Isotretinoin, a potent retinoid, is widely used in dermatology for the treatment of severe acne. While its efficacy is well-documented, the management of patients on isotretinoin requires careful consideration due to its potential side effects and teratogenicity.   

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Medical Chronicle recently hosted a CPD-accredited webinar on this topic, presented by dermarologist Dr Hetesh Pitamber. The webinar was sponsored by Adcock. Here, we outline the key messages from his presenation for prescribing and managing isotretinoin therapy.  

  Do’s  

1. Comprehensive patient evaluation: Before initiating isotretinoin, conduct a thorough patient history and physical examination. Assess for contraindications such as pregnancy, liver disease, and hyperlipidaemia. Baseline laboratory tests, including liver function tests, lipid profile, and a pregnancy test for women of childbearing potential, are essential. 
2. Informed consent: Educate patients about the potential side effects of isotretinoin, including teratogenicity, mucocutaneous effects, and psychiatric symptoms. Obtain informed consent, ensuring that patients understand the importance of adherence to contraceptive measures and regular follow-up appointments. 
3. Contraceptive measures: For female patients of reproductive age, ensure the use of effective contraception one month before, during, and one month after isotretinoin therapy. Dual contraception methods are recommended to minimise the risk
   of pregnancy. 
4. Regular monitoring: Schedule monthly follow-up visits to monitor for side effects and assess treatment efficacy. Repeat laboratory tests, including liver function and lipid profile, at regular intervals. For female patients, conduct monthly pregnancy tests. 
5. Patient education: Provide detailed instructions on the proper use of isotretinoin, including the importance of taking the medication with food to enhance absorption. Educate patients on managing common side effects such as dry skin and lips, and advise on the use of moisturisers and lip balms. 
6. Psychiatric assessment: Monitor patients for signs of depression, anxiety, or other psychiatric symptoms. While a direct causal relationship between isotretinoin and psychiatric effects is not established, it is crucial to remain vigilant and provide appropriate referrals if needed. 

  Don'ts 

1. Avoid in pregnancy: Never prescribe isotretinoin to pregnant women or those planning to become pregnant. The teratogenic effects of isotretinoin can lead to severe congenital malformations. Ensure strict adherence to contraceptive measures and regular pregnancy testing. 
2. Do not overlook side effects: Be proactive in managing side effects.
   Common adverse effects include dry
   skin, cheilitis, and epistaxis. Educate patients on preventive measures and
   provide symptomatic treatment as
   needed. For severe side effects,
   consider dose adjustment or
   discontinuation of therapy.  
3. Avoid excessive sun exposure: Advise patients to minimise sun exposure and use broad-spectrum sunscreen with a high SPF. Isotretinoin increases skin sensitivity to UV radiation, leading to a higher risk of sunburn. 
4. Do not ignore mental health: Pay attention to any changes in the patient's mood or behaviour. Promptly address any psychiatric symptoms and consider collaboration with mental health professionals for comprehensive care. 
5. Avoid alcohol consumption:
   Advise patients to limit or avoid alcohol intake during isotretinoin therapy. Alcohol can exacerbate liver toxicity and hyperlipidaemia, increasing the risk of adverse effects. 
6. Do not prescribe without proper training: Isotretinoin should only be prescribed by healthcare professionals experienced in managing its use. Ensure that you are familiar with the guidelines and protocols for isotretinoin therapy to provide safe and effective care. 

In conclusion, isotretinoin is a valuable treatment for severe acne, but it requires careful patient selection, education, and monitoring. By adhering to these dos and don'ts, healthcare professionals can optimise treatment outcomes while minimising the risk of adverse effects.