Is a 25-year-old female patient at high risk for complications from tretinoin (retinoic acid) that would necessitate a referral to dermatology (derm) instead of internal medicine (IM) management?

From the Guidelines

I strongly recommend referring this 25-year-old female patient to a dermatologist for tretinoin management rather than prescribing it yourself. While tretinoin isn't classified as a "high-risk" medication like isotretinoin (Accutane), it still requires proper evaluation and monitoring, as noted in the guidelines of care for the management of acne vulgaris 1. As an internal medicine physician who doesn't typically manage this medication, it's appropriate to defer to specialists who regularly prescribe it.

You could respond to the patient by acknowledging her request, explaining that dermatologists are better positioned to evaluate her skin condition, determine the appropriate tretinoin concentration (typically starting at 0.025% and potentially increasing to 0.05% or 0.1%), and provide guidance on managing side effects like dryness, peeling, and photosensitivity, as these agents can be comedolytic, resolve the precursor microcomedone lesion, and are anti-inflammatory 1.

Some key points to consider when referring the patient to a dermatologist include:

• The importance of proper evaluation and monitoring of tretinoin use
• The need for guidance on managing side effects and potential interactions with other medications
• The role of dermatologists in determining the appropriate tretinoin concentration and treatment regimen
• The importance of discussing important considerations like sun protection and potential purging phases

Additionally, dermatologists can rule out contraindications and discuss important considerations like sun protection and potential purging phases. This referral ensures she receives comprehensive care from a provider experienced with tretinoin management, which is particularly important since tretinoin is a pregnancy category C medication requiring proper counseling, as noted in the guidelines 1.

From the FDA Drug Label

The effects of the sun on your skin. As you know, overexposure to natural sunlight or the artificial sunlight of a sunlamp can cause sunburn. Overexposure to the sun over many years may cause premature aging of the skin and even skin cancer The chance of these effects occurring will vary depending on skin type, the climate and the care taken to avoid overexposure to the sun. Therapy with tretinoin may make your skin more susceptible to sunburn and other adverse effects of the sun, so unprotected exposure to natural or artificial sunlight should be minimized. If you do become sunburned, stop your therapy with tretinoin until your skin has recovered. Avoid excessive exposure to wind or cold. There have been reports that, in some patients, areas treated with tretinoin developed a temporary increase or decrease in the amount of skin pigment (color) present.

High-Risk Medication: Tretinoin can be considered a high-risk medication due to its potential to cause severe local irritation, increase susceptibility to sunburn, and possible interactions with other medications.

• Key Considerations:
  • Sun exposure should be minimized
  • Patients with sensitive skin or eczematous skin should exercise caution
  • Concomitant use of certain medications or products should be avoided
  • Patients should be advised to use sunscreen and protective clothing
• Referral to Dermatologist: Given the potential risks and the fact that you usually refer patients to a dermatologist for management of this medication, it would be prudent to refer the patient to a dermatologist for further evaluation and guidance on the use of tretinoin 2, 2.

From the Research

Tretinoin Overview

• Tretinoin is a retinol (vitamin A) derivative used in the topical treatment of photodamaged skin and acne vulgaris 3, 4.
• It has been shown to be effective in improving fine wrinkling, roughness, and pigmentation, with a relatively mild or moderate adverse event profile 3.

Referral to Dermatologist

• As an internal medicine (IM) specialist, referral to a dermatologist may be considered for patients requiring tretinoin, especially if you do not typically manage this medication 3, 4.
• Dermatologists have expertise in managing skin conditions and can provide guidance on the use of tretinoin and other topical retinoids 5, 6.

High-Risk Medication

• Tretinoin is not typically considered a high-risk medication, but it can cause dermatitis (retinoid skin reaction) in some patients 3, 4.
• However, this condition is usually mild or moderate in nature and may persist for up to 3 months 3.

Patient Education and Management

• Patients should be educated on the potential benefits and risks of tretinoin, as well as the importance of proper use and adherence to treatment 7.
• Combining tretinoin with other topical agents or procedures, such as superficial chemical peels, may help improve hyperpigmentation and acne lesions 7.