If Acne Returns After Stopping Isotretinoin — The Real Acne Treatment Is What Comes After

Three-Line Summary

• Isotretinoin is less a drug that ends acne than a bridge to skin that can be managed without medication. Quite a few people need treatment again after stopping, so treatment extends to the care that follows stopping.
• The time to stop is set not by the day the acne disappears but by the point at which a long enough stretch has passed with no new spots appearing. The guideline from the UK National Institute for Health and Care Excellence (NICE) says to consider stopping when the response has been adequate and no new acne has appeared for 4–8 weeks.
• After stopping, topical maintenance treatment and skincare suited to acne-prone skin take over, and procedures at the dermatology clinic focus on what cannot be done at home, such as marks and scars.

Why Isotretinoin Is a Good Drug — It Acts on Several Causes of Acne Together

Acne develops when four things overlap: sebum is overproduced, pore openings become blocked, acne bacteria increase and inflammation sets in. In its background section, a Cochrane systematic review (Costa et al., Cochrane Database of Systematic Reviews, 2018) describes isotretinoin as a drug that acts on all of these main causes. Other acne medications usually act on one or two of them. It does not, however, act directly on bacteria the way antibiotics do, and the same review rated the quality of the evidence as low for most of the outcomes it examined.

The acne guideline issued by the American Academy of Dermatology (AAD) in 2024 points the same way. It strongly recommends isotretinoin for severe acne, for acne that leaves scars or carries a heavy psychological burden, and for acne that does not respond to standard oral or topical treatment. This is not a recommendation with a graded level of evidence but an ungraded item presented as a "good practice statement".

That is why we, too, recommend it without hesitation to those who need it. But however good a drug is, it cannot be taken for life. It is well known for the risk of birth defects when taken during pregnancy, so women who can become pregnant need contraception from before they start, throughout treatment and for a set period after stopping, and chapped lips and dry skin are also common. In the end, it is a drug that has to be stopped at some point, and treatment has only truly finished when the skin holds up even after stopping.

Acne That Needs Isotretinoin, and Acne That Does Not Yet

If you have a few small comedones and only the occasional inflamed spot, there is no need to reach for isotretinoin first. In that case, the right order is to try proper topical medication and skincare first. By skincare we mean skincare suited to acne-prone skin, not skincare that is simply gentle.

The treatments given a strong recommendation in the 2024 AAD guideline are likewise topical ones, such as benzoyl peroxide, topical retinoids and topical antibiotics (topical antibiotics are not used on their own). Using medications with different modes of action together is also recommended as good practice. Put together well, topical medications can make for quite a strong treatment.

That Does Not Mean You Should Just Put Up With It

In a study of 1,972 patients with acne seen by dermatologists in the US (Tan et al., Journal of Drugs in Dermatology, 2017), 43% had acne scars, and 69% of those with scars had mild or moderate acne at the time of the survey. The same study reported that the longer it took from the onset of acne to the first effective treatment, the more likely scarring was, and the authors regarded delay in treatment as a key modifiable risk factor for scarring.

So for mild acne, the right order is not "putting up with it instead of taking isotretinoin" but "doing topical treatment and skincare properly before isotretinoin". It is also not unusual for people whose acne is severe to hold out for a long time with pharmacy ointments and miss the right time for treatment. If you have started with a pharmacy ointment, you may also find it helpful to read our article on pharmacy acne ointments.

If nodules keep coming back, if depressed scars have already started to form, or if acne keeps appearing even after several months of using topical medication properly, that is the time to consider isotretinoin. For skin that scars easily, it is sometimes recommended earlier, whatever the severity of the acne.

How Long to Take It — About Four Months Is Standard, and the Skin Decides When It Ends

The standard regimen in the US prescribing information is 0.5–1 mg per kilogram of body weight a day, taken for 15–20 weeks. That comes to roughly four months. This dose is based on the US label, however, so rather than applying it as it stands, the actual daily dose is set by looking at body weight, the state of the acne and side effects.

