Acne and Rosacea: Dr. Baldwin

Hilary Baldwin:
Hi there. I'm Hilary Baldwin, and I'm coming to you from beautiful Maui, Hawaii, where we just finished the Acne and Rosacea Symposium at Maui Derm. And I was part of the last session, which was looking at interesting cases in treating acne and rosacea. And my topic didn't actually make it to the stage. We ran out of time before it. So I thought I would share it with you anyway because I think it's a very important topic, and that is emergency contraception in patients on Isotretinoin. So my case was a 16-year-old girl who called me up in hysterics at two o'clock in the morning saying that the condom had broken. Now, interestingly, or not surprisingly perhaps, her form of birth control while she was on Isotretinoin was abstinence. Oops. And that's a topic for another day.

But here she is, 16 years old. She doesn't want to tell her mother. She doesn't want me to tell her mother. But here I am, this whole situation is dumped in my lap. So what are my options? My options are emergency contraception, which includes something that we refer to generally as Plan B, or Ella, both of which are pills which are available for anyone at any age. Ella by prescription, and Plan B you can just go into the pharmacy and ask for it. They have to be taken really early. Which is why the time for you to educate yourself on emergency contraception is now, before you put the patient on Isotretinoin. And because when the time comes, you've got 72 hours to get that medication into the patient if it's going to work. Plan B is about 85% successful, more so if it's taken within 14 hours of contraception failure. Ella can be taken a little bit later. Both of them are dependent on the patient's weight. And once you get above a BMI of about 25, Plan B doesn't work so well. Ella, up to about a BMI of maybe 35.

If you have a particularly heavy patient, you're going to need to go to the emergency IUD placement. And I'll talk about that in a second. So both of these are available in pharmacies. Although in some states, the pharmacies have been allowed to decide for themselves whether they think it's an ethical approach. So in some of the southern states, for example, you can't get it at ordinary pharmacies. In most pharmacies Plan B is stored right there on the shelf. In some, they hide it behind the desk so you actually have to walk up to the pharmacist and ask for it. Which of course is a little bit of a problem for a 16-year-old. So you need to plan ahead because the Ella is only stored in maybe 10 to 20% of pharmacies, they're going to have to go and order it.

So this is very, very time-sensitive. You can write a prescription for Plan B and it's going to be free. But you have to remember if that prescription goes through her parents' insurance, they're going to eventually find out. So you have to have all these thoughts in your head as well as your feeling about treating this patient without discussing it with her patients. In most states, you're actually obligated, unless the patient is about to harm herself or others, to keep her secret for her. So this is all your job and you need to be prepared ahead of time. Easiest thing to do is to have a nice relationship with a gynecologist because the emergency IUD placement is 99% effective and can be done quite a bit later than the pills that I was discussing before.

So find yourself a gynecologist to have a good relationship with. Think about it ahead of time. What's the local laws in your state that govern this whole concept. And be ready because once it happens, you have to really jump on it. Oh, one last thing. Those attestations that the patient signs says, "I have been told about emergency contraception," and you sign off on that attestation. So if I haven't convinced you that medically you need to be ready to roll, medical legally you need to be ready to roll as well.