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.

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.

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?

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.

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.

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.

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?

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 more than simply contraception.

It is contraception, it's emergency contraception and it's termination of pregnancy.

And that really speaks to the complexity of sexual health medicine in the current world.

The guidelines are on contraception.

There is some divergence, but most guidelines recommend dual contraception.

The key piece from it, from a clinician's perspective, is about how to manage pregnancy prevention in women who are not sexually active.

And most of the current guidelines recommend that women who are not sexually active, that the use of hormonal contraception is not mandatory.

And that's an important clinical piece because often young women in the our women are not sexually active.

And there is an ethical issue of coercing women to take hormonal contraception, which brings its own litany of side effects.

So I guess one of my questions to you is what do you think about the divergence in the different guidelines?

Do you think that these are divergent enough that we might not be able to find a consensus about what we should be doing, for instance, in general practice around blood tests?

Or do you think that we should be developing new guidelines in terms of potentially how general practice could take prescribing of isotretinoids forward?

I was involved in a paper published with the BMJ in January of 2025 which looked at the New Zealand experience of GPS prescribing isotretinoid from 2008 onwards.

And a single policy change in New Zealand to enable GPs to issue isotretinoin had a seismic effect on the subsequent access to isotretinoin since 2008.

Back in 2008, almost all isotretinoin in New Zealand was prescribed by dermatologists.

In 2023, 80% of isotretinoin is prescribed by GPs in New Zealand and there's a very substantial enhanced access to ethnic minorities, particularly Maoris, Asians and Pacific people, less so with socially deprived people, but certainly an increased access.

So enabling, Supporting and resourcing GPs in New Zealand to take on this work has certainly helped overcome the access barriers that people have described and the inequity I think we can learn from the New Zealand experience.

And the two big pieces that they found with gps in New Zealand required were education supports and resources.

And we are, the research team are currently looking at the education resources that are required for GPs to safely prescribe isotretinoin.

And then the final piece is the resourcing, because prescribing isotretinoin is resource intensive.

Patients are seen usually once a month, possibly for six months or so.

So it is resource intensive.

There is a global shortage of GPs.

There is a shortage of GPs in most Western countries.

The UK, Ireland, Canada all describe severe GP workforce shortages.

So GPs, if they are to take on this work and the clinical competencies, suggest that we may be able to.

But there is a resourcing issue which needs to be addressed at policy level, at national level, so that gps can incrementally take on this work and support our patients with safe, timely, equitable access to isotretinoin.

And that touches on a point that I wanted to pick up on, really was about the perspective of GPs and dermatologists and patients.

And I think you touch on this in the discussion.

And do we know from the New Zealand model what is coming out from those perspectives?

And could that help inform what happens in the future?

Elsewhere, the New Zealand model has found that the GPs have embraced access to isotretinoin.

And incrementally, the number of patients prescribed isotretinoin has grown year on year.

In 2008, it was just under 8000 patients a year in New Zealand, and in 2023 it was almost 24,000.

So the number of patients accessing isotretinoin in New Zealand has almost trebled in that time, showing that there is a very significant unmet need and also that the gps, with appropriate resources and education supports, can incrementally deliver that service in a safe, timely and equitable fashion for patients.

And I suppose one thing really to touch upon is that, as you say, this would be an equitable way of accessing these treatments for a range of patients that may not necessarily get to have these due to long wait times from dermatology or a fear of coming in to speak to a dermatologist or a specialist.

And I just wonder if from your own practice you have any thoughts about how potentially being able to prescribe these medications might impact on patients and their use of these medications and their perspectives as well.

Certainly I have found it very positive in my practice.

I've been prescribing isotretinoin for in excess of a decade at this stage.

I take referrals from other GPs in the area.

The patient experience is very positive.

I have young people coming in and initially, often when they come in, they're very downcast, they're.

Their mood is quite low, they avoid eye contact, and then they're back a month later and they're feeling much better.

So the psychological impact of acne on our young people is enormous.

We have described the clinical competencies that are required.

GPs meet these clinical competencies, but we do require education and resources to incrementally adopt this work.

And I think one word that you're using repeatedly is incrementally and I think that's a really important word to keep in mind as well as we try to learn more about what's actually needed in terms of resourcing and workload implications as well?

So there are very significant workload and resourcing implications.

It is a resource intensive piece and we know that young people like the New Zealand experience shows that there is an incremental expansion in people using isotretinoin.

So there is definitely an unmet need, there is an equity barrier.

Working with our patients and our dermatology colleagues, we can safely and equitably address this education gap, this resource gap, this service provision gap, and improve the, you know, the well being of our patients with acne.

I think a lot of the findings from your paper have implications at a policy level, at a broader system level.

But do you have any thing that you want to say to gps practicing who are managing patients with acne?

Do you have any take home messages for them in terms of what they can be doing now in terms of the results of this scoping review?

I think that gps are already managing this very well.

Many of them are already managing the mental health assessments, they're managing the ongoing pregnancy prevention contraception piece of it.

Many of them are doing the blood testing.

They're also looking after the mild and moderate acne.

It's a small additional increment of clinical expertise required.

We know that in the UK, many GPs already working within dermatology departments are actually doing this work under dermatologist governance.

So there is very substantial expertise already within the UK GP community.

And we would encourage GPs to consider, albeit the workforce challenges and workload challenges that we all are very familiar with, whether this is a role that might, in time, migrate increasingly into general practice and into our surgeries.

Thank you for that.

It's very thoughtful words and I think it's very wise of you to think about the clinical benefits, but also consider very carefully the system changes that may need to be be allowed to support this as well in the future.

And we know that if GPs take this work, you know, there are opportunity costs that if GPs are seeing patients with acne, then they may not be available to see other patients.

So we need to consider the implications of any evolution of access to isotretinoin and balance that against the current inequitable access which adversely affects women, ethnic minorities and people from socioeconomic economically deprived Macrons.

Great.

Thank you, Dermod.

That's been a really great chat around this paper and I just wanted to say thank you again for joining us to talk about it today.

My pleasure, Nada.

And thank you all very much for your time here and for listening to this BJGP podcast.

Dermid's original research article can be found on bjgp.org and the show notes and podcast audio can be found@bjgplife.com it's been great to chat to Dermot about a very clinically relevant topic, and I hope you all have a chance to go back and read the paper.

Thanks again for listening.

Bye.