The guideline from the UK National Institute for Health and Care Excellence (NICE), NG198, adds one more criterion to this. It says to take the drug until a cumulative dose of 120–150 mg per kilogram of body weight is reached, but to consider stopping earlier if the response has been adequate and no new acne has appeared for 4–8 weeks. For a body weight of 60 kg, for example, that is a cumulative 7,200–9,000 mg, an amount that would take roughly 2 to 2½ years at 10 mg a day.

How Solid Is the Evidence Behind 120–150 mg/kg?

To give the conclusion first, the evidence is weaker than you might think. In a study that reviewed the literature on this criterion (Tan et al., Journal of Cutaneous Medicine and Surgery, 2016), only 2 studies had directly evaluated this cumulative dose, and both had a low level of evidence. It is, in other words, a widely used number but not a thoroughly validated one. A consensus of 8 experts from 8 Latin American countries (Rocha et al., Anais Brasileiros de Dermatologia, 2024) likewise recommended deciding on treatment by assessing the skin in clinic rather than looking only at the cumulative dose (all participants agreed).

That does not mean, on the other hand, that the cumulative dose is meaningless. In a cohort study that used US insurance claims data to analyze 19,907 people who had taken isotretinoin for 4 months or more (Lai and Barbieri, JAMA Dermatology, 2025), the higher the cumulative dose, the less relapse there was. Among those whose cumulative dose reached 120 mg per kilogram of body weight or more, however, raising the daily dose did not reduce relapse. In other words, "how much in total, taken steadily until the skin settles" seems to matter more than "how strong a dose each day".

We recommend at least 3–4 months and usually around 6 months, but the duration and dose vary with the state of the acne. Rather than fixing the length of the course on the calendar in advance, we have patients take it steadily and decide by looking at how far the skin has settled.

Early Flare — Why Acne Can Get Worse in the First Few Weeks

Some people find that their acne actually gets worse after starting the medication. This is often called "purging", but in the medical literature it is called an early flare. The UK Summary of Product Characteristics (SmPC) states that acne may occasionally flare up sharply early in treatment, that this usually settles within 7–10 days with continued treatment, and that the dose usually does not need to be adjusted. In clinic, we also see people in whom it lasts a little longer than this.

How common is it? In a study that enrolled and followed 244 people taking isotretinoin (Demircay et al., European Journal of Dermatology, 2008), 79 (32%) had a flare on the face or trunk. It was mild in 18%, moderate in 10% and severe in 4.5%, so most flares were on the mild side. These proportions are based on the 244 people enrolled; 161 people completed the study.

Why it happens has not yet been established. Isotretinoin increases a protein called p53 and gradually reduces sebaceous gland cells, and there is a hypothesis that this process is also linked to the inflammation seen early on (Melnik, Cells, 2023). In clinic, to make it easier to understand, we often describe it as a time when acne that was sitting deeper in the skin comes out.

Not Every Flare Passes Lightly

In the same study, the factors that predicted a severe flare were being male, severe acne, a very large number of comedones on the face (more than 44), multiple nodules on the face and nodules on the trunk. The authors concluded that because a severe flare can lead to long-lasting scars, it needs to be prepared for in advance.

Starting the drug while you have large blocked comedones (macrocomedones) in particular can cause a bad flare-up. These comedones often do not clear with the drug alone, so it is a good idea to have comedone extraction done alongside it. A consensus from the Brazilian Society of Dermatology (Bagatin et al., Anais Brasileiros de Dermatologia, 2020) recommends that, when there is extensive, severe acne reaching the face, chest and back, macrocomedones or a family history, treatment start at a low dose of 0.1–0.2 mg per kilogram of body weight a day, with an oral steroid (prednisone) used alongside it for the first 2–4 weeks.

