Beyond Isotretinoin: Long Term Management, Controversies, and What’s Next in Acne

Beyond Isotretinoin: Long Term Management, Controversies, and What’s Next in Acne

Part two of this Acne Awareness Month series picks up with the questions that can make isotretinoin feel a little complicated. Jamie Restivo, PA-C, and John Barbieri, MD, MBA, move into the issues clinicians counsel on constantly, like psychiatric safety, inflammatory bowel disease, lab monitoring, supportive skin care, maintenance after treatment, and newer as well as trending acne therapies.  Dr Barbieri brings a measured, evidence-based approach to psychiatric counseling, acknowledging that mood changes can occur while emphasizing the broader context of acne’s psychosocial burden. He also discusses how he talks about inflammatory bowel disease, why acne and IBD may share inflammatory pathways, and the ways prior antibiotic exposure can complicate interpreting risk.  The episode then turns to lab monitoring, where practice patterns still vary widely. Dr Barbieri walks through his approach to baseline and peak-dose testing, triglycerides, liver enzymes, and less frequent monitoring. The conversation stays practical, with attention to what actually changes management vs what may simply add burden for patients.  From there, Restivo and Dr Barbieri move into the supportive care patients need to get through treatment: barrier-focused cleansers and moisturizers, lip care, dry eye, nasal dryness, and what to avoid while on isotretinoin. They also discuss the end of a course, including when doing nothing may be appropriate, when topical retinoids may make sense, and recognizing patient anxiety about recurrence in the plan.  The episode closes by widening the lens to acne care beyond isotretinoin, including LED light devices, hormonal therapy, topical retinoids, clascoterone, and oral antibiotics. It is a jam-packed conversation about prescribing thoughtfully, counseling honestly, and building acne treatment plans that are both evidence-based and real-world.

Optimizing Isotretinoin: Clinical Pearls That Change Practice Tomorrow

Isotretinoin is one of the most effective therapies in acne care, but a successful course is not as simple as reaching a number and stopping. In part one of this Acne Awareness Month episode, host Jamie Restivo, PA-C, sits down with John Barbieri, MD, MBA, to talk through treatment endpoints, recurrence, dosing, absorption, and the day-to-day decisions that shape long-term outcomes.  Dr Barbieri reframes the goal of isotretinoin as long-term remission rather than a guaranteed cure, a distinction that changes how clinicians counsel patients from the beginning. He discusses why cumulative dose still matters, how clinical endpoints can help individualize care, and why getting patients clear for several months may be more meaningful than stopping at a fixed threshold alone.  The conversation also gets into recurrence in a way that feels useful in practice—who may be at higher risk, recent data on relapse and retrial, and how hormonal therapies may still have a role for select patients after isotretinoin, even when they did not seem to work before. From severe inflammatory presentations to adult female acne patterns, the episode keeps returning to the same clinical truth: treatment plans should be individualized.  Restivo and Dr Barbieri also spend time on absorption, once-daily dosing, micronized isotretinoin, omega-3 supplementation, antihistamines, and expectation setting that can make a course more tolerable and less frustrating for patients. The result is a practical, thoughtful discussion for clinicians who prescribe isotretinoin often, but still want to do it with more precision, flexibility, and confidence.

Smart Integration: Evidence Based Dermatology Beyond Prescriptions

Patients are already asking about diet, supplements, oils, probiotics, “natural” products, and what they saw online before they even make it into the exam room. In this episode of The Spot Check, Jamie Restivo, PA-C, sits down with Lauren Stewart, PA-C, for a practical conversation on integrative dermatology and how clinicians can respond with curiosity, caution, and a clear understanding of what the evidence can and cannot tell us.  Stewart defines integrative dermatology as taking a step back rather than a step away from conventional medicine. The goal is not to replace medical therapy, but to look more broadly at what may be contributing to flares, triggers, or disease burden in conditions like atopic dermatitis, and what might help support patients between visits. Her approach blends Western medicine with nutrition, barrier support, select supplements, and other integrative tools, always with an emphasis on clinical realism and practical patient care.  Much of the conversation centers on atopic dermatitis, where Stewart uses integrative strategies most often. She discusses practical counseling around fragrance free products, ceramide containing moisturizers, coconut and sunflower oils, hypochlorous acid, probiotics, and topical vitamin B12, while also highlighting the importance of “putting the fire out first” when inflammation is active in moderate to severe disease.   The discussion emphasizes that traditional Western medical therapies are often necessary upfront to gain control of the disease, while supportive integrative strategies can then help maintain the skin barrier, reduce flares and overall disease burden between visits, and improve quality of life. The message is not that integrative therapies replace more advanced medical treatment, but rather that they can work alongside conventional therapies to better support long term disease management.  They then move through other common disease states including psoriasis, acne, hidradenitis suppurativa, actinic keratoses, molluscum, and warts with quick, clinically useful considerations for each.  The episode also addresses one of the more challenging aspects of this space: deciding what is truly worth recommending. Stewart talks about reviewing studies, listening carefully to patient experiences, and weighing safety, access, cost, and plausibility when the evidence is not as robust as it is for FDA approved therapies.  The takeaway is not that every clinician needs to become an integrative specialist. It is that patients are already using these integrative therapies, and clinicians should be helping guide those conversations with better questions, clearer guardrails, and thoughtful recommendations that support the care they are already providing.  The views expressed in this episode are those of the speakers and do not necessarily reflect those of Dermsquared. This program is intended for health care professionals and is provided for educational purposes only.   Clinicians are responsible for applying independent clinical judgment in patient care.

