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Conversations about emergency contraception (EC) between dermatologists and patients taking isotretinoin can decrease pregnancies, which result in birth defects in at least one-third of infants exposed to the anti-acne medication in utero.

According to experts writing in , therapeutic abortion occurs in 34% of patients who become pregnant while taking isotretinoin. With abortion access tightening in some parts of the country, the experts wrote, the need to prevent potentially problematic pregnancies is gaining new urgency.

Co-author Andrea Zaenglein, MD, professor of dermatology, pediatric dermatology, and pediatrics with Penn State Health in Pennsylvania, discussed the paper and potential clinical guidance with the Reading Room. The exchange has been edited for length and clarity.

What led you to co-author an opinion article on this topic?

Zaenglein: In March 2023, the federal government released data on the efficacy and specifics of the iPLEDGE program -- a safety program designed to manage isotretinoin's ability to cause defects in a developing fetus and to minimize fetal exposure. These data included pregnancies occurring in patients who were taking isotretinoin. We've learned that about 180-190 pregnancies a year are reported in patients taking isotretinoin.

When the iPLEDGE program was introduced, EC was just coming out and not readily available. Therefore, EC was never really incorporated into iPLEDGE materials, and there has been resistance to enhancing provider and patient education on this subject. As a result, we're not really arming patients and providers with the ability to prevent these pregnancies, which is the goal of the iPLEDGE program.

People become pregnant on isotretinoin mainly because of failure to adhere to abstinence and failure to use a secondary form of birth control, like a condom. With that in mind, EC seems like a very important educational point to me.

That education has been an initiative in our own department. I'm trying to educate my colleagues on the importance of this, especially in light of the Supreme Court's decision on abortion.

Ultimately none of us wants our patients to become pregnant on isotretinoin. I don't want my patients faced with having to choose to have an abortion or not have an abortion given the risks of this medicine. So why are we not better at educating our patients?

Why do you think there is resistance to embrace or educate around EC?

Zaenglein: Dermatologists are trained to practice as they do, and it can be hard to make changes. I think it just kind of defaulted to people not doing it.

Whenever I bring this issue up with colleagues, they recognize they should be discussing EC with their patients. We just have to bring it to the fore. With the changes in access to abortion, now is a really good time to start highlighting why this is important.

I also think there are a lot of misconceptions about EC, even in the medical community. People often think it's an abortion pill, but it's not the same. It is contraception. It prevents pregnancy. If you were pregnant and you took EC, it would not disrupt your pregnancy.

What was the main conclusion of your Viewpoint?

Zaenglein: Our conclusion is simple: dermatologists should be counseling and prescribing EC to patients who are at the highest risk of becoming pregnant on isotretinoin. Also, the iPLEDGE system should increase educational materials to better educate providers or prescribers of isotretinoin and their patients on how to use and obtain EC.

How can dermatologists better incorporate EC education into practice?

Zaenglein: At my institution, any patient who chooses abstinence as their form of birth control is prescribed EC at the start of therapy. Everyone is counseled on EC and how to use it and this information is reinforced at every visit. Ideally, EC education should be reinforced monthly; therefore, this cannot be delegated to other specialties like gynecology.

I'm not sure that if you ask many of my colleagues how to use EC, especially older dermatologists, they would really be aware of how to do it. The educational initiatives in our department taught them why it's important and exactly how to use it.

We have data to show that this is a practice gap. Fortunately, this is an easy fix, and it's one we really need for our patients. It's not a big deal; we just have to do it.