When a few large spots come up within a few weeks of starting the drug, some people decide it does not suit them and stop it on their own. It may really be that the drug does not suit them, or they may be in the middle of getting through this phase. So when we first prescribe it, we tell patients in advance that an early flare can occur, and ask them to contact us right away, rather than putting up with it, if the spots suddenly become larger, more numerous or more painful, or if they bleed. This is because a mild flare can be left to pass, whereas a severe flare has to be brought under control quickly to reduce the chance of it leading to scars.

Low-Dose and Intermittent Dosing — What Changes with the Way It Is Taken

Even with the same isotretinoin, there are many ways of taking it. They range from a conventional dose every day, a low dose every day over a longer period and intermittent dosing in which it is taken for just one week a month, to taking it once a week or only when acne breaks out.

A study in which a Korean research team randomly assigned 60 patients with moderate acne to different regimens and compared them (Lee et al., British Journal of Dermatology, 2011) gives a fairly direct answer to this question. The three groups were a conventional dose every day (0.5–0.7 mg per kilogram of body weight a day), a low dose every day (0.25–0.4 mg), and a conventional dose for only 1 week in every 4. The two daily groups were similarly effective, while the intermittent group was less effective than both. Even with all its dosing periods added together, the intermittent group took the drug for only 6 weeks, far shorter than the daily groups (24 weeks).

At 1 year after the end of treatment, 2 of 16 people in the conventional-dose group had relapsed, compared with 3 of 17 in the low-dose group and 9 of 16 in the intermittent group. The low-dose daily group had fewer side effects than the conventional-dose group, and its satisfaction was the highest of the three groups. This is why daily low-dose treatment (usually one or two 10 mg capsules a day) is a good option for moderate acne.

To be fair, the studies pointing the other way need to be looked at too. In a study in which 80 adults over 25 took it for 1 week in every 4 over 6 months (Goulden et al., British Journal of Dermatology, 1997), 88% (68 people) of those assessed cleared. By 12 months after treatment, however, 39% (26 people) had relapsed, and the authors themselves advised narrowing patient selection to adults whose acne is mainly on the face, with little inflammatory acne.

A systematic review that pooled 15 randomized controlled trials (Lin et al., Advances in Dermatology and Allergology, 2025) summarized low-dose and intermittent dosing as giving effects similar to high-dose treatment with fewer side effects. It also stated clearly, however, that long-term outcomes such as relapse need further research.

To sum up, intermittent dosing is a studied option for mild acne or for people who find the side effects hard to tolerate. For severe acne, or when the aim is to reduce relapse, however, there is more evidence in favor of taking it steadily every day.

Taking It Once a Week, or Only When Acne Breaks Out

For once-weekly dosing, a small study in which 19 people took 1–1.5 mg per kilogram of body weight once a week for four months (Karlin et al., SKIN The Journal of Cutaneous Medicine, 2022) reported that 18 of the 19 improved, but it had no comparison group and did not look at relapse after stopping. Within the scope of our search for this article, we did not find any study testing the approach of taking it only when acne breaks out. The intermittent dosing described in studies is mostly "every day for 1 week in every 4", which is different from this approach.

The prescribing information for one US product (standard capsules taken with food) gives the half-life of isotretinoin as about 21 hours on average and that of its main metabolite as about 24 hours (some labels give different figures depending on the formulation). From this, one could reason that taking a single capsule now and then, only when acne breaks out, would make it hard to keep the sebaceous glands suppressed until the next dose, but this has not been measured directly. And, as we will see below, the risk of relapse was higher when inflammatory acne was still present at the end of treatment. Taking it when acne breaks out and stopping as soon as it settles may fit this relapse risk factor.

When to Stop — Why It Is Not Stopped as Soon as the Skin Looks Clear

The time to stop is set not by the day the acne disappears but by the point at which a long enough stretch has passed with no new spots appearing. The NICE criterion mentioned earlier works this way. It recommends considering stopping when the response has been adequate and no new acne has appeared for 4–8 weeks. That means watching for several more weeks from the day the skin looks clear on the surface.

