In this episode, we speak to Dr Diarmuid Quinlan, a GP and MD candidate based at the Department of General Practice at University College Cork.

Title of paper: Competencies and clinical guidelines for managing acne with isotretinoin in general practice: a scoping review

Available at: https://doi.org/10.3399/BJGP.2025.0135

There is evidence of inequitable access to the most effective treatment for severe acne, isotretinoin. This scoping review identified the clinical competencies to safely manage acne using isotretinoin. No global consensus exists among clinical practice guidelines (CGPs) on whether GPs are appropriate prescribers of isotretinoin. Appropriately resourced and CPG-guided patient access to isotretinoin in primary care may promote safe, timely, and equitable acne management for patients and improve antimicrobial stewardship.

Transcript:

This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A

00:00:01 .440 - 00:01:07 .850

Hello and welcome to BJGP Interviews. My name is Nada Khan and I'm one of the associate editors of the bjgp. And welcome to our autumn edition of the BJGP podcast.

We're kicking off with a new set of interviews for the next few months. So thanks again for joining us.

Today we're speaking to Dr. Dermod Quinlan, who is a practicing GP in Cork and is also an MD candidate at University College Cork in Ireland.

We're here today to discuss his paper, recently published in the BJGP titled Competency and Clinical Guidelines for Managing Acne with Isotretinoin in General Practice. A Scoping Review. So thanks very much, Dermid, for joining me here today to talk about this paper.

But yeah, I guess I just wanted to start by saying that this is a really interesting paper and I think it covers a very common condition that we see in general practice and covers treatment, which can be quite difficult as well for acne.

But I wonder if you could just start by telling us a little bit about why you wanted to do this research and just a bit about the treatment of it and why you focused down on this topic, really.

Speaker B

00:01:09 .610 - 00:02:59 .510

So lovely to meet you, Nada. I'm first and foremost a GP and I see patients three days a week, 20 hours a week.

And I did a diploma in dermatology over a decade ago and I still do some online tutoring. So I have a long standing interest in dermatology and have an extended role in dermatology.

I work in an urban practice with lots of young teenagers and young people in it.

Acne is a common chronic disorder and I would see a lot of young people with acne of all grades of severity, mild, moderate and severe, and very severe. And as a clinician, very clearly recognize that behind acne is a patient very commonly suffering profound distress.

And we know that the morbidity associated with acne and particularly severe acne, is very extensive.

There's the emotional morbidity, there's psychological morbidity, it impacts people's employment opportunities, their education achievements, and then more widely, because treating acne is resource intensive, it has an impact on the healthcare workforce. And then there are concerns about the very prolonged use of antibiotics in acne, raising real antimicrobial stewardship concerns.

So I have an interest in this. And then we decided that we would do research into it because we don't know the clinical competencies for safe use of isotretinoin.

So I was particularly interested in severe acne and the management of severe acne, and also it didn't clearly identify which were the clinicians that could be safely tasked with managing acne using isotretinoin. So they were the two research questions that we set out to look at.

Speaker A

00:02:59 .750 - 00:03:27 .250

The first thing is I just wonder if you could talk us through, because typically in general practice, at least in the places where I've practiced, we wouldn't, as gps typically, be expected to start isotretinoids in practice. And I wonder if that was part of your reasoning for doing this research.

So did you go into it trying to establish whether GPs could be clinically competent to prescribe these medications?

Speaker B

00:03:27 .650 - 00:04:48 .480

For many years, I transcribed prescriptions initiated by dermatologists and then increasingly found that patients faced challenges in access to dermatologists and waiting to see a dermatologist. The research clearly shows there are issues with timely and equitable access to isotretinoin.

And in terms of equity, the inequity particularly affects ethnic minorities, people from lower social classes and women. So there are very real issues for patients accessing isotretinoin.

One of the concerns about isotretinoin is that it is a very potent teratogen, causing severe fetal abnormalities. GPs are competent in managing many other teratogenic medicines, lithium, methotrexate, sodium valproate, ACEs and ARBs, to name a few.

And GPS can are good at providing contraceptive advice and pregnancy prevention. So I felt that as a gp, that I had a lot of the skill set but didn't know what the guidelines say.

So that that was what led us and led me like it was the equity piece, it was a timely access and also it was the skill set required with clinical competencies to safely manage acne using isotretinoin hadn't been defined in.

Speaker A

00:04:48 .480 - 00:05:34 .780

The literature, so all really topical issues in terms of access and equity.

And as you say, this research aimed to look at clinical practice guidelines and consensus statement recommendations to look to see what should be the clinical competencies for prescribing oral isotretinoids in practice. And you did a scoping review? And we won't go too much into the methods because it followed sort of established methods for doing a scoping review.

And I really just wanted to focus on the results, really. So what did you find? So you found eight clinical practice guidelines, is that right?

And talk us through those and just how you looked at those and what you found really, in terms of what should be the clinical competencies and how you think that applies to general practice.

Speaker B

00:05:35 .180 - 00:08:18 .270

So we identified eight clinical practice guidelines, five of which originated from Europe, one each, then from America, Canada, and Malaysia. The Clinical Practice guidelines identified four clinical competencies for doctors to safely manage isotretinoin.

And these are dermatology, blood testing, mental health, and a pregnancy prevention program. And to take these one by one, the dermatology piece.

Obviously, doctors, GPs need to be able to diagnose acne and more especially need to be able to identify those patients with acne which should perhaps be treated with isotretinoin.

And they are, you know, people with severe acne, acne resistant to treatment, acne causing scarring, or acne which is having a severe psychological impact on patients.

The blood testing has reduced very substantially in recent years because the evidence for undertaking blood tests in otherwise fit largely young people indicates that the benefit is relatively modest. There is some heterogeneity among the guidelines as to what tests should be done and when they should be done and how often they should be done.

But largely there is an agreement that some blood tests are prudent, but not excessive blood testing. The two big pieces really are around mental health and pregnancy prevention.

Mental health is a concern with isotretinoin, and isotretinoin has been on the mark now since licensed in 1982 by the FDA. So it's around a very long time. And there have been concerns expressed continually about mental health and isotretinoin.

It's very reassuring that the evidence also identifies that at a population level, there isn't an increase in suicide. But case reports continue about raising concerns about mental health.

So the guidelines all recommend that people should have regular mental health assessments.

And while we can look at the potential adverse side effects of using isotretinoin to treat acne, we must also be very cognizant of the other side of the equation, where young people and people in general with severe acne can suffer very substantial emotional and psychological harms and burdens by virtue of their severe acne. And parents and doctors will be very familiar with the adverse psychological, emotional, social issues that arise with severe acne.

So, as in everything else in medicine, it's balancing the risks and the harms.

Speaker A

00:08:19 .230 - 00:08:26 .350

And then the final thing was around contraception, is that right? But again, here the guidelines diverged in some areas, didn't they, on their recommendations?

Speaker B

00:08:26 .830 - 00:09:34 .750

Absolutely, yeah.

So again, and pregnancy prevention and isotretinoin and all teratogenic medicines like, it's a really important piece that we can safely manage acne using isotretinoin. And pregnancy prevention is m