How do you manage lamotrigine or lithium-induced acne?
For Lithium, I have referred patients to dermatology but it seems the interventions suggested such as Doxycycline, Spironolactone, or Bactrim do not fully help. I try to reduce the dose if possible or switch to another mood stabilizer if the acne is severe and bothersome that it is making the patient's depression worse.
If the medication cannot be discontinued, a trial of photodynamic therapy, which consists of the application of levulenic acid incubated for 1 hour or more, followed by application of blue light for 16:40 seconds. Patients must strictly avoid the sun for 48 hours after. Even ambient light can cause burning, so post-treatment sunscreen for 48 hours is a must. Regrettably, it is not generally covered by insurance for this indication, but I have seen it have life-changing results in some patients in whom isotretinoin is not an option.
As a derm, I have only treated one patient for cystic acne caused by lithium. I treated with accutane and it was successful.
According to the American Academy of Dermatology Consensus Conference: “There are no known absolute or relative psychiatric contraindications to isotretinoin therapy in a patient who is carefully monitored. Patients with a known history of prior suicide attempts should be referred to a mental health professional prior to the initiation of acne therapy with isotretinoin.”
As long as the patient and parents are fully informed and the patient is being followed closely by psych, I do not think it is unreasonable to refer to derm for Accutane consideration.
I have treated thousands of patients with accutane and in my clinical experience, I do not see a strong correlation with Accutane and depression. That doesn’t mean I don’t take it seriously and monitor closely. Also, there are multiple articles that have studied this and have questioned the correlation.
Here is a reference, but there are more: Huang & Cheng, PMID 28291553
If the acneiform eruption is induced by lamotrigine or by other factors, isotretinoin can be a very useful adjunct in therapy.
If there is a pustule or lesion present that has sufficient material for culture or PCR analysis (i.e., Vikor swab), this can assist in therapeutic decision-making.
Recently had a few cases where the overarching element was cultibacterium acnes in 2 cases, and malassezia in another 2 cases.
Tailoring OTC/Rx therapy for the culture results was very helpful in these situations.
Low-dose/intermittent-dose isotretinoin (i.e., 20-40 mg once/twice weekly) has been surprisingly impactful on patients as well.
If the acne is mild to moderate and there are no other obvious or possible inducers of acne other than lithium or lamotrigine that have alternate treatments, it can be managed by topical acne creams such as benzoyl peroxide.
If the acne is severe, it is important to collaboratively come up with a plan to wean off the medication and start another mood stabilizer. If the patient is willing to stay on the medication, or lithium/lamotrigine are the only mood stabilizers that have worked for the patient, I generally refer to a dermatologist to manage the acne.
Does Lamictal actually cause or worsen acne? What is the evidence for that?