10.5826/dpc.1201a36
Introduction: The COVID-19 pandemic drastically changed the priorities in healthcare services; outpatient management of acne has changed during this period.
Objectives: We aimed to investigate treatment practices, outcomes and identify modified follow-up schedules applied during the pandemic.
Methods: The patients who were admitted to dermatology outpatient clinic between March 13 and July 13, 2020, were included. Patients who were admitted between March 13 and July 13, 2019, were served as controls for the study. For each patient, age, gender, treatment protocols, treatment intervals, compliance with the treatment, treatment modifications, and adverse events were recorded.
Results: The total number of acne patients admitted to dermatology outpatient clinics during the pandemic period was 278 and consisted of 12.3% (278) of all admissions. Isotretinoin treatment was started in only 16 (5.8%) of the patients. The proportion of patients who were under follow-up was significantly higher during the pandemic period (P &lt; 0.005). There was no difference between the pandemic period and the non-pandemic period in terms of starting isotretinoin treatment (P &gt; 0.05). During pandemic period, 79% of the patients who used isotretinoin were followed-up every two or more months. Extended follow-up intervals showed no difference for detecting side effects (P &gt; 0.05).
Conclusions: Acne patients constitute an important part of dermatology outpatient clinics. During the pandemic period, the majority of acne patients came for follow-up. Extended follow-up periods were adopted by physicians and were found safe and effective in the current study. Thus, isotretinoin treatment seems efficacious and safe during pandemic period.
text/xml
2160-9381
1817
en
Banu Farabi
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
pandemic
Isotretinoin Treatment Practices and Outcomes in Acne Patients During the COVID-19 Pandemic: A Single Center, Retrospective, Comparative Study
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-02-02
2021-05-31
2022-02-02
2022-03-07
e2022036
Dermatol Pract Concept
Introduction: The COVID-19 pandemic drastically changed the priorities in healthcare services; outpatient management of acne has changed during this period.
Objectives: We aimed to investigate treatment practices, outcomes and identify modified follow-up schedules applied during the pandemic.
Methods: The patients who were admitted to dermatology outpatient clinic between March 13 and July 13, 2020, were included. Patients who were admitted between March 13 and July 13, 2019, were served as controls for the study. For each patient, age, gender, treatment protocols, treatment intervals, compliance with the treatment, treatment modifications, and adverse events were recorded.
Results: The total number of acne patients admitted to dermatology outpatient clinics during the pandemic period was 278 and consisted of 12.3% (278) of all admissions. Isotretinoin treatment was started in only 16 (5.8%) of the patients. The proportion of patients who were under follow-up was significantly higher during the pandemic period (P &lt; 0.005). There was no difference between the pandemic period and the non-pandemic period in terms of starting isotretinoin treatment (P &gt; 0.05). During pandemic period, 79% of the patients who used isotretinoin were followed-up every two or more months. Extended follow-up intervals showed no difference for detecting side effects (P &gt; 0.05).
Conclusions: Acne patients constitute an important part of dermatology outpatient clinics. During the pandemic period, the majority of acne patients came for follow-up. Extended follow-up periods were adopted by physicians and were found safe and effective in the current study. Thus, isotretinoin treatment seems efficacious and safe during pandemic period.
Banu Farabi
2022/02/02
10.5826/dpc.1201a36
e2022036
Department of Internal Medicine, Saint Peter’s University Hospital, New Brunswick, NJ, USA
2160-9381
pandemic
en
e2022036
Choi JS, Koren G, Nulman I. Pregnancy and isotretinoin therapy. CMAJ. 2013;185(5):411-413. DOI: 10.1503/cmaj.120729. PMID: 23296582. PMCID: PMC3602257.
Isotretinoin Treatment Practices and Outcomes in Acne Patients During the COVID-19 Pandemic: A Single Center, Retrospective, Comparative Study
https://dpcj.org/index.php/dpc/article/download/1817/1489
   Isotretinoin Treatment Practices and Outcomes
  in Acne Patients During the COVID-19 Pandemic:
 A Single Center, Retrospective, Comparative Study
        Mehmet Fatih Atak1,2, Banu Ismail Mendi2, Incilay Kalay Yildizhan2, Hatice Sanli2,
                                         Banu Farabi3


