MedicalResearch.com Interview with:
Arielle Nagler MD
Instructor, Department of Ronald O. Perelman Department of Dermatology
NYU Langone Medical Center
Medical Research: What is the background for this study of acne patient who eventually require isotretinoin?
Dr. Nagler: Isotretinoin is a highly effective medication for the treatment of severe acne. In fact, it is the only medication that has been shown to provide patients with a durable cure for acne. However, its use is limited by its known teratogenicity as well as controversies regarding its relationship with psychiatric disturbances and inflammatory bowel disease. For many patients, systemic antibiotics provide an effective treatment for inflammatory acne. However, antibiotics do not provide the long term clearance that isotretinoin provides. Moreover, antibiotics are getting increasing attention due to fears of emerging bacterial resistance. There has been a recent emphasis on limiting antibiotic use in acne. As a result, this study sought to understand antibiotic use patterns amongst patients who eventually received isotretinoin.
Medical Research: What is the background for this study? What are the main findings?
Dr. Nagler: In this retrospective study, spanning 10 years of charts at a large academic center, we found that the average duration of antibiotic use for acne amongst patients who eventually required isotretinoin was 331.3 days (approximately 11 months). This exceeds many of the consensus statements and recommendations for limiting antibiotics to 3-6 months in the treatment of acne. In addition, we found that these long antibiotic durations were associated with extensive delays between first discussions of isotretinoin with patients and isotretinoin prescriptions. In this study, we identified a patient population (patients who require isotretinoin) in which efforts could be made to decrease the duration of antibiotic use.
Medical Research: What do you suspect are the factors leading patients or providers (or both) to delay introduction of isotretinoin into the treatment plan? (parental or patient fear of adverse effects? liability concerns? extra work required of the health care providers? IPledge restrictions or ‘red tape’?)
Dr. Nagler: There are many factors that contribute to delays in the introduction of isotretinoin. In an anecdotal review of the charts included in this study, reasons for the delay included patient and family members’ fears of the controversial association between isotretinoin and inflammatory bowel disease, depression, and other psychiatric disturbances. Isotretinoin requires routine lab monitoring, office visits, and counseling so future or potential interruptions in care such as a moving to college and sleep-away camp were also cited as reasons. Additionally, the prescription of isotretinoin requires enrollment and compliance with national online iPLEDGE database. This can be a cumbersome system and may also contribute to delays in prescriptions.
Medical Research: What recommendations do you have to facilitate faster incorporation of isotretinoin into patient care?
Dr. Nagler: Dermatologists should be cognizant of the total duration of antibiotics patients have used for the treatment of acne. In this study, we found that patients who have seen multiple providers are particularly at risk for extended antibiotic durations. As a result, dermatologists should make an effort to obtain a complete antibiotic history from all of their new acne patients. Additionally, early recognition of patients with severe or recalcitrant acne is also important in decreasing antibiotic duration and initiating isotretinoin. If patients do not respond to systemic antibiotics within 6-8 weeks, discussions about isotretinoin should begin. Earlier discussions of isotretinoin may help to limit the use of antibiotics in acne.
Arielle Nagler MD (2015). Earlier Isotretinoin Discussion May Decrease Long-Term Antibiotic Use For Acne