Hoarseness during isotretinoin therapy

Abstract

To the Editor: Isotretinoin is an effective therapeutic agent for acne. Its use is often associated with adverse reactions, such as excess granulation tissue formation. A 38-year-old woman with papulopustular acne began isotretinoin therapy at a dose of 30 mg daily (0.6 mg/kg). Three weeks later, she noticed mild hoarseness. In a laryngeal examination, two incipient nodules, one over each vocal cord, were observed. As the patient had a history of vocal abuse caused by teaching activities, the lesions were thought to be secondary to it. Six weeks later, when the hoarseness became severe, a second laryngoscopic examination revealed a complete replacement of both nodules by granulomatous tissue. Surgical removal of the lesions was proposed, and meanwhile, after 5 months of treatment, isotretinoin therapy was stopped. Two weeks later, the hoarseness started to improve and completely dissapeared 6 weeks after the drug's withdrawal. A third laryngoscopic examination showed no granulomatous tissue over the original nodules of the vocal cords. Retinoid therapy is known to be associated to excess granulation tissue responses.1.Hodak E. David M. Feuerman E.J. Excess granulation tissue during etretinate therapy.J Am Acad Dermatol. 1984; 11 ([letter]): 1166-1167Abstract Full Text PDF PubMed Scopus (28) Google Scholar, 2.Campbel J.P. Grekin R.C. Ellis C.N. Matsuda-John S.S. Swanson N.A. Voorhees J.J. Retinoid therapy is associated with excess granulation tissue responses.J Am Acad Dermatol. 1983; 9: 708-713Abstract Full Text PDF PubMed Scopus (75) Google Scholar, 3.Kanoh H. Izumi T. Hiramatsu T. Ohnishi M. Murai M. Seishima M. Granulomatous nodule on vocal cord possibly induced by etretinate therapy.Br J Dermatol. 2000; 142 ([letter]): 1258-1259Crossref PubMed Scopus (2) Google Scholar The cause is unknown, although minor trauma may be a possible trigger.4.Katayama H. Okabe N. Kano T. Yaoita H. Granulation tissue that developed after a minor trauma in a psoriatic patient on long-term etretinate therapy.J Dermatol. 1990; 17: 187-190PubMed Google Scholar In our patient, vocal abuse could have been the origin of this response. We report the first case of hoarseness possibly caused by excess granulomatous tissue formation over nodules on the vocal cords during isotretinoin therapy. We consider it important to be aware of this newly recognized adverse reaction to avoid a surgical procedure for a potentially reversible lesion.