Differences in Depression and Distress Between Acne Patients on Isotretinoin vs Oral Antibiotics

February 2021 | Volume 20 | Issue 2 | Original Article | 172 | Copyright © February 2021

Published online January 15, 2021

Joshua Hekmatjah BS,a Vipawee S. Chat BA,b Tiffany J. Sierro BS,c Charlotte Read MBBS BSc,c,d Ari A. Kassardjian BS,c April W. Armstrong MD MPHc

aWestern Michigan University, Homer Stryker MD School of Medicine, Kalamazoo, MI
bMedical College of Georgia, Augusta, GA
cDepartment of Dermatology, University of Southern California, Keck School of Medicine, Los Angeles, CA
dDepartment of Medicine, Imperial College London, London, UK

Background: Little is known regarding differential effects of systemic anti-acne treatments on mental health.
Objective: To determine whether differences exist in mental health outcomes between acne patients treated with isotretinoin versus oral antibiotics (doxycycline, minocycline, or tetracycline).
Methods: Population study utilizing the 2004-2017 Medical Expenditure Panel Survey. Depressive symptoms were assessed using Patient Health Questionnaire 2 (PHQ-2); psychological distress was measured by the Kessler 6-Item Psychological Distress Scale (K6). Acne patients completed both the PHQ-2 and K6 during treatment with isotretinoin or oral antibiotics. Lower scores on both measures indicate better mental health outcomes.
Results: After adjusting for socio-demographic characteristics, patients on isotretinoin had fewer depressive symptoms than patients on oral antibiotics, as measured by mean PHQ-2 scores (isotretinoin 0.280 vs oral antibiotics 0.656, difference=0.337, P<0.01). The adjusted comparison also showed patients on isotretinoin had less psychological distress than patients on oral antibiotics, as measured by K6 scores (isotretinoin 2.494 vs oral antibiotics 3.433, difference=0.759, P=0.043).
Limitations: No direct assessment of acne severity.
Conclusion: Acne patients on isotretinoin experienced less depressive symptoms and psychological distress as compared to oral antibiotics.

J Drugs Dermatol. 20(2):172-177. doi:10.36849/JDD.2021.5559


Acne vulgaris is a common skin disease that affects approximately 50 million people in the United States (U.S.) and approximately 70% of the population during their lifetime.1-3 Due to its predilection for the face, acne can have substantial, negative effects on body image and self-confidence, and it can lead to psychological distress.4-8 Specifically, both anxiety and depression are more common in acne patients than in healthy controls.9,10 For example, acne patients are twice more likely to develop anxiety compared to healthy controls.11 Acne patients are also at an increased risk for developing major depressive disorder up to 5 years after diagnosis.12 Furthermore, suicidal ideation occurs twice more often in acne patients compared to that of general medical patients.13 Severe acne patients are also three times more likely to report suicidal ideation than those with no or little acne.14

Oral antibiotics are among the most commonly used systemic treatments for moderate-to-severe acne.1 The most commonly used oral antibiotics are the tetracyclines, which include doxycycline, minocycline, and tetracycline. These agents have antimicrobial activity against Cutibacterium acnes and anti-inflammatory properties.15,16 However, the use of the oral tetracycline class may be limited by potential side effects, such as gastrointestinal disturbance and antimicrobial resistance. Isotretinoin is one of the most effective therapies for patients with severe or nodulocystic acne.17 The potential risks of isotretinoin include xerostomia, hyperlipidemia, retinoid dermatitis, depression, and suicidal ideation.18

The impact of systemic anti-acne treatments on mental health is not well studied. For example, controversy exists regarding the effects of isotretinoin on depression and suicidal ideation.19 At the present, a critical knowledge gap exists in defining the association between systemic anti-acne treatments and mental health outcomes. In this study, we sought to determine whether differences exist in mental health outcomes between patients treated with isotretinoin versus those treated with oral antibiotics.