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CPD ACTIVITY 43 Expected side effects The occurrence of dry lips should be considered a certainty.46 Patients should be encouraged to use lip balms to reduce the incidence of cheilitis.34 Petroleum jelly or nasal oils can be used for dryness of the nose, as almost half of patients will experience nose bleeds during their treatment.47 Some recent trials have also suggested taking desloratadine daily to reduce the severity of dose related adverse effects from ITT.48,49,50 Evaporative dry eye disease (DED) is the most common ocular adverse effect from ITT treatment.51 While there is no evidence for treatments specifically for DED due to ITT, it is reasonable to recommend the use of low-risk interventions such as ocular lubricants and lid washes.49 While most resources discuss an increased photosensitivity for patients using oral retinoids, there is limited conclusive evidence to substantiate the severity of this adverse effect.19,52 A recent retrospective review of more than 3000 participants found that only 2.6 per cent of patients experienced sun sensitivity.45 However, it’s still appropriate to provide general advice concerning the need to use sunscreen. Advice to minimise harm Patients should be reminded to inform a GP immediately if they notice any changes in their vision.19 Due to the potentially irreversible retinal toxicity of ITT, patients should know that any disruption to colour perception, night vision or continual feeling of a foreign body in the eye should prompt an immediate visit to the hospital or doctor.49 Due to the changes in the skin structure and sensitivity, it’s essential that patients don’t wax their skin for at least six months after completing a course of ITT.53 Females should be reminded to use two forms of contraception during treatment and for one month after ceasing.19 Avoid any supplements containing vitamin A.19 While the presence of a causal association with ITT and depression is not clear, it remains important for any adolescent to be familiar with services or know which family members they can reach out to in times of crisis.7,9,19,39 To optimise compliance and treatment effectiveness Patients should be aware that it can take several weeks for the symptoms of acne to improve, and they may even get worse before they get better.17 The need to continue taking ITT daily after the symptoms subside, for up to two months, should also be reiterated.34 Taking ITT with a meal has been shown to significantly improve its bioavailability.54,55 Table 1. Counselling points when dispensing oral isotretinoin. providing clinically sound counselling. In general, the prescription should be written by a dermatologist (or specialist physician as per state requirements) and annotated by the prescriber. Many counselling points can be discussed, and it can be challenging not to overwhelm the patient or discourage them from using this potentially life changing medicine.34 The goal of counselling should be to inform the patient of the expected adverse effects and how to manage them, reduce the potential for harm and optimise adherence (See Table 1 for more details). References 1. Gebauer K. ‘Acne in adolescents’. Aust Fam Physician, 2017 Dec; 46 (12): 892–5. 2. Tuchayi SM, Makrantonaki E, Ganceviciene R, Dessinioti C, Feldman SR, Zouboulis CC. ‘Acne vulgaris’. Nature Reviews Disease Primers, 2015 Sep 17; 1 (1): 1-20. 3. Berg M, Lindberg M. ‘Possible gender differences in the quality of life and choice of therapy in acne’. Journal of the European Academy of Dermatology and Venereology, 2011 Aug; 25 (8): 969-72. 4. Rowe C, Spelman L, Oziemski M, Ryan A, Manoharan S, Wilson P, Daubney M, Scott J. ‘Isotretinoin and mental health in adolescents: Australian consensus’. Australasian Journal of Dermatology, 2014 May; 55 (2): 162-7. 5. Niemeier V, Kupfer J, Gieler U. ‘Acne vulgaris: Psychosomatic aspects’. Journal der Deutschen Dermatologischen Gesellschaft (JDDG), 2006 Dec; 4 (12): 1027-36. 6. Cunliffe WJ. ‘Acne and unemployment’. The British Journal of Dermatology, 1986 Sep 1; 115 (3): 386. 7. Ritvo E, Del Rosso JQ, Stillman MA, La Riche C. ‘Psychosocial judgements and perceptions of adolescents with acne vulgaris: A blinded, controlled comparison of adult and peer evaluations’. BioPsychoSocial Medicine, 2011 Dec; 5 (1): 1-5. 8. Layton AM. ‘Optimal management of acne to prevent scarring and psychological sequelae’. American Journal of Clinical Dermatology, 2001 Jun; 2 (3): 135-41. 9. Gupta MA, Gupta AK. ‘Depression and suicidal ideation in dermatology patients’. Psychosomatic Medicine, 1999 Jan 1; 61 (1): 88. 10. Therapeutic Guidelines Limited. Acne \[Internet\]. eTG complete \[digital\]. Melbourne: 2015 \[cited 2021 Apr 21\]. Available from: tgldcdp.tg.org.au/ viewTopic?topicfile=acne&guidelineName= Dermatology&topicNavigation= navigateTopic 11. Connolly D, Vu HL, Mariwalla K, Saedi N. ‘Acne scarring: Pathogenesis, evaluation, and treatment options’. The Journal of Clinical and Aesthetic Dermatology, 2017 Sep; 10 (9): 12. 12. Dréno B, Pécastaings S, Corvec S, Veraldi S, Khammari A, Roques C. ‘Cutibacterium acnes (Propionibacterium acnes) and acne vulgaris: A brief look at the latest updates’. Journal of the European Academy of Dermatology and Venereology, 2018 Jun; 32: 5-14. 13. Claudel JP, Auffret N, Leccia MT, Poli F, Dréno B. ‘Acne from the young patient’s perspective’. J Eur Acad Dermatol Venereol, 2020 May; 34 (5): 942–7. 14. Su P, Chen Wee Aw D, Lee SH, Han Sim Toh MP. ‘Beliefs, perceptions and psychosocial impact of acne TO PAGE 44 adverse effects is particularly difficult to determine as adolescents are especially vulnerable to changes in mental health in addition to the well-defined effect of acne on mental health.5,40 The concerns with ITT were ostensibly triggered by multiple case reports of teenage suicides, which were given considerable media attention in the US.29 However, the Australian Therapeutic Guidelines suggests that depression should not be considered a contraindication to treatment with ITT.10 However, it’s recommended that prescribers should ask about the patient’s mental health before prescribing, as a means of determining their baseline.4 The scientific debate concerning the plausible connection of ITT treatment and depression continues. In 2018, a systematic review by Oliveira et al deemed that the association between ITT and depression is likely to be positive, and that worsening symptoms of depression is rare.41 This is congruent with more recent prospective studies finding that ITT use is associated with a decreased risk of depression and other psychological disorders typically associated with acne.42,43,44 The preponderance of peer reviewed evidence indicates that if there is any psychological effect from ITT, it’s most likely to be a positive effect. The psychological benefits of treating acne far outweigh the risks. However, it’s plausible that some individuals are more vulnerable to experiencing significant psychological effects after using ITT.34,45,46 Patients starting treatment should be encouraged to discuss any changes in mood with their prescriber and have emergency contact numbers to call if they feel acutely unstable.4,44 Counselling When dispensing ITT, pharmacists should be familiar with legislation relating to the treatment specific to the jurisdiction in which they are practising, in addition to Introducing the new look Australasian College of Pharmacy Now is a great time to become part of the College community. Visit acp.edu.au to learn more and sign up for updates. RETAIL PHARMACY • JUN 2021 21_00006N