1 Dermatology Department, Tokat State Hospital, Tokat, Turkey
2 Dermatology Department, Ankara University, Ankara, Turkey
3 Department of Internal Medicine, Saint Peter’s University Hospital, New Brunswick, NJ, USA



Key words: Isotretinoin, treatment, acne, COVID-19, pandemic
Citation: Atak MF, Ismail Mendi B, Kalay Yildizhan I, Sanli H, Farabi B. Isotretinoin treatment practices and outcomes in acne patients
during the covid-19 pandemic: a single center, retrospective, comparative study. Dermatol Pract Concept. 2022;12(1):e2022036.
DOI: https://doi.org/10.5826/dpc.1201a36
Accepted: August 30, 2021; Published: January 2022
Copyright: ©2022 Atak et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication. MFA: Conceptualization, data curation, formal analysis,
methodology, resources, validation, writing-original draft, writing review & editing; BF: Methodology, resources, supervision, validation,
writing-original draft, writing review & editing; BI: Data curation, resources; IKY: Writing-review & editing; HS: Revision of the content
Corresponding author: Banu Farabi, Department of Internal Medicine, Saint Peter’s University Hospital, New Brunswick, NJ, USA.
E-mail: banufarabi91@gmail.com




  ABSTRACT             Introduction: The COVID-19 pandemic drastically changed the priorities in healthcare services;
                       ­outpatient management of acne has changed during this period.
                       Objectives: We aimed to investigate treatment practices, outcomes and identify modified follow-up
                       schedules applied during the pandemic.
                       Methods: The patients who were admitted to dermatology outpatient clinic between March 13 and
                       July 13, 2020, were included. Patients who were admitted between March 13 and July 13, 2019, were
                       served as controls for the study. For each patient, age, gender, treatment protocols, treatment intervals,
                       compliance with the treatment, treatment modifications, and adverse events were recorded.
                       Results: The total number of acne patients admitted to dermatology outpatient clinics during the
                       pandemic period was 278 and consisted of 12.3% (278) of all admissions. Isotretinoin treatment was
                       started in only 16 (5.8%) of the patients. The proportion of patients who were under follow-up was
                       significantly higher during the pandemic period (P < 0.005). There was no difference between the
                       pandemic period and the non-pandemic period in terms of starting isotretinoin treatment (P > 0.05).
                       During pandemic period, 79% of the patients who used isotretinoin were followed-up every two or
                       more months. Extended follow-up intervals showed no difference for detecting side effects (P > 0.05).




Original Article | Dermatol Pract Concept. 2022;12(1):e2022036                                                                               1
                      Conclusions: Acne patients constitute an important part of dermatology outpatient clinics. During
                      the pandemic period, majority of acne patients came for follow-up. Extended follow-up periods were
                      adopted by physicians and were found safe and effective in the current study. Thus, isotretinoin treat-
                      ment seems efficacious and safe during pandemic period.




