Acne treated with isotretinoin — SCE Dermatology MCQ

Correct answer: B — Confirm pregnancy-prevention requirements and baseline testing

The correct answer is B, confirm pregnancy-prevention requirements and baseline testing. Isotretinoin is a highly teratogenic drug, and before initiation in any woman of childbearing potential the MHRA Pregnancy Prevention Programme requires a negative pregnancy test, counselling on highly effective contraception (given her inconsistent condom use), monthly pregnancy tests during treatment, and baseline bloods (liver function and fasting lipids) plus a mood/psychiatric assessment before the first prescription. Her irregular condom use and lack of a second reliable method mean contraception must be secured and documented before, not after, starting the drug. A history of resolved mild depression requires monitoring for mood change during treatment but is not itself a bar to isotretinoin, so completing these safety checks first is the step that must precede any prescribing decision. Why the other options are wrong: A. Start isotretinoin at the first visit: this skips mandatory pregnancy testing, contraceptive counselling and baseline liver/lipid bloods, breaching the MHRA Pregnancy Prevention Programme requirements. E. Avoid isotretinoin because of past depression: past, resolved mild depression is not an absolute contraindication; current UK guidance requires mood monitoring during treatment, not automatic exclusion. D. Use long-term lymecycline with topical retinoid: this under-treats severe nodulocystic acne, which has scarring potential and is an accepted indication for isotretinoin after specialist referral, and prolonged antibiotic use is discouraged due to resistance and limited efficacy in nodulocystic disease. C. Give a short course of oral prednisolone alone: steroids are not a definitive treatment for nodulocystic acne and are reserved for rare fulminant flares alongside other therapy, not as monotherapy. Key point: before any isotretinoin prescription in a woman of childbearing potential, pregnancy exclusion, effective contraception and baseline liver/lipid (and mood) assessment must be confirmed first, regardless of psychiatric history.

Reference: MHRA Drug Safety Update, Isotretinoin: Pregnancy Prevention Programme, gov.uk (2024), https://www.gov.uk/drug-safety-update/isotretinoin-updates-to-prescribing-guidance-and-survey-of-services