Studies that looked at relapse point the same way. In a study that followed 52 patients with moderate to severe acne at a French university hospital (Quéreux et al., Dermatology, 2006), the risk of relapse was higher when a lot of inflammatory acne remained at the end of treatment.

We have patients take it steadily every day for the first 3–4 months, and after that, up to around 6 months, we lower or adjust the dose while watching the state of the skin. It is taken every day, but when to finish is decided by the symptoms.

Within the scope of our search, we did not find a randomized study testing this exact approach. It does, however, bring together for clinical practice the direction shared by the labeled regimen of 15–20 weeks of daily dosing, the NICE criterion of considering stopping when there have been no new lesions for 4–8 weeks, the research linking inflammatory acne remaining at the end of treatment to relapse, and an Indian expert consensus (Kandhari et al., Dermatology and Therapy, 2026) that recommended low-dose maintenance on a case-by-case basis when acne persists even after conventional-dose treatment.

Taking one capsule a day for close to 1 year is an approach based on a 6-month low-dose study and expert consensus (see the frequently asked questions below; within the scope of our search, we did not find a study of a 1-year course). We think the more important difference lies not in the length itself but in whether it is taken steadily every day to keep the sebaceous glands suppressed, and whether the time to stop is judged by the state of the skin. During long courses, we combine regular check-ups with any blood tests that are needed.

Relapse After Stopping — Why the Numbers Differ from Study to Study

So how often does acne come back after stopping? Looking at the numbers alone, the results vary.

• A cohort of 19,907 people from US insurance claims data (Lai and Barbieri, JAMA Dermatology, 2025) — 22.5% relapsed and 8.2% took isotretinoin again. Relapse was counted as being prescribed oral acne medication again after stopping.
• A population-based study of 17,351 first-time users in Quebec, Canada (Azoulay et al., British Journal of Dermatology, 2007) — 41% relapsed and 26% had a second course of isotretinoin. Relapse was counted as receiving acne medication again.
• A prospective study of 52 people at a French university hospital (Quéreux et al., Dermatology, 2006) — 52% relapsed.
• A study of 116 people at a single US university hospital who answered a survey 12 months later (Blasiak et al., JAMA Dermatology, 2013) — 32.7% relapsed. Relapse was counted as using a topical or oral medication prescribed after stopping.

The main reason the numbers are this far apart is that the criteria for counting relapse, the people studied and the length of follow-up differ from study to study. So these figures cannot be compared with one another directly, and it is hard to pin down the relapse rate with any single number. They do have something in common, though: quite a few people need treatment again after stopping.

When Relapse Tends to Happen, and in Whom

In a UK study that followed patients for an average of 9 years after treatment (Layton et al., British Journal of Dermatology, 1993, 88 patients), 96% of those who relapsed did so within 3 years of stopping. In other words, getting through a few months after stopping does not mean you can relax.

In the French study mentioned above (Quéreux et al., 2006), the factors that raised the risk of relapse were heavy sebum production or a lot of inflammatory acne still present at the end of treatment, young age, a family history of acne, acne that began before puberty and acne that had spread to the trunk. The one to note here is "inflammatory acne remaining at the end of treatment". It is a finding that ties in directly with the principle of "not stopping before the skin is clear".

Maintenance Treatment After Stopping — When Topical Medication Takes Over

Rather than applying nothing at all from the day after stopping, it is better to allow a period in which topical medication takes over. This is especially so for people who have had frequent relapses.

The NICE guideline says to consider maintenance treatment after a course of acne treatment (this is not a recommendation specific to isotretinoin) for people whose acne has relapsed often, and recommends a fixed combination of adapalene and benzoyl peroxide first. If that does not suit, it says to use just one of adapalene, azelaic acid or benzoyl peroxide, and to reassess after 12 weeks to decide whether to continue. The same guideline also says to explain that maintenance treatment is not necessarily needed by everyone, and recommends carrying on with appropriate skincare after treatment has finished.