Introduction                                                      through electronic medical record system. A total number
                                                                  of 278 acne patients seen in our clinic for 4 months period
COVID-19 pandemic affected the healthcare practices all
                                                                  during the pandemic was included in the study. For each
over the world in 2020. It drastically changed the priorities
                                                                  patient age, gender, treatment protocols, treatment intervals,
in healthcare services, thus outpatient management of elective
                                                                  compliance with the treatment, adverse events were recorded.
diseases such as acne have also been shaped during this period
                                                                  Patients were stratified according to age as follow: younger
[1]. Restrictions and the fear of infection altered outpatient
                                                                  than 18 years of age, and 18 years or older. Treatment proto-
clinic patient profile in dermatology clinics and resulted
                                                                  cols were assessed in three categories as follows: topical treat-
implementation of teledermatology visits [2].
                                                                  ment, systemic antibiotic treatment with topical treatments,
     The effects of pandemic on dermatological practices have
                                                                  and oral isotretinoin treatment. Treatment intervals were
been investigated especially in chronic diseases treating with
                                                                  determined in two different categories as follows: monthly or
immunosuppressive or immunomodulatory drugs, but there
                                                                  in every two months or longer. Adverse events were recorded.
are not enough studies focusing on the effects of acne and its
                                                                  The patients admitted in the outpatient clinic between March
management during the pandemic. Acne patients consist of an
                                                                  13 and July 13, 2019, served as controls for the study.
important part of the routine dermatology outpatient clinics,
                                                                      Statistical analysis was performed using the SPSS 22.0
thus further studies are required to establish the management
                                                                  program. Mean, standard deviation and percentage were
of acne [3].
                                                                  used for descriptive statistics. Chi-square test was performed
                                                                  to examine differences between categorical variables in same
Objectives                                                        groups and the P value of less than 0.05 was accepted as
                                                                  statistically significant.
We aimed to investigate the treatment practices, treatment
outcomes, adherence of acne patients and to identify modified
                                                                  Results
follow-up schedules during the pandemic period.
                                                                  The total number of patients admitted to outpatient clinic
                                                                  during pandemic period was 2265. Acne patients consisted of
Methods
                                                                  12.3% (278) of all admissions. On the other hand, the total
The IRB approval for the study was obtained from the              number of patients admitted to dermatology outpatient clinic
Ankara University Ethics Committee on April 2021. The             during non-pandemic period was 7604 and 7.5% (577) were
patients visited the dermatology clinic between March 13          acne patients. The distribution of the patients according to
and July 13, 2020, when first restrictions were imposed by        the gender and age is shown in Table 1, and there was no sig-
the Turkish government due to pandemic, have been retro-          nificant difference between two periods according to gender
spectively reviewed for the clinical diagnosis of acne vulgaris   and age (P > 0.05).


          Table 1. Demographic Characteristics of Patients Before and After The Pandemic Period
    Demographic characteristics of
         the acne patients              Pandemic period (n = 278)         Non-pandemic period (n = 577)               P values
 Sex
 Male                                            179 (64.4%)                          383 (66.4%)
                                                                                                                         0.57
 Female                                          99 (35.6%)                           194 (33.6%)
 Age, years (mean)                            22.80 (SD ± 7.12)                     22.16 (SD ± 6.98)                    0.22
 < 18                                             64 (23%)                            122 (21.1%)
                                                                                                                         0.53
 > 18                                             214 (87%)                           455 (88.9%)

SD: standard deviation.



