INTRODUCTION
Oral isotretinoin is known for its success in treating acne.1-5 However, given its requirement for monthly monitoring, it requires frequent clinic visits which often poses a challenge for patients who lack access to regular dermatologic care.1,2 Without regular follow-up the gold standard regimen of isotretinoin is no longer plausible, and providers must find a way to continue to treat patients effectively. Bellevue Hospital, a safety-net hospital as part of the New York Health and Hospitals System (NYCHHC), delivers care to more uninsured patients than any other hospital in New York City.6 NYCHHC provides care to all patients regardless of their socioeconomic or racial status.7 Given this, many patients evaluated at Bellevue Hospital experience unique challenges in accessing care. Here we describe three cases that highlight patients who had barriers to care and how their subsequent treatment with isotretinoin was managed.
CASE SERIES
Case 1
A 22-year-old woman presented to the dermatology clinic for severe acne vulgaris in February 2021 (Figure 1). Prior to this visit, she had missed four visits consecutively. She was registered in iPledge at that visit to begin isotretinoin. She was lost to follow-up until September 2021, at which time she was re-registered. The following month, she started isotretinoin 40 mg daily. From October 2021 to April 2022, the patient attended all scheduled appointments, apart from a missed appointment that was subsequently rescheduled for the following day; her dose of isotretinoin was up-titrated during this time. She did not show up for two scheduled appointments in April 2022 and subsequently did not receive additional refills. Over 5 months, her cumulative dose was 13,940 mg (goal: 12,000 to 16,260 mg). She re-presented in October 2022 with a flare of her acne and interest in re-starting isotretinoin. Blood work was ordered, as well as the first pregnancy test, and a follow-up was scheduled four weeks later for a second pregnancy test and initiation of isotretinoin with a plan to start a second course.
Case 2
A 42-year-old male presented to our clinic with acne vulgaris. He had been on isotretinoin for four to five months about eight years prior with significant improvement in his acne. When he presented for worsening of his acne in April 2021, he was initiated on a topical regimen (Figure 2). Without much improvement, he