Melanoma Today: Prevention, Prognosis, and Precision Testing

In this episode of The Spot Check, Jamie Restivo, PA-C, is joined by Andrew Baker, MBA, PA-C, for a timely, practice-focused discussion on where melanoma care stands in 2026. From prevention strategies that change patient behavior to advances in risk stratification and precision testing, they break down what’s working, what remains challenging, and how emerging tools are reshaping clinical decision-making. They begin with prevention, still the highest-leverage intervention but one that remains difficult to translate into daily behavior. Baker emphasizes simple, concrete messaging—sunburns, especially blistering ones, carry real weight over time, and indoor tanning before age 35 significantly increases risk. The challenge is making risks feel immediate enough to matter. From there, they discuss adherence. Sunscreen works, but only if patients use it. Anchoring use to existing routines, prioritizing cosmetic elegance, and connecting UV exposure to visible changes like photoaging are what actually move the needle. “Behavior change isn’t just about education alone,” Baker says. “It’s really about designing habits that are easy to repeat.” They then step back to review the broader epidemiology. Melanoma incidence continues to rise, driven in part by better detection and more frequent screening, but also by cumulative UV exposure and an aging population. At the same time, mortality has not declined proportionally, largely because more aggressive subtypes don’t follow predictable patterns and are harder to catch early. When it comes to diagnosis, the fundamentals still hold. Breslow depth, ulceration, and mitotic rate remain central to staging and prognosis.  Layered onto that is a growing role for gene expression profiling (GEP). Tests like DecisionDx and Merlin add another level of biologic insight, helping refine decisions around surveillance, referral, and procedures like sentinel lymph node biopsy. The throughline is integration. Melanoma care today is about combining prevention, clinical examination, pathology, and tumor biology to more precisely define patient risk and guide management. The views expressed in this episode are those of the speakers and do not necessarily reflect those of Dermsquared. This program is intended for health care professionals and is provided for educational purposes only.   Clinicians are responsible for applying independent clinical judgment in patient care.

Scalp Health, Innovation & Building a Brand Beyond the Bedside

In this episode of The Spot Check, Jamie Restivo, PA-C, sits down with Erica Ramos, DMSc, PA-C, to unpack a familiar clinical frustration: scalp disease that should respond, but often doesn’t.   Ramos traces the gap back to adherence. Patients stretch time between washes, rinse too quickly, or avoid medicated shampoos altogether, whether to preserve color, manage texture, or simply keep up with daily life. “Nobody’s leaving it on long enough,” she says. “That’s why I encourage people to use it as a mask.”   Their conversation then moves beyond ingredients and into behavior. They explore how cultural hair practices, mobility limitations, and cosmetic priorities shape treatment success—often more than the prescription itself. The issue, as Restivo frames it, isn’t a lack of options. It’s asking patients to adopt routines they’re unlikely to follow.  Ramos’s response was to build something that fits into that reality, like a leave-on, dry formulation designed to extend contact time without disrupting hair care practices. She walks through the thinking behind the formulation—anchored by salicylic acid as a keratolytic and supported by ingredients selected for anti-inflammatory and antimicrobial effects—and why delivery matters just as much as mechanism.  The conversation broadens into a more practical philosophy of care to meet patients where they are, layer therapies when needed, and think in terms of tools rather than single solutions. Or, as Ramos puts it, “We can lead a horse to water, but we can’t make them drink.”   It’s a grounded and nuanced look at what happens when we stop blaming the treatment and start redesigning how it’s used.  The views expressed in this episode are those of the speakers and do not necessarily reflect those of Dermsquared. This program is intended for health care professionals and is provided for educational purposes only.    Clinicians are responsible for applying independent clinical judgment in patient care.