calories - which is an ideal amount of fat for a teenage or adult woman to maintain healthy hormonal balance anyway). Aim for healthy non saturated fats as found in nuts and avocado.
Studies to derive a cumulative dose for maximum benefit and reduced relapse rate have confirmed that there is a definite effect of both dose and duration of therapy but that there is not a prior pharmacokinetic reason to support the concept of accumulation of the drug or a cumulative dose effect.
Post-therapy relapse is minimized by treatment courses that amount to a total of at least 120 mg/kg, but there is not necessarily an added benefit when 150 mg/kg is exceeded. Relapse has been shown to be more common with the lower daily doses due to less cumulative drug exposure over time.
Nevertheless, some patients receiving higher daily doses also relapsed within the first few years after completing therapy (1)(2). The reasons for these high-dose relapses could be caused by any of the factors mentioned here. The rate of relapse requiring retreatment with oral isotretinoin was highest in those patients treated with 0.1mg/kg/day, which was twofold higher than with 0.5mg/kg/day, and fourfold higher than with 1mg/kg/day.
New research now suggests that relapse is more common if acne lesions were still present when your final course of Accutane is completed. The recommendation now is to extend the isotretinoin course 2 months after all acne lesions have been removed to reduce relapse rate and increasing the cumulative dose as well.
So how long and how much of isotretinoin is taken (in consideration with how much is absorbed via proper consumption practices) may determine how well your body responds, and the risk of relapse.
Demographic factors, such as age, sex, and how long someone has had acne, may also affect rate of response and relapse. Males with extensive truncal acne, more severe acne, and/or suffering from acne for less than 7 years, tend to have a poorer result and relapse more quickly than, female patients with predominantly facial acne of a less severe grade. The risk of relapse was twice as high among men.
Analysis of slow responders to isotretinoin shows that the cause may also be due to the presence of hyperandrogensim. Unusual variants may lead to slow response and some female patients with hormonal dysfunction, due, for example, to a polycystic ovarian syndrome, may need additional treatment with a hormonal preparation. The risk of relapse was 3.5 times higher among women not receiving antiandrogen therapy; maintenance treatment with androgen treatment in women helped to prevent relapse.
Some patients do not appear to metabolize isotretinoin as well as others and therefore may require higher doses. Mucocutaneous side effects, particularly cheilitis, are usually a good measure of absorption. If you aren't experiencing increased dryness around your lips with increased dosage it's likely your body isn't absorbing the medication well enough, and this may lead to an increased risk of relapse.
Plus, there is a simple fact that acne is a disease that has no cure. We are never truly cured of acne - we are just in remission. Drugs like Accutane are the most effective available medication for putting acne in remission, but it isn't a guarantee.
Some people need more than one course, some people need longer courses, higher doses, etc. No matter what, though, there's no guarantee that acne won't come back - ESPECIALLY when our hormones are still changing.
However, while Accutane is not always a sure thing solution, and relapse after Accutane may occur (it is usually less severe), it does offer patients a much longer remission time than other treatment options available to them, sometimes several years.
Further courses of therapy are usually successful when required, and each subsequent course generally further reduces the risk of relapse. There are no reports of cumulative toxicity from using repeat courses and tachyphylaxis has not been noted.
So, it's not that Accutane didn't "work" - it's that there may be variables that affected the long-term remission of your acne. Don't be discouraged - there's still hope!
Accutane provides great results for most people. You can see the below results from Kali myfacestory after a 6-month course of Accutane. Although she relapsed after Accutane and had acne come back, it wasn't nearly as severe as her original acne and she's learned to be more confident in her skin.
6 Months After Accutane
As you can see, Accutane provides great results in a reasonable amount of time. If you'd like to know about Accutane, read about its side effects and properties here.
Relapse of acne after an initial course of isotretinoin may refer to a re-emergence of acne that ranges in severity, and varies to the types of acne lesions (i.e., comedonal vs. superficial inflammatory vs. nodular), and differs in the type of retreatment that is used (topicals only, topicals + oral antibiotic, second course of oral isotretinoin).
So basically, an acne relapse after Accutane could mean any form of acne coming back from mild, to severe.
Accutane relapse rates in patients with acne after treatment with oral isotretinoin vary between 10% and 60%.
In lower-dose treatment groups the acne relapse rate is around 47% compared with 27% in the high-dose group. So, in some cases, relapse rates can be quite high, and in other cases, they are quite rare in a several-year period.