The Latin American expert consensus (Rocha et al., 2024) went a step further and recommended 1 year of topical maintenance treatment for all patients after isotretinoin treatment (7 of 8 agreed). In a study in which patients applied an adapalene–benzoyl peroxide combination gel for 12 months after their acne had gone into remission on isotretinoin (Bettoli et al., Dermatology, 2013), 2 of the 68 who completed the study (2.94%) relapsed during the maintenance period. This study had no comparison group, however. Among studies with a comparison group, a small randomized double-blind trial split 20 men who had finished isotretinoin into tretinoin gel and placebo gel groups for 24 weeks (Vender et al., Dermatology Research and Practice, 2012); the tretinoin group had fewer lesions, but with so few participants this could not be confirmed statistically. Within the scope of our search, we did not find a randomized controlled trial large enough to confirm the effect.

So from the point when isotretinoin is being tapered, we tend to add a topical retinoid little by little, checking that the skin tolerates it, and hand over to it. Among retinoids, we mainly recommend adapalene or trifarotene for acne, and we also explain how much to apply and how.

Skincare — After Stopping, Go Back to a Routine Built for Acne-Prone Skin

"The medication stops the oil, so I don't need to worry about skincare, right?" We hear this often in clinic, and it is only half right. While you are taking the drug, you can take a break from skincare aimed at acne, but you do need to look after dryness.

While Taking It — Look After Dryness, but Heavy Formulations Are Not Needed

A modified Delphi consensus of 20 Indian dermatologists (Kandhari et al., Dermatology and Therapy, 2026) strongly recommends using a gentle, soap-free cleanser and lip balm (all participants agreed), a non-comedogenic moisturizer (95% agreement) and a non-comedogenic sunscreen (80% agreement) together during treatment. The same paper explains that topical retinoids are generally avoided during treatment to limit damage to the skin barrier.

The word to note here is non-comedogenic, meaning a formulation designed not to clog pores. Even while you are taking the drug, your skin is still acne-prone, so there is no need to go as far as heavy formulations such as barrier creams for atopic skin. During treatment, we mainly recommend a low-pH cleanser and a gentle moisturizer.

After Stopping — Back to an Acne-Prone Skin Routine, One Step at a Time

As the effect of the drug wears off, sebum increases again, yet skincare often stays exactly as it was during treatment. These are cases where the heavy moisturizer used against dryness while on the drug, and a cleanser with weak cleansing power, are still in use months after stopping; we see this often in clinic, and in many of these cases the acne also comes back quickly. So after stopping, skincare is brought back to an acne-prone-skin routine one step at a time.

• Topical medication — the maintenance medications mentioned above, such as a retinoid or benzoyl peroxide. The cleanser and moisturizer are also chosen according to whether they let you apply this medication every day.
• Cleanser — move from a low-pH cleanser toward one that clears out dead skin cells and sebum inside the pores, such as a salicylic acid (BHA) cleansing gel. The 2024 AAD guideline gave topical salicylic acid a conditional recommendation (meaning there is evidence, but not enough to recommend it strongly), and the Latin American expert consensus (Rocha et al., 2024) also named salicylic acid and LHA (lipohydroxy acid), among others, as cosmetic ingredients for acne-prone skin. This does not mean scrubbing hard, though. A cleanser that is too strong, or washing too often, only builds up irritation.
• Moisturizer — switch from a thick formulation such as a barrier cream to something lighter, such as a non-comedogenic hydrating cream or gel cream. Why barrier creams for atopic skin do not suit acne-prone skin is set out in our article on oil–water balance and choosing a moisturizer.

Not everything is changed at once. Starting a retinoid and a salicylic acid cleanser on the same day causes stinging that makes it easy to give up on the maintenance medication. An expert recommendation paper on Asian skin phototypes (Andriessen et al., Journal of Drugs in Dermatology, 2021) likewise summarized that, across several studies of topical acne treatments, Asian people were more sensitive and tolerated them less well than Caucasians. That is why changes are made one at a time while watching how the skin responds.

