Initiation of Isotretinoin Delayed in Patients With Severe Acne and Psychiatric History

Patients with severe acne and a psychiatric history frequently — especially women — experience a delay in initiation of isotretinoin, researchers reported in study findings published in the Journal of the European Academy of Dermatology and Venereology.

The population-based study sought to determine whether isotretinoin was less frequently initiated in patients with severe acne and a psychiatric history compared with those without a psychiatric history.

Data were obtained from the Echantillon Généraliste des Bénéficiaires (EGB) database, which includes participants in the French health care insurance system. Patients were 15 to 25 years of age and received 1 or more tetracycline courses for acne from January 1, 2011 through December 31, 2018. Follow-up began with the initiation of tetracyclines, and psychiatric history was assessed with hospitalization data and psychotropic drug dispensations.

The time from baseline to isotretinoin initiation was the primary endpoint. Patients were censored at the time of death, when they left the EGB, or at the study’s end. Cox proportional hazards analysis was used to assess the association between psychiatric history and time to isotretinoin introduction, with age as a time scale.

A total of 5532 men (mean age, 18.02 [SD 2.7] years) and 7029 women (mean age, 19.01 [SD 3.1] years) were included. Second-line systemic anti-acne therapy with isotretinoin was initiated in 679 men and 535 women, and 5% of men and 7.1% of women presented with a psychiatric history.

Psychiatric history was associated with a longer time lapse to isotretinoin initiation after tetracycline initiation in women (hazard ratio [HR] 0.53; 95% CI, 0.35-0.82), according to multivariable analysis. The association was not significant in men (HR 0.73; 95% CI, 0.5-1.1) but also indicated a delay in isotretinoin treatment for those who had a psychiatric history. Low-income status (women: HR 0.56; 95% CI, 0.40-0.77; men: HR 0.50; 95% CI, 0.36-.067) and initial care by a nondermatologist (women: HR 0.43; 95% CI, 0.34-0.53; men: HR 0.61; 95% CI, 0.52-0.71) also were associated with an increased time lapse to isotretinoin initiation in men and women, investigators found. Other variables such as seasonal tetracycline starting period had a nonsignificant association, and no statistical interaction was found between psychiatric history and covariates.

Study limitations include the absence of clinical information on acne severity, and the low number of available socio-economic indicators could account for residual confounding.

“Reluctance to treat acne in this population could imply the perpetuation of the acne-related psychiatric morbidity, which would be alleviated with a highly efficacious anti-acne treatment such as isotretinoin,” stated the study authors. “When prescribing systemic therapy for severe acne in patients with psychiatric morbidity, the individual risk-benefit ratio should be carefully assessed, and a careful follow-up should be implemented to assess changes.”