Yes, you can go on another course of Accutane after the first course is completed if more treatment is required. For some people who have had their acne return after Accutane, a second course knowing the history and total dosage and length of the initial treatment is needed so create an adjusted dosage.
Possibly something where the dosage is gradually increased, and taken over a longer period of time for a period of 2 extra months after all acne is cleared. If the acne is mild, other topical alternatives may be explored first before deciding to go on another course of Accutane.
Accutane won't heal acne scars, it only treats the acne. Accutane won't cause acne scars either. The acne scars that may remain after Accutane could have been there before taking the medication, or it could be scarring that is caused by the new acne forming during the purging process of Accutane.
We recommend The Banish Kit for acne scars: Banish Kit 2.0 To Reduce Look Of Acne Scars - $99
The Banish Kit is based off of collagen induction therapy also known as microneedling. It's a less invasive treatment compared to heat based treatments like lasers.
This shouldn't be used until after finishing your entire Accutane course, and you may want to wait a few months after before starting. Many have seen a large improvement in their acne scars with consistent use after a couple months.
Recommended Read: 8 microneedling benefits for acne scars
I first got acne in high school, and it came back in my early adulthood. I was able to struggle through those difficult times and come out of it a stronger, wiser, healthier person as a result. I'm here to help you do the same thing!
September 20, 2022
I was on 40 mg a day for 6 months of accutane. My doctor assured me I wouldn’t relapse and I could get off all my antibiotics. I have struggled with acne since my mid teens. After the first month I purged so bad I did want to be in public, this lasted for about 2.5 months. My skin completely cleared up by month 4-6. A month after getting off of accutane I started breaking out again. My breakouts weren’t as bad but are progressively getting worse! I changed my whole diet, gluten free, diary free, no eggs, no soy etc and I feel like I’m back to square one. I am in my late 30s and feel like accutane should of worked for me. It’s just frustrating.
August 10, 2022
I took accutane when I was about 22 or 23… I’m 35 now and I’m starting to experience pretty bad breakouts. I turned to accutane because it was the only thing that worked… I tried everything. I had severe cystic acne my entire teenage years. It looked like my face was bruised. I was on it for 9 months or so and it worked… But now I’m 35 and getting pretty bad acne again. Not sure why.
June 09, 2022
I have taken accurate twice and now using retina and my face is showing signs of scaring that wasn’t there before? Will this go away, i just started using retina a month ago please help
May 09, 2022
Thanks, useful. I’m quite sad about it. Just finished my 6 months and today I had a pimple :(. Not had one for 2 months while on treatment. The first 4 months I still had spots coming. My skin cleared well in the two months. I would have it after lunch every day, I’m 45kg, so had 40mg of roaccutane. I had fish yesterday with sweet potato and salads. No dairy except sour cream and a very tiny amount with my sweet potatos. Just sad, I feel hopeless
August 23, 2019
Firstly thank you so much for the detailed explanation and the awareness you’re spreading with respect to Isotretinoin. I have been suffering from cystic acne for about 10 years now. Have been on Accutane but have experienced relapse. Can you please tell me, does a low dose isotretinoin for long term is beneficial? And does it have any sever side effects?
It would be great if yoh can throw some light on it
April 27, 2017
Same happened with me. After completing my accutane journey I lead to break out again and I started my second course now and apart from this
Holding on a good diet. Cut out my dairy and meat, chicken even being gluten free. Hope this work for me too. And decided to do wet cupping
That will remove the bad blood from my body and inflammation. It has sessions, I will do every month in sha ’Allah.
March 26, 2017
I have been on roaccutane 3 times. I had used everything from chemist products, proactive, benzac to prescription topical creams and gels and antibiotics and nothing worked. I first started getting acne when I was 10-11 years old, nothing to serious just enough to be embarrassed and frustrated with it. By the age of 13 I had very severe cystic acne on my face, neck, chest and back, and I was referred to a dermatologist in Sydney who put me on roacutane. It worked absolute wonders and I was so happy until about 8 months after, when it came back everywhere except my back. I put up with it but by the age of 15 I went back to my dermatologist and had a second corse but the same thing happened and I went back again at 17 and again the same thing happened. I’m now 21 and over the past 2-3 years I have just put up with my bad skin. The acne never returned on my back and after the third treatment I only have cystic acne on the bottom half of my face and my neck. This I can live with because it is not as bad as my original skin but I am thinking of going for a 4th course as it is very painful. I wake up with whiteheads on the edge of my lips that leave terrible scars and run so deep and also lots of blind pimple that never seem to leave. I do get sick of taking roacutane but it’s worth it to have those couple of months of beautiful skin!.