It is only for the few months on isotretinoin that the routine is temporarily geared toward dryness; once you stop, it goes back to the original standard. When attention goes to medication and procedures, everyday cleansing and moisturizing at home are easy to overlook. On the day we prescribe, we decide on the cleanser, the moisturizer and even the sunscreen together, and we change them once more when the drug is stopped. In the end, a simple routine you can keep up every day lasts longer than a complicated one.

Procedures — Marks and Scars Are Where Dermatology Should Focus

In active acne, procedures play a supporting role to medication and topical treatment. The 2024 AAD guideline made no recommendation either for or against procedures such as peels, lasers and photodynamic therapy. When acne is severe, procedures are sometimes combined with medication, but medication is at the center of treating active acne.

That does not mean procedures are of no use. There are cases where medication cannot be used, and cases where procedures are combined with medication. And there are clearly areas that oral medication, topical medication and skincare cannot resolve. Red marks need a vascular laser, brown marks a pigment laser, and depressed scars treatments such as a fractional laser, needle RF or subcision — treatments that cannot be done at home.

The US study of patients with acne mentioned earlier (Tan et al., Journal of Drugs in Dermatology, 2017) concluded that there is as yet no treatment that fully resolves acne scars, and it also named relapsing acne as a risk factor for scarring. So preventing scars from forming matters as much as reducing them once they have formed, and managing relapse after stopping is itself scar prevention. How well scar treatment is likely to work is covered in detail in our article on the prognosis of acne scar treatment.

Are Procedures Ruled Out Altogether While You Are Taking It?

That is not the case. It used to be common advice to put off procedures for 6–12 months after stopping, but this received wisdom was based on 3 small case series from the mid-1980s. A systematic review and expert consensus that examined 32 publications (Spring et al., JAMA Dermatology, 2017) concluded that there is insufficient evidence to delay procedures such as superficial chemical peels and fractional lasers. It did not, however, recommend mechanical dermabrasion or lasers that strip away the whole surface of the skin (fully ablative lasers). If you are taking the drug or have just stopped, we decide on the type and timing of any procedure after looking at the state of your skin.

In Summary

Isotretinoin is less a drug that ends acne than a bridge to skin that can be managed without medication.

• If you have small comedones and the occasional inflamed spot, start with topical treatment and skincare; if nodules keep coming back or scars have started to form, it is time to consider isotretinoin.
• If you are already taking it, check first when you will stop and what will take over; if you have already stopped, check first whether your skincare is still stuck where it was while you were on the medication.
• We believe a dermatology clinic should sort out what can be done at home from what cannot, and focus on the parts that cannot be done at home, such as marks and scars.

If you are taking isotretinoin now, be sure to ask these two questions at your next appointment: "When will I stop, and what state does my skin need to be in first? What will I apply after stopping?" Stopping is not the end of treatment but the beginning of ongoing care.

Precautions and Limits of the Evidence

The right dose, duration and approach to maintenance treatment differ according to each person's skin condition, the severity of the acne, body weight and medication history. This article is general information and does not replace an individual prescription.

Isotretinoin commonly causes cheilitis (inflamed, dry lips) and dryness of the skin, eyes and mucous membranes, and acne may temporarily get worse early in treatment. Because taking it during pregnancy carries a risk of birth defects, women who can become pregnant need contraception from before they start, throughout treatment and for a set period after stopping, and a doctor's supervision, including blood tests, is needed while taking it. Depending on the type, procedures can cause redness, swelling, pigmentation and other effects, and exfoliating ingredients such as salicylic acid can cause stinging or dryness when you first start using them.

Relapse rates cannot be compared directly because each study defines relapse differently, looks at different people and follows them for a different length of time. Of the consensus statements cited, all the authors of the Latin American expert consensus declared ties to a cosmetics company, such as speaker or consulting fees. The approach of changing cleanser and moisturizer after stopping has not been compared in studies; it is based on clinical experience and expert consensus.

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