Hilary Baldwin, MD, Discusses Impacts of Isotretinoin Use

It is crucial for dermatology clinicians to be aware of the impacts of isotretinoin use on patients with acne, including inflammatory bowel disease (IBD), depression, and emergency contraceptive options. During the 2023 Acne and Rosacea Meeting’s (ARM) Yourself With Knowledge webinar, organized by Masterclasses in Dermatology, Hilary Baldwin, MD, reviewed the latest updates in literature and consensus guidelines for acne treatment using isotretinoin.

Baldwin, a board-certified dermatologist and medical director of the Acne Treatment & Research Center in Brooklyn, New York, and clinical associate professor of dermatology at Rutgers Robert Wood Johnson Medical Center, first reviewed recent large case-controlled and cohort studies demonstrating that there is no link between increased incidence of IBD with isotretinoin, despite concerns raised in 2010.

Having acne is an independent risk factor for depression, anxiety, and suicidal ideations in patients, and mainly boys, with severe acne, according to Baldwin. A meta analysis showed that isotretinoin use actually improved the psychological wellbeing of 17 patients with acne. To best help her acne patients taking isotretinoin, Baldwin gives out her personal cell phone number for any emergency calls from her patients.

Lastly, Baldwin noted that there still is not enough clarity for clinicians about what to do with emergency contraceptives and patients taking isotretinoin. “In a survey of 57 pediatric dermatologists, 68% said they had never received any education; it's not part of the core curriculum for residents, and the termination of pregnancy conversation needs to take place basically, regardless of our personal opinion on the subject,” said Baldwin.

Transcript

Hilary Baldwin, MD: Let's talk briefly about inflammatory bowel disease: does isotretinoin cause it is associated? Is it a coincidence? And to answer that question, I think we have to start by looking at the background data. Crohn's and ulcerative colitis are incredibly common in the age group that we're treating with isotretinoin. There's a very high incidence of family history of both of them, especially Crohn's; 26-fold increased risk if a sibling has Crohn's and 50% monozygotic twin concordance, not quite as much for ulcerative colitis. So, we started worrying about this back in 2010. When a case-control study showed a minimal dose-dependent risk for ulcerative colitis, but not for Crohn's. Since then, we've had 4 large case-control and cohort studies showing no link, a large Mayo Clinic study showing a reduced incidence of IBD, and a meta analysis of 9.7 million pulled patients again showing no link with IBD. What are the consensus guidelines saying? Most of them don't mention it. Ours says there's no evidence to support a link or risk. And I think the Canadian guidelines make the most sense saying inquiry about IBD symptoms and family history is prudent prior to instituting isotretinoin care.

Quickly looking at depression we again we have a ton of background noise. Being 18 to 25 is an independent risk factor for mental health issues. It's the highest as well as depression, as well as suicide attempts in that particular age group. Having acne is also an independent risk factor for depression, anxiety, and suicidal ideation, especially in more severe acne and especially in boys. So there's a lot of noise at baseline and we're superimposing isotretinoin treatment on top of that. So does it make any difference? Or is the depression that we're seeing based on the age and the acne condition of the patient? Well, a meta analysis and systematic review looked at 20 studies that met criteria; 3 showed no association, 17 showed an improved psychological wellbeing after the use of isotretinoin. And the conclusion of these authors was that the use of isotretinoin is associated with an improvement in depression symptoms. So what are we going to do? What's the goal here? Keep a high index of suspicion, not so much because we think isotretinoin is causing the depression, but because the patients in our care are in an age group, in a disease group, that are likely to develop depression, make sure the patients with a prior psych history are plugged in. And in my opinion, all patients on isotretinoin should be given 24-hour emergency contact information, not with an answering service, but with me. I share my cell phone number and I have to tell you, in 20 years of doing it, I've never had a patient misuse that right.

So just one word on pregnancy. I think we do not understand well enough what to do with emergency contraception. And I think it's very important in treating our women of childbearing potential with isotretinoin. It's barely mentioned in the iPLEDGE brochure. In a survey of 57 pediatric dermatologists, 68% said they had never received any education, it's not part of the core curriculum for residents, and the termination of pregnancy conversation needs to take place basically, regardless of our personal opinion on the subject. If we're not having the conversation with them, someone in the office needs to have that conversation. And this of course, is even more important since the reversal of Roe v Wade. And speed is of the essence here because we have 2 options. The much easier is the morning-after pill on the left often called Plan B, which has to be taken within five days of intercourse. The mechanism of action here is that it delays or inhibits ovulation. This does not affect implantation. So specifically, the Dobbs V. Jackson lawsuit that overturned Roe v Wade does not include the activity of plan B as the destruction of what Roe called "potential life." So, it's not nearly as difficult to deal with as the abortion pill on the right, which is way more expensive. It can be taken, however, up to 70 days to after the last menses and does cause a medical abortion. So, this is something that we need to consider. We need to think about, we need to educate ourselves on it so that we're prepared when the patient calls and says, “what do I do? Last night the condom broke,” or “last night I had unprotected intercourse.”

[Transcript lightly edited for clarity]

Reference

Baldwin H. Isotretinoin's impact on irritable bowel syndrome, depression, and need for emergency contraception. Presented at: 2023 ARM Yourself With Knowledge: Acne and Rosacea Meeting; October 3, 2023.