2                                                                      Original Article | Dermatol Pract Concept. 2022;12(1):e2022036
    Table 2 summarizes the treatment modalities of the                 (P < 0.05). There was no statistically significant difference in
patients with the first admission and under follow-up in both          the two periods according to the number of treatment naïve
pandemic and non-pandemic periods. Among the patients                  patients, the first admission patients previously treated with
who applied to dermatology outpatient clinic during pan-               any systemic agent, and patients to whom was given systemic
demic period, 124 (44.6%) had first admission and 150                  treatment in first admission (P > 0.05). The rate of acne
(54%) were under follow-up for different acne treatments,              patients treated with isotretinoin during the pandemic period
and 4 of them were consultation patients. One hundred                  and non-pandemic period were 50% and %39.3, respectively.
and sixteen (93.5%) patients with first admission did not              Isotretinoin use was found significantly higher in the pan-
receive treatment for acne previously, whereas 8 of them               demic period (P = 0.003). There was no statistically significant
were under systemic treatments (oral isotretinoin n = 2, dox-          ­difference between the pandemic period and the non-pan-
ycycline n = 6). Of the 116 treatment naïve patients, topical          demic period in terms of starting isotretinoin treatment in
treatment was given to 77 (n = 27.7%), oral isotretinoin               patients with first admission (P > 0.05). There was no signifi-
treatment to 16 (5.8%) and systemic antibiotic treatment               cant difference for using isotretinoin treatment in patients who
with topicals to 23 (8.3%) patients. Of the 8 patients taking          were under follow-up in the two groups (P = 0.17).
systemic treatment at first admission, doxycycline treatment              Follow-up intervals, drop-out rates and reported adverse
was switched to oral isotretinoin for 3 patients and to azithro-       events in patients treated with isotretinoin during pandemic
mycin for one patient, and the others continued their current          and non-pandemic period are given in Table 3. The rate of
systemic treatment (oral isotretinoin n = , doxycycline n = 2).        patients who used isotretinoin and dropped out from follow-up
    During the pandemic, 26 (9.4%) of the follow-up patients           during the pandemic period was significantly higher than the
were under only topical treatments, 10 patients (3.6%) were            control group (P <0.001). During the pandemic period, the
under systemic antibiotic treatment with topical treatment,            rate of patients using isotretinoin, which was followed in every
and 114 patients (41%) were under oral isotretinoin treat-             two or more-months, was significantly higher than the control
ment. During this period, for 3 patients topical treatments            group (P < 0.001). Side effects in pandemic and non-pandemic
were switched to oral isotretinoin because of the severity of          period were seen in 10.1% and 19.8% of the patients, respec-
acne and 1 of the patients under doxycycline treatment was             tively. The rate of patients using isotretinoin who developed
switched to isotretinoin due to lack of efficacy. The rate of          side effects was found significantly higher in the non-pandemic
total acne patients treated with isotretinoin during the pan-          period compared to the pandemic period (P = 0.01).
demic period was 50% (139 patients). Of these patients, 114               In the 4-month pandemic period (March-July 2020), only
(41%) were follow-up ones, 16 (5.8%) of them were started              two patients were diagnosed with SARS-Cov-2 infection. One
isotretinoin treatment in their first visits.                          of the patients (aged 27 years) was using isotretinoin and she
    The number of patients with first admission was statis-            only showed mild upper respiratory tract infection symptoms.
tically higher in non-pandemic period and the number of                Other patient (aged 39 years) was using topical treatments.
follow-up patients was statistically higher in pandemic period         Neither of them was hospitalized.


   Table 2. Treatment Status of Patients Admitted During the Pandemic and Non-Pandemic Period
                                                  Pandemic period (n = 278)         Non-Pandemic period (n = 577)          P values
 Patients with first admission                            124 (44.6%)                          336 (58.2%)                  < 0.005
 Treatment naïve                                          116 (93.5%)                          318 (94.6%)                   0.652
 Treated with any systemic agent                            8 (6.5%)                             18 (5.4%)
 (antibiotics and oral isotretinoin)
 Treatment naive patients started                          39 (31.4%)                          129 (38.3%)                    0.34
 systemic isotretinoin
 Follow-up patients                                        150 (54%)                           239 (41.4%)                  < 0.005
 Isotretinoin treatment                                    114 (76%)                           173 (72.4%)                    0.17
 Systemic antibiotic treatment and                          10 (6.7%)                            8 (3.3%)                     0.06
 topical treatments
 Only topical treatments                                   26 (17.3%)                           58 (24.3%)                    0.06
 Treatment status in all patients
 Isotretinoin treatment                                    139 (50%)                           227 (39.3%)                   0.003
 Systemic antibiotic and topicals                          36 (12.9%)                          103 (17.9%)                    0.43
 Only topical treatment                                   103 (37.1%)                          247 (42.8%)                    0.43



