Isotretinoin for a Minor With a Prior Suicide Attempt
A 16-year-old girl with severe nodulocystic acne and early scarring requests isotretinoin. She has a history of major depressive disorder and one suicide attempt 10 months ago; she has been stable on fluoxetine for 6 months and sees a psychiatrist monthly. Her parents are divorced and share legal custody. Her mother accompanies her and consents; her father does not attend and has told the mother by phone that he refuses. The patient is not sexually active but says she will not discuss contraception with her father. Alanine aminotransferase is 65 U/L (upper limit 40), fasting triglycerides are 180 mg/dL, and a pregnancy test is negative. She is academically strong and understands the risks.
1. How do you approach consent and capacity, given that the mother consents, the father refuses, and the patient requests treatment?
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Capacity and assent
The patient is 16 and shows understanding of the risks and benefits, so her assent should be documented. She does not have independent legal authority to consent to isotretinoin in most Iranian settings; a legal guardian must consent.
Legal consent
The father’s refusal cannot be ignored if he holds legal guardianship or joint legal custody. Do not proceed on the mother’s signature alone. Explain the situation to the hospital legal or ethics committee and ask the parents to resolve consent, or obtain a court or legal authorization if the parents remain in conflict. If the father refuses after discussion, respect that decision unless an emergency exception applies; this is not an emergency.
Confidentiality
The patient’s reluctance to discuss contraception with her father is understandable. Explain that pregnancy prevention is a safety requirement and that her reproductive care can be kept confidential within the limits of the law. Do not disclose unnecessary personal details to the father; discuss the minimum needed for consent.
2. How do the abnormal liver enzymes and psychiatric history affect your decision to start isotretinoin?
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Liver enzymes
An ALT of 65 U/L is about 1.6 times the upper limit of normal. Mild elevation is not an absolute contraindication, but it should be investigated before starting. Repeat ALT in 2–4 weeks; check hepatitis B and C serology, autoimmune markers if indicated, and review other causes such as obesity, alcohol, and medications. Do not start if the elevation is greater than 2 times the upper limit or rising, or if there is evidence of active liver disease.
Psychiatric history
A history of depression or a suicide attempt is not an absolute contraindication to isotretinoin. The evidence linking isotretinoin to suicide is debated. However, this patient is high-risk and requires coordination with her psychiatrist before and during treatment. Assess current mood, suicidal ideation, and social support; document a safety plan; involve her family as appropriate; and review mood at each visit. Do not withhold effective acne treatment solely because of a past attempt, but do not start without psychiatric input.
3. What pregnancy-prevention and monitoring plan would you require if treatment proceeds?
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Pregnancy prevention
Isotretinoin is highly teratogenic. Require a negative pregnancy test before starting, a second negative test with a documented menstrual period, and effective contraception or documented abstinence. If she becomes sexually active, she must use reliable contraception and understand that isotretinoin does not protect against pregnancy. Provide emergency contraception counseling without requiring parental disclosure where legally permitted. Monthly pregnancy testing is required during treatment and for 1 month after stopping.
Monitoring
Check liver enzymes and fasting lipids at baseline and 4–8 weeks after starting, then periodically. Repeat the lipid test after dietary counseling because 180 mg/dL is mildly elevated. Monitor mood monthly and coordinate with psychiatry. Teach her to avoid vitamin A supplements and unnecessary hepatotoxic drugs. Stop treatment if pregnancy occurs or if liver enzymes rise significantly. Document all counseling and consent carefully.