February 02, 2017
I have been on accutane/isotretinoin 3 times. First 2 times were consecutive with a few months of a break in between, which I took twice because I clearly did not get the results I expected the first time. Over the years, my acne slowly started coming back which resulted in my entire face being back to the same amount of acne as before. So 3 years later, I went on a third round of accutane. The results were good for about 6 months and now they’re slowly coming back again. If I were to give you a suggestion, don’t go on it more than once. Chances are, if the acne came back, it will definitely come back again the next time around. Just learn to love your skin with its flaws and they will go away on their own eventually.
December 30, 2016
Haha I think you’re right! I’m wondering if I’m having a relapse but if I’m to be honest and realistic, it’s more likely that I’m having a few breakouts due to oily skin during summer. My breakouts lately are absolutely nothing compared to the huge swollen red angry acne I used to get, but just that my fear that these mild breakouts will turn into something worse and an unrealistic expectation that Roaccutane would keep me 100% clear for the rest of my life did initially make me wonder if it was a relapse..
December 11, 2016
Hey, I am 27 now, have had acne since 14, tried everything to chemical peeling, but never wanted to go on acnetane , till three months ago, and my acne cleared , although I was using azelaic acid before and it did wonders, unfortunately I couldn’t finish the acnetane course because I had an anxiety attack ,and I got freaked out, so I only did 3 months of acnetane. I am hoping it doesn’t come back. Even if I didn’t take it till the 4th month.
December 05, 2016
I am 24 years old and did not have a problem with acne till i was 20. i went on accutane from December 2015 to June 2016. Now its December and late last month i started getting bad break out. I am on antibiotics and my derm says i might go back for another round if this does not work. that treatment costs a lot and should work.
October 14, 2016
I took accurate for 2 times and izusopra for 3 times and my acne is still sever and acute. I’m so depressed I’ve been treating my skin since I was 14 and now I’m 30 and I’m still facing this disease !! Who ever has a solution for me pls let me know
October 04, 2016
I’m a 26 year old male:
I was on isotretinoin from November 2015 to the beginning of June 2016. It was fantastic and cleared my skin completely. Now 4 months later and my acne has come back moderately to severely around my mouth, jawline and spreading closer to my cheeks again. I’ve been trying for the past 3 weeks to stop the spread (using a benzoyl peroxide wash once a night for a week now twice a day) but I don’t think I’ll be able to contain it. Right when I got off iso I started producing the same amount of oil I was before being on it, which in my case I think is a huge contributor to my acne, along with breaking out moderately to severely each time I shave. 3 weeks is long enough for me. I’m going to my doctor relatively soon. I hope they give me another course – I’m not sure topical are going to work :-(
September 02, 2016
When I was in the Philippines I didnt have acne at all. I barely get acne when I’m on my period. But when I migrated here in Canada thats all it started. I thought its gonna go away but no it didnt. I tried so many antibiotics, creams, and gels and it didnt work! I wasted all my money. Then one of my friend had the same issue as mine. She tried the accutane first and she told me about it. So I went to my derma and discussed about it. At first she gave me 30mg for 2 months and i took a blood test my ALT was very high so she made it 20mg a day. I took accutane for almost a year. After 3 months off the medicine my oilyness came back and I had so much white head and red spots on my face. My acne came back. So I went back to my doctor and said it came back. She was surprised that it came back so she gave me another 2 months to take the 20mg a day. I just wanna ask if is it safe to take low dose maintenance of the accutane? Like 10mg a week?
July 01, 2016
I am a female and I took accutane when I was 13/14 and my acne was VERY servere. Ten months after being off (I still have to use a topical though) my acne has come back almost as servere as it was before accutane.
December 30, 2020
I agree with you, had to do some biomolecular tests to confirm my body was well adaptable to it. Been following this blog over here for more on what to do. http://talkingacne.com/blog/accutane-effective-prescription-acne/
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February 27, 2023
I was on accutane from December 2021-May 2022. I was only prescribed 5 months worth because my blood tests essentially concluded I wasn’t able to go for the full 6 months (I am female and started accutane when I was 17 years old). It’s been around 8-9 months later and my acne has came back severely on my forehead only. My problem areas used to be on my cheeks and not my forehead. I have an appt in a month and will hopefully be able to go back on accutane.