Original Article | Dermatol Pract Concept. 2022;12(1):e2022036                                                                        3
    Table 3. Changes in Follow-Up Intervals, Patient Drop-Out Rates, and Reported Adverse Events in
                                         Isotretinoin Patients
      Number of isotretinoin patients          Pandemic period (n = 139)          Non-pandemic period (n = 227)           P values
 Followed-up for extended intervals                     79 (56.8%)                            65 (28.6%)                   < 0.001
 Lost to follow-up                                      30 (21.6%)                             6 (2.6%)                    < 0.001
 Reported adverse events                                14 (10.1%)                            45 (19.8%)                     0.01
 liver enzyme abnormality                                 5 (3.6%)                            10 (4.4%)
 hypertriglyceridemia                                     2 (1.4%)                             6 (2.6%)
 back pain                                                2 (1.4%)                              9 (4%)
 nasal bleeding                                           2 (1.4%)                             3 (1.3%)
 psychiatric symptoms                                     1 (0.8%)                             3 (1.3%)
 headache                                                 1 (0.8%)                             1 (0.4%)
 severe xerosis-eczematous dermatitis                     1 (0.8%)                             4 (1.8%)
 dry eye syndrome                                             -                                7 (3.1%)
 photosensitivity                                             -                                1 (0.4%)
 anal fissure                                                 -                                1 (0.4%)



Conclusions                                                             Theoretically, isotretinoin treatment may cause disrup-
                                                                     tion of the basement membrane of the mucosal surfaces by
Novel coronavirus pandemic has caused significant changes            causing mucosal dryness and thinning. This, hypothetically,
in dermatology practices [3]. As depicted in our study, the          can increase the risk of COVID-19 transmission [9]. There
accessibility to outpatient clinics and patient compliance with      is no established guideline regarding the use of isotretinoin
systemic treatments were affected by the pandemic. According         during the pandemic period. In the beginning of the pandemic
to recent literature, acne patients consisted of the majority        British Association of Dermatologists recommended starting
of the patients who are admitted to dermatology outpatient           or continuing oral isotretinoin treatment where the risks are
clinics [1], and treatment compliance was the highest in this        outweighed by the benefits with monthly follow-up [10].
group [3]. This might be due to that acne is relatively common       According to this statement, if there is no risk of pregnancy,
condition in younger individuals and younger patients seek           the prescriptions for several months could be given taking
more care because of the psychosocial effect of the disease          into account the need to monitor blood test and side effects
[4]. Additionally, the knowledge of the mild disease course          with remote consultations. In situations where it is not pos-
of COVID-19 infection might cause young patients to reach            sible to perform monthly pregnancy tests, home pregnancy
hospital clinics without fear compared to elderly population ].      tests are recommended as a suitable alternative [11]. With
Another reason for increased percentage of acne patients can         the rapid growth of teledermatology, these recommendations
be intense use of masks, thus causing increased prevalence of        have been practiced and the patients were able get their
‘mask acne’, likely result of increased usage of personal pro-       prescriptions instead of in-person visits [2]. A recent study
tective equipment with the current pandemic ]. The percent-          by Ruggiero et al reported high degree of satisfaction and
age of acne patients admitted to dermatology outpatient clinic       well-being after teledermatology visits [12].
during the pandemic period was found significantly increased            Between the pandemic and non-pandemic periods, there
compared to non-pandemic period in the current study.                was no significant difference in the rate of starting systemic
     Starting from March 2020, social distancing measures and        treatment for acne patients who were admitted for their
restrictions were imposed to prevent the spread of the virus         first visit. Additionally, the percentage of patients using
by Turkish Authorities, however, hospital admissions were            isotretinoin during pandemic period was significantly higher
exempted. These restrictions were thought to not affect the          compared to non-pandemic period. This was due to a relative
admissions of acne patients. While the rate of acne patients         increase of the number of patients who were followed-up with
admitted for their first visit was significantly low in pandemic     their current isotretinoin treatment. In our clinic, isotretinoin
period, the rate of patients who were admitted for follow-up         therapy was not avoided during the pandemic period.
visits was significantly higher. This is probably as a result of        Isotretinoin treatment needs to be monitored in terms
avoidance of hospital visits due to non-emergent conditions          of both teratogenesis and bone marrow and metabolic side
during the pandemic period and high treatment compliance             effects (leukopenia, hypertriglyceridemia, liver enzyme abnor-
rate of our patient population.                                      malities) [14,15]). Although there are many studies that



