Shanna Miranti, PA-C, discusses highlights from her lecture, Lessons Learned in Acne & Rosacea, at the 2nd Annual Elevate-Derm Alliance Summer Conference at the Grand Hyatt Deer Valley in Park City, Utah.

In this video

Speaking with co-host Buchi Nnita, PA-C, on the SkinSync podcast, Miranti calls isotretinoin "a life-changing medication" and reminds providers that "there really is no rule book" — most of what she teaches is lessons learned over 23 years of practice. She stresses knowing exactly which of the roughly 15 generics you're comfortable prescribing, since they vary in absorption and tolerability and each is "really only about 80% of the integrity of the original drug." Continuity matters, so she sets up pharmacy protocols to keep patients on a consistent version, and works with front-office staff to build dedicated follow-up slots so patients can be seen every four weeks with labs in hand.

On counseling, she acknowledges the medication is "not for the faint of heart" and often spends time "talking parents off the ledge" about TikTok-fueled misconceptions versus the actual warnings. To prevent recurrence she checks three boxes — at least 20 weeks of therapy, a cumulative dose of 125–150 mg/kg (up to 200 mg/kg on a repeat course), and 100% clinical clearance for at least one month — and warns patients that clearance "is not a cure." For lingering hyperpigmentation and scarring, she starts a topical retinoid (tazarotene or trifarotene) the night of the last isotretinoin dose and gets patients consulting with a cosmetic provider before they finish, since the old six-month waiting rule has been dispelled.

  • Know your generics: with ~15 isotretinoin versions varying in absorption and tolerability, unexpected outcomes should prompt you to check exactly which version the patient received.
  • Build protocols and templates — dedicated four-week follow-up slots and pharmacy agreements — so scheduling, labs, and continuity of care don't derail treatment.
  • Have the tough conversations: require two forms of birth control (abstinence counts as one), and counter social-media rumors by discussing the actual warnings and side effects.
  • Prevent recurrence by hitting three checkboxes — at least 20 weeks on the drug, a cumulative dose of 125–150 mg/kg (up to 200 mg/kg for repeat courses), and 100% clinical clearance for at least a month.
  • Address PIH and scarring from day one: start tazarotene or trifarotene the night of the last dose, reinforce sun protection, and set up cosmetic consultation early since non-ablative and even aggressive laser/microneedling treatments no longer require a six-month wait.