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Dermatologists treating adolescents with severe acne using isotretinoin should consider prescribing emergency contraception (EC) as a precaution, according to Andrea L. Zaenglein, MD, a professor of dermatology and pediatrics at The Pennsylvania State University. Zaenglein discussed the importance of hormonal therapies in managing pediatric acne at the Society for Pediatric Dermatology (SPD) 2024 Annual Meeting.
The Need for Emergency Contraception
Emergency contraception (EC) is a method used to prevent unintended pregnancy after unprotected sexual intercourse or contraceptive failure. Despite its importance, many doctors are reluctant to prescribe EC due to discomfort or lack of training, Zaenglein told Medscape Medical News. This reluctance persists despite isotretinoin’s known teratogenicity risks, which are managed through the iPLEDGE Risk Evaluation and Mitigation Strategy. However, from 2011 to 2017, between 210 and 310 pregnancies per year were reported to the US Food and Drug Administration by patients taking isotretinoin, as per a 2019 study in JAMA Dermatology.
Zaenglein and colleagues have identified a significant knowledge gap among dermatologists regarding EC, partly perpetuated by the iPLEDGE program’s inadequacies in guiding clinicians or educating patients about EC use. EC options include oral levonorgestrel (Plan B), available over the counter; oral ulipristal acetate (Ella), requiring a prescription; and copper/hormonal intrauterine devices.
Understanding Adolescent Sexual Activity
Zaenglein emphasized that not all adolescents taking isotretinoin can be expected to remain sexually abstinent. She cited research indicating that 39% of female high school students have had sexual relations, suggesting that EC should be prescribed as a backup for these patients. She highlighted a common misunderstanding that EC is an abortion pill, clarifying that it is a contraceptive method and does not affect an existing pregnancy.
Outgoing SPD President Sheilagh Maguiness, MD, echoed Zaenglein’s concerns, noting the practice and knowledge gaps that need to be addressed. Zaenglein urged clinicians to assume that female patients on isotretinoin are or could be sexually active and to discuss the risks to the fetus explicitly, considering the patients’ past compliance.
Hormonal Therapies for Acne
Zaenglein described acne as a complex, multifactorial inflammatory disorder involving increased sebum production, hyperkeratinization, Cutibacterium acnes, and inflammation. She noted the significant role of androgens in acne development, which is why some treatments aim to block androgen receptors.
One such treatment is spironolactone, increasingly used for female adolescents with acne. A Mayo Clinic study of 80 patients with moderate to severe acne found that 80% showed improvement with spironolactone, though response rates are higher in adults. Side effects can include menstrual disturbances, breast enlargement, and premenstrual syndrome-like symptoms.
Zaenglein also recommended considering combined oral contraceptives (COCs) for adolescents with acne. Despite their proven effectiveness, a US survey revealed that only 60% of dermatology residents felt comfortable prescribing COCs to healthy adolescents, with many feeling inadequately trained on their efficacy and safety. Contraindications for COCs include thrombosis, migraine with aura, lupus, seizures, and hypertension.
Preventing Drug Interactions and Addressing PCOS
Clinicians should perform an acne assessment to prevent drug interactions before prescribing hormonal therapy. For instance, the antibiotic rifampin can interact with COCs, and the herbal supplement St John’s Wort can reduce their efficacy. Regular monitoring of blood pressure and weight is also advised.
Zaenglein urged dermatologists to consider polycystic ovarian syndrome (PCOS) before starting hormonal therapy, as acne is common in adolescents with PCOS. Using a PCOS checklist to screen for symptoms and family history can aid early diagnosis and intervention, which is crucial for managing the long-term effects on cardiovascular health and fertility.
Zaenglein’s presentation highlights the importance of comprehensive care for adolescents on isotretinoin, including the consideration of EC and hormonal therapies to manage the complexities of acne and associated conditions like PCOS.