4                                                                        Original Article | Dermatol Pract Concept. 2022;12(1):e2022036
do not support monthly laboratory testing for isotretinoin                     systemic therapy during the period of strict lockdown. Ann Med
[15], there are many centers that apply monthly laboratory                     Surg (Lond). 2020;60:571-4. DOI: 10.1016/j.amsu.2020.11.056.
                                                                               PMID: 33251007. PMCID: PMC7686756.
follow-up in clinical practice, especially in terms of teratoge-
                                                                          4.   Aslan Kayiran M, Karadag AS, Jafferany M. Psychodermatology
nicity [16]. Monthly laboratory monitoring is also a common
                                                                               of acne: Dermatologist’s guide to inner side of acne and man-
practice among physicians in our clinic. When we compared                      agement approach. Dermatol Ther. 2020;33(6):e14150. DOI:
the monthly follow-up to in every two or more-month fol-                       10.1111/dth.14150. PMID: 32770727.
low-up rate between the 2 groups, in every 2 or more-month                5.   Pasion R, Paiva TO, Fernandes C, Barbosa F. The AGE Effect
follow-up the rate was higher during the pandemic period.                      on Protective Behaviors During the COVID-19 Outbreak:
                                                                               ­Sociodemographic, Perceptions and Psychological Accounts. Front
Our retrospective analysis showed that extended follow-up
                                                                                Psychol. 2020; 11:561785. DOI: 10.3389/fpsyg.2020.561785.
intervals showed no significant difference for detecting side
                                                                                PMID: 33178069. PMCID: PMC7595956.
effects of isotretinoin. Additionally, the reported side effect           6.    Searle T, Ali FR, Al-Niaimi F. Identifying and addressing “Maskne”
rate was significantly lower during the pandemic period. This                   in clinical practice. Dermatol Ther. 2021;34(1):e14589. DOI:
might be due to the lock-down and increased use of skin care                    10.1111/dth.14589. PMID: 33244836.
products due to easy accessibility to emollients and other                7.    Han C, Shi J, Chen Y, Zhang Z. Increased flare of acne caused
                                                                                by long-time mask wearing during COVID-19 pandemic among
protective measures.
                                                                                general population. Dermatol Ther. 2020;33(4):e13704. DOI:
    In the 4-month follow-up, only one patient under isotreti-
                                                                                10.1111/dth.13704. PMID: 32472634. PMCID: PMC7300566.8.
noin treatment had a positive SARS-Cov-2 PCR result and she               8.    Damiani G, Gironi LC, Grada A, et al. COVID-19 related masks
showed only mild upper respiratory tract infection symptoms.                    increase severity of both acne (Maskne) and rosacea (Mask rosa-
Thus, isotretinoin treatment seems efficacious and safe during                  cea): Multi-center, real-life, telemedical, observational prospective
pandemic. We recommend extended intermittent laboratory                         study. Dermatol Ther. 2021:e14848. DOI: 10.1111/dth.14848.
                                                                                PMID: 33533563. PMCID: PMC7995182.
follow-up to reduce the risk of SARS-Cov-2 transmission,
                                                                          9.    A b d e l m a k s o u d A , Ve s t i t a M , E l - A m a w y H S , e t a l .
however further large cohort studies are required to elaborate
                                                                                ­Isotretinoin ­therapy in the era of COVID-19. Dermatol Ther.
the risks.                                                                       2020;33(4):e13482. DOI: 10.1111/dth.13482. PMID: 32358858.
    Acne patients constitutes an important part of dermatol-                     PMCID: PMC7261989.
