Dr. Hilary Baldwin discusses the latest with isotretinoin, including COVID risk, rhabdomyolysis risk, the iPLEDGE program, and the ongoing birth control quandary.
Hilary Baldwin, MD, Medical Director of the Acne Treatment & Research Center, Brooklyn, New York, and Clinical Associate Professor, Rutgers Robert Wood Johnson Medical Center, New Brunswick, New Jersey.
“This is not the audience with which to discuss the use and side effects of isotretinoin. I thought, rather, I would look at the news on isotretinoin from 2020, and condense it into a few topics,” said Hilary Baldwin, MD, who presented “What Happened With Isotretinoin in 2020?” at Maui Derm 2022.
“What I found in 2020 was a lot of questions regarding isotretinoin and COVID-19. Does isotretinoin increase the risk of COVID acquisition? Should we be worried about it?”
The short answer appears to be no, said Dr. Baldwin.
“About two-thirds of our patients complain of very dry nasal mucous membranes. We also know that the virus binds to the nasal mucosa and gains entry from there. So might this dry nasal mucosa mean that our patients on isotretinoin are at a higher risk of acquiring infection?”
In two studies1,2 that looked at COVID infection rates in people on and not on isotretinoin, researchers found no difference in infection incidence, said Dr. Baldwin.
Notably, another study3 examined repurposing 672 drugs to prevent or treat COVID. Isotretinoin ranked 1 out of 672 in its ability to decrease binding of the virus to the nasal mucosa.
“So, there is no evidence that isotretinoin use increases the risk of COVID infection, and it appears that we can continue routine use of the drug.”
iPLEDGE
Updates to the iPLEDGE program late last year disrupted patient care, creating challenges for dermatologists and their patients. But it did solve one problem, said Dr. Baldwin.
“There were many articles in 2020 regarding iPLEDGE deficiencies. Several identified inequities with the transgender public, who were forced to identify themselves as either female or male.”
Fortunately, with recent changes to the website, patients are more appropriately referred to as people who can and people who cannot get pregnant, said Dr. Baldwin.
The articles identified other issues with iPLEDGE, including education and socioeconomic iniquities.
“Studies have shown that iPLEDGE marginalizes women, it marginalizes patients in poor neighborhoods, and it marginalizes those who don’t have the money for computers or internet access. Language used in the iPLEDGE materials is above national literacy levels, creating issues for many of our patients.”
Until the system is fixed, one solution is to provide computer access to patients in the office, said Dr. Baldwin. A dedicated computer with limited access to iPLEDGE can be used to assure that patients have completed all items before they leave the office.
A Question of CK
“Should we be checking CK [creatine kinase], especially in our athletic boys?”
It’s a question that dermatologists have asked for years, said Dr. Baldwin.
“There are case reports of increased CK levels in patients on isotretinoin, but they were far and few between and most physicians do not check CK.”
However, a study4 published by Guy Webster, MD, PhD, in 2017 showed a frequency and magnitude of CK elevations among physically active male patients that suggested CK monitoring is warranted in this population, she said.
“Two papers in 2021 detailed several athletic males with very high CK levels, 10 to 20 times normal, on low levels of isotretinoin. Many case reports throughout the medical literature identify that athletic males are at highest risk for rhabdomyolysis. An unanswered question is whether the CK elevations are due to the at-risk population, isotretinoin use, or a combination of both. In the meantime, it seems prudent to evaluate CKs in athletic males on isotretinoin.”
The Birth Control Quandary
“Over the years, I have informally queried dermatologists at educational meetings regarding their prescribing habits for oral contraceptives in patients about to start isotretinoin. Each time the audience was evenly split between those who prescribe contraceptives and those who refer to gynecologists.”
According to Dr. Baldwin, past studies have shown that dermatologists get poor marks as contraceptive counselors.
Research also shows that the counseling dermatologists provide is generally limited to oral contraceptives without any significant attention to other methods that are, in fact, more likely to result in compliant behavior with superior efficacy, namely intrauterine and subdermal implants.5
“Presumably this is due to the comfort level of dermatologists. We don’t feel comfortable talking about implants and IUDs, and the only conversation that we have with most of our female patients is the use of oral contraceptives.”
In a recent study,6 physicians at The Ohio State’s dermatology clinics were trained to administer subdermal implants.
“Once they knew how to do it, they were much more likely to have a real conversation with their patients, talking about all the various options for birth control,” said Dr. Baldwin.
Of the 36 study participants on isotretinoin, 25% chose the subdermal implant. Researchers concluded that physician counseling on contraceptive options may have a significant effect on selection.
“The bottom line is that we need to be well educated in all methods of contraceptives if we are going to counsel our patients effectively. Otherwise, we should turn the job over to the gynecologists.”
Disclosure:
Dr. Baldwin is an advisor and speaker for Sun Pharma.
References
- Demirel Öğüt N, Kutlu Ö, Erbağcı E. Oral isotretinoin treatment in patients with acne vulgaris during the COVID-19 pandemic: A retrospective cohort study in a tertiary care hospital. J Cosmet Dermatol. 2021 Jul;20(7):1969-1974. doi: 10.1111/jocd.14168. Epub 2021 Apr 29. PMID: 33884755; PMCID: PMC8251193.
- Takci Z, Simsek GG, Karabulut H, Buran Y, Karadag AS. Effect of systemic isotretinoin therapy on mucociliary clearance and nasal surface mucosa in acne patients. J Drugs Dermatol. 2013 Aug;12(8):e124-8. PMID: 23986172.
- Sinha S, Cheng K, Schäffer AA, Aldape K, Schiff E, Ruppin E. In vitro and in vivo identification of clinically approved drugs that modify ACE2 expression. Mol Syst Biol. 2020 Jul;16(7):e9628. doi: 10.15252/msb.20209628. PMID: 32729248; PMCID: PMC7390914.
- Webster GF, Webster TG, Grimes LR. Laboratory tests in patients treated with isotretinoin: occurrence of liver and muscle abnormalities and failure of AST and ALT to predict liver abnormality. Dermatol Online J. 2017 May 15;23(5):13030/qt7rv7j80p. PMID: 28537864.
- Werner CA, Papic MJ, Ferris LK, Lee JK, Borrero S, Prevost N, Schwarz EB. Women’s experiences with isotretinoin risk reduction counseling. JAMA Dermatol. 2014 Apr;150(4):366-71. doi: 10.1001/jamadermatol.2013.6862. PMID: 24258663.
- Macklis P, Vandersall A, Benedict J, Tyler K, Kaffenberger J. Factors influencing patients’ choice of contraceptives when starting isotretinoin. J Am Acad Dermatol. 2021 Sep;85(3):737-738. doi: 10.1016/j.jaad.2019.07.066. Epub 2019 Jul 25. PMID: 31351892.