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A female patient recently presented to my office for a case of dry lips and acne flare-ups. After my initial tirade and scolding, I discussed the nuts and bolts of managing isotretinoin use with her as well as the consequence of her behavior. There are risks to the patients and risks to the providers. Who is going to manage that? And more importantly, will there now be a discrepancy in how many dermatologists use the iPledge system? Are dermatologists who may be frustrated with the system and the requirements of iPledge going to tell their patients to go ahead and buy isotretinoin online and bypass the whole system, especially considering situations such as female patients who are on low-dose, long-term regimens, or patients who are using isotretinoin long-term for off-label indications such as treating rosacea?

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