What should you look for on your physical exam? What types of questions should you be asking so that you can have a good presentation to your attending?

One of the first things to look for is just to make sure it is acne because some people come in, they're bothered by pimple-like things that might not be acne.

So one really key differentiator of acne from other stuff is comedones.

So if you go and you evaluate that patient and they don't have comedones, that's a sign that you should be thinking more about things like periorficial dermatitis or rosacea or piteous boron folliculitis.

So that's one of the first things to look for is are there comedones? If there are comedones, then you're really in the acne space.

If there aren't, you want to start thinking about those other diagnoses.

And to just briefly touch on them, periofacial dermatitis, you'll often see these inflammatory papules, sometimes pustules, they'll be clustered kind of around the periofacial areas.

How do you approach starting this patient? What dose are you starting them on? Are you starting on them on any adjunct therapies to reduce side effects?

How do you approach screening prior to initiation?

Yeah.

So I think let's just start with the data on the really outcomes that we worry about, which are like depression, antidepressant use, and suicidality with isotretinoin.

So first off, I really do believe that isotretinoin can cause mood changes.

Both anecdotally, I feel like I've seen people who've developed mood lability, including sadness and depression, as well as irritability from it and have had improvement when they stopped it.

and there's certainly these challenging challenge studies that i think are compelling where people take the drug they have these symptoms they stop they feel better they take it again they recur so i really do think that this can happen that's the first thing right that being said when you look at the observational data so you look at these big cohort studies that compare people who are treated with isotrinoin versus people get treated with other drugs like oral antibiotics other treatments for monitor acne those who get treated with isotrinoin consistently have lower rates of depression, antidepressant use, and suicidality.

So if the decision is to be on isotretinoin or be on something else for acne, there I think the expected value is you're actually less likely to get a psychiatric comorbidity or complication on isotretinoin than other treatments.

How do you approach that?

What was the impetus behind the study? Talk to me about that.

Yeah.

You know, when we think about isotranone, again, we have this, like, there's not a right dose for everyone.

So what are some, one thing we want to understand are what are factors that predict long-term clearance and just kind of how often does this happen? I think, unfortunately, many people view isotranone as a cure for acne.

And as you notice, I've been very careful to not use that word at all.

Yes, you were.

The goal is really to try and create long-term remission.

How do you propose this to patients? What do you tell them?