ogy outpatient clinics. The proportion of acne patients was              10.     British Association of Dermatologists. Guidance for Managing
observed as significantly higher during the pandemic period.                     Patients on Isotretinoin During The Coronavirus Pandemic
                                                                                 2020. Available from: https://www.bad.org.uk/shared/get-file.
This most likely reflects young individuals seek for more care
                                                                                 ashx?itemtype=document&id=6661.
due to psychosocial effects of the disease and less fear of infec-
                                                                         11.     Pathoulas JT, Farah RS, Fiessinger L, Mansh M. An opportunity
tion by SARS-Cov-2. Another reason for increased percentage                      for improvement: iPLEDGE policy changes during the coronavi-
of acne patients is intense use of masks, causing increased                    rus pandemic. Dermatol Ther. 2020;33(6):e14411. DOI: 10.1111/
prevalence of ‘mask acne’, likely result of increased usage of                 dth.14411. PMID: 33052629. PMCID: PMC7646038.
personal protective equipment with the current pandemic.                 12.   Ruggiero A, Megna M, Annunziata MC, et al. ­Teledermatology
                                                                               for acne during COVID-19: high patients’ satisfaction in
During pandemic period, the majority of acne patients was
                                                                               spite of the emergency. J Eur Acad Dermatol Venereol.
admitted for follow-up and physicians did not avoid using
                                                                               2020;34(11):e662-e663. DOI: 10.1111/jdv.16746. PMID:
isotretinoin treatment in the follow-up patients. Extended                     32534472. PMCID: PMC7323158.
follow-up periods were adopted by physicians and were                    13.   Kim JK, Crimmins EM. How does age affect personal and social
found safe and effective in the current study. Thus, isotreti-                 reactions to COVID-19: Results from the national ­Understanding
noin treatment seems efficacious and safe during pandemic.                     America Study. PLoS One. 2020;15(11):e0241950. DOI:
                                                                               10.1371/journal.pone.0241950. PMID: 33170903. PMCID:
                                                                               PMC7654776.
References                                                               14.   Dessinioti C, Zouboulis CC, Bettoli V, Rigopoulos D. Compar-
                                                                               ison of guidelines and consensus articles on the management of
 1. Kutlu Ö, Güneş R, Coerdt K, Metin A, Khachemoune A. The                    patients with acne with oral isotretinoin. J Eur Acad Dermatol
    effect of the “stay-at-home” policy on requests for dermatology            Venereol. 2020;34(10):2229-2240. DOI: 10.1111/jdv.16430.
    ­outpatient clinic visits after the COVID-19 outbreak. Dermatol            PMID: 32277497.
     Ther. 2020;33(4):e13581. DOI: 10.1111/dth.13581. PMID:              15.   Lee YH, Scharnitz TP, Muscat J, Chen A, Gupta-Elera G, Kirby
     32401401. PMCID: PMC7272831.                                              JS. Laboratory Monitoring During Isotretinoin Therapy for
 2. Sharma A, Jindal V, Singla P, Goldust M, Mhatre M. Will                    Acne: A Systematic Review and Meta-analysis. JAMA Dermatol.
     ­teledermatology be the silver lining during and after COVID-19?          2016;152(1):35-44. DOI: 10.1001/jamadermatol.2015.3091.
      ­Dermatol Ther. 2020;33(4):e13643. DOI: 10.1111/dth.13643.               EPMID: 26630323.
       PMID: 32441373. PMCID: PMC7267127.                                16.   Choi JS, Koren G, Nulman I. Pregnancy and isotretinoin t­ herapy.
 3. Alshiyab DM, Al-Qarqaz FA, Muhaidat JM. Impact of COVID-19                 CMAJ. 2013;185(5):411-413. DOI: 10.1503/cmaj.120729.
       pandemic on the continuity of care for dermatologic patients on         PMID: 23296582. PMCID: PMC3602257.




Original Article | Dermatol Pract Concept. 2022;12(1):e2022036                                                                                           5
