Expert Consensus on the Rational Approach to Isotretinoin Usage for Effective Management of Acne: ERAISE ACNE Recommendations

Oral isotretinoin remains the gold standard for severe acne, with expanding use in broader subtypes. However, clinical practice varies across regions in terms of dosing, monitoring, and adjunctive care. A consensus was developed by 20 dermatology experts through a modified Delphi process and literature review (2000-2024) to provide practical recommendations. High consensus supported first-line isotretinoin among adults for severe acne variants (conglobata, nodulocystic, and papulopustular), acne with scarring or psychological distress, and moderate acne featuring frequent relapse, significant scarring, strong family history, and marked psychosocial burden. Similar agreement was achieved for adolescents (12-18 years). High consensus supported isotretinoin for special clinical scenarios, including treatment-resistant acne, gram-negative folliculitis, and acne fulminans. Early initiation was favored to prevent acne progression and scarring, with high agreement on quality-of-life improvement with isotretinoin use. Conventional dosing (0.5-1 mg/kg/day) was preferred for severe acne forms; low-dose (0.1-0.5 mg/kg/day) was acceptable for moderate/persistent acne. The consensus acknowledged common adverse effects, less frequent systemic effects, and the well-established teratogenic risk of isotretinoin. Laboratory monitoring, especially in metabolic risk, was advised. Low consensus persisted around cumulative dosing, laboratory testing frequency, and duration of posttreatment washout before pregnancy. The Expert consensus on the Rational Approach to ISotretinoin usage for Effective management of ACNE (ERAISE ACNE) algorithm offers a practical guide for isotretinoin use in Indian clinical practice, emphasizing early initiation, tailored dosing, safety-focused monitoring, and is applicable to settings with similar patient demographics and challenges.