What advice should be given to a 24-year-old female patient with a history of herpes simplex (HSV) and viral mononucleosis, currently prescribed isotretinoin (13-cis-retinoic acid) and tretinoin (all-trans retinoic acid) 0.025% cream, during an annual physical?

From the Guidelines

I would advise this 24-year-old female patient to continue her prescribed acne treatments, isotretinoin and tretinoin 0.025% cream, but with important precautions to minimize potential side effects and ensure safe use. She should use daily broad-spectrum sunscreen (SPF 30+) and practice sun protection while on isotretinoin and tretinoin, as these medications significantly increase photosensitivity 1. Monthly pregnancy tests are essential during isotretinoin therapy due to its severe teratogenic effects, and she must use two reliable forms of contraception. Regular blood work to monitor liver function and lipid levels is necessary while on isotretinoin, as isotretinoin can cause changes in liver function and lipid profiles 1. For her history of herpes simplex, she should be aware that retinoids might trigger outbreaks, so recognizing early symptoms and having antiviral medication available is important 1. Regarding her past mononucleosis, no specific precautions are needed unless she's experiencing ongoing fatigue. She should maintain adequate hydration and use moisturizers to manage the drying side effects of these medications. I would also recommend avoiding alcohol during isotretinoin treatment to reduce liver stress and advise against donating blood while on this medication and for one month afterward due to its teratogenic potential.

Some key points to consider:

• Isotretinoin is highly effective for severe acne, but its use requires careful monitoring due to potential side effects 1.
• The patient should be aware of the potential for increased photosensitivity and take steps to protect her skin from the sun 1.
• Regular monitoring of liver function and lipid levels is necessary to minimize the risk of adverse effects 1.
• The patient's history of herpes simplex and mononucleosis should be taken into consideration, and she should be aware of the potential for retinoids to trigger outbreaks 1.

Overall, with careful monitoring and precautions, the patient can safely use isotretinoin and tretinoin to manage her acne, while minimizing the risk of potential side effects.

From the FDA Drug Label

When outside, even on hazy days, areas treated with tretinoin should be protected. An effective sunscreen should be used any time you are outside (consult your physician for a recommendation of an SPF level which will provide you with the necessary high level of protection). If you are pregnant, think you are pregnant or are nursing an infant: No studies have been conducted in humans to establish the safety of tretinoin in pregnant women. If you are pregnant, think you are pregnant, or are nursing a baby, consult your physician before using this medication. Signs and symptoms of depression, as described in the brochure (“Recognizing Psychiatric Disorders in Adolescents and Young Adults”), include sad mood, hopelessness, feelings of guilt, worthlessness or helplessness, loss of pleasure or interest in activities, fatigue, difficulty concentrating, change in sleep pattern, change in weight or appetite, suicidal thoughts or attempts, restlessness, irritability, acting on dangerous impulses, and persistent physical symptoms unresponsive to treatment.

The patient should be advised to:

• Use sunscreen and protective clothing when going outside to prevent excessive sun exposure
• Be aware of the potential for depression and other mental health issues associated with isotretinoin therapy, and to report any symptoms to their physician
• Follow the instructions for using tretinoin cream, including applying it once daily before bedtime and avoiding excessive exposure to wind or cold
• Consult their physician before using tretinoin if they are pregnant, think they are pregnant, or are nursing an infant
• Monitor their skin for signs of irritation or other adverse reactions, and to discontinue use if necessary 2 3 Key points to discuss with the patient:
• Importance of sun protection
• Potential mental health side effects of isotretinoin
• Proper use of tretinoin cream
• Pregnancy and nursing precautions
• Monitoring for adverse reactions

From the Research

Patient Advice

To advise the 24-year-old female patient with a history of herpes simplex (HSV) and viral mononucleosis, currently prescribed isotretinoin and tretinoin 0.025% cream, consider the following points:

• The patient should be aware of the potential psychological effects of isotretinoin, including the possibility of depressive disorders, which have been reported in 1% to 11% of patients in different studies 4, 5.
• It is essential to monitor the patient's mental health and adjust the treatment plan if necessary, as some studies suggest that isotretinoin may have a therapeutic effect in acne-associated depression 4.
• The patient should be informed about the potential benefits of combining isotretinoin with tretinoin, as this combination has been shown to be effective in correcting abnormalities of acne 6.
• The patient should be advised to follow the prescribed treatment plan and attend regular follow-up appointments to monitor the efficacy and potential side effects of the treatment.

Treatment Considerations

When considering the treatment plan for this patient, keep in mind:

• Isotretinoin is most effective for patients with acne who fail to respond to other forms of treatment, and virtually all patients respond to isotretinoin 7.
• The patient's history of HSV and viral mononucleosis should be taken into account, as these conditions may affect the treatment plan or increase the risk of certain side effects.
• The patient should be advised to use the tretinoin 0.025% cream as directed, as it can cause irritation, erythema, and desquamation, especially if used incorrectly 8.

Follow-up and Monitoring

To ensure the patient's safety and the efficacy of the treatment, consider the following:

• Regular follow-up appointments should be scheduled to monitor the patient's response to the treatment and adjust the plan as necessary.
• The patient should be encouraged to report any changes in their mental health or any side effects they experience during the treatment.
• The patient's acne lesions should be counted and graded at each follow-up appointment to assess the efficacy of the treatment 8.