Supporting patients who are taking isotretinoin

Patients being prescribed isotretinoin need to be supported throughout their course of treatment. They need advice with regards to managing a range of issues (Box 10.5).

Box 10.5 Checklist of topics that need to be discussed with patients on isotretinoin Change in mood Contraception (in women) Dryness: eyes, mouth, lips, nose (nosebleeds), genitalia Joint and/or muscle discomfort Sun protection/avoidance Avoiding Alcohol Waxing/exfoliating Avoiding planned surgery/cosmetic procedure Should not give blood Avoid vitamin supplements

It is not possible to totally ameliorate the drying effects of the drug, but certain protective behaviours may help (Box 10.6).

Box 10.6 Advice that may help with the drying effects of isotretinoin Avoiding activities which dry the skin, e.g. taking hot showers/baths and using soap; Using emollients extensively if skin becomes dry; Not using exfolliants or topical treatments that will dry the skin further. All topical acne treatments should be stopped; Not waxing; Having a chapstick handy for dry lips and using this frequently (may need to be hourly); Avoiding exposure to UV radiation and not making use of sunbeds. Always using an oil-free sunscreen of at least SPF 15; Wearing soft contact lenses or glasses are likely to be more comfortable than hard contact lenses; Using hypromellose eye drops; Keeping a bottle of water handy at all times, to sip.

The drug’s effect can be significantly enhanced by taking it with food. It is thought that 40% is absorbed if taken with a meal whereas only 20% is absorbed if it is taken on an empty stomach (Gollnick et al., 2003). The drug can be taken as a single dose once a day or divided and taken as two doses at different times of the day. If the drug dose is to be split, it may be helpful for the patient to use a dosing box to ensure that they keep track of their tablets.

Preventing pregnancy is key for female patients who are on isotretinoin. Contraceptive advice should be given to all sexually active patients. Teenagers who attend with parents may be unwilling to admit they are sexually active; however, information should still be given. It is advised that one or preferably two types of contraception are used. Depending on the level of advice needed, the woman may need to be referred to a family planning service to ensure that the most effective and suitable contraception is provided. Contraception must be used for a month prior to the planned start of treatment, during treatment and for 5 weeks after the end of treatment. This is because it takes this length of time for the isotretinoin to be excreted from the body completely.

Although very low levels of isotretinoin may be found in the semen of men on the drug, these are not thought to be sufficient to harm an unborn child or their sexual partner.