Course Of Isotretinoin Research Articles

Maintenance Acne Treatment With Topical Tazarotene after Oral Isotretinoin: Overview and Case Reports

Introduction: Acne vulgaris is a common dermatologic disorder that may require treatment over months or years. Acne negatively impacts quality of life, and acne of any severity increases the risk of long-term sequelae such as scarring. Common treatments for severe/nodulocystic acne include oral isotretinoin, an oral antibiotic combined with a topical (benzoyl peroxide or a retinoid), an oral combined contraceptive, or oral spironolactone (females). Though oral antibiotics and isotretinoin are not recommended for long-term use, there is scarce guidance or published research on maintenance therapy. Topical retinoids—a mainstay of initial acne treatment—may be prescribed for maintenance once initial oral treatments are complete. Additionally, some retinoids such as tretinoin and tazarotene are indicated for the treatment of fine wrinkles and certain pigmentation disorders, and some studies have shown that adapalene and tazarotene may also reduce acne-induced scarring. Tazarotene 0.045% polymeric emulsion lotion is a well-tolerated retinoid that has demonstrated efficacy in acne treatment and may reduce acne-induced post-inflammatory hyperpigmentation (PIH) and melasma. Further, tazarotene lotion provides rapid and sustained improvements in skin barrier function/moisturization. Herein is presented a report of patients with acne who received maintenance treatment with topical tazarotene 0.045% lotion after an initial course of oral isotretinoin.
 Methods: Patients with severe recalcitrant acne vulgaris were treated with once daily oral isotretinoin for at least 20 weeks until deemed clinically clear. All patients received 40 mg isotretinoin once daily for the first 30 days. The dosage was then increased to 1 mg/kg of bodyweight (treatment naïve) or 1.5 mg/kg (repeat treatment). After 20 weeks, patients who achieved clinically clear skin initiated once-daily topical tazarotene 0.045% lotion monotherapy on the day of their last isotretinoin dose. Follow up visits occurred at 6 months and 1-year post-isotretinoin treatment.
 Results: Patients (n=12) had a mean age of 17.8 years (standard deviation [SD]: 3.8) and the majority were female (58.3%) and White (66.7%). Oral isotretinoin was used for an average of 24.3 weeks (SD: 6.7), with a mean cumulative dose of 184.6 mg/kg. One patient required a repeat course of isotretinoin prior to tazarotene initiation. Post-isotretinoin, patients received tazarotene 0.045% lotion for an average of 13.0 months (SD: 6.7). No patients relapsed and all showed subjective visual improvements in acne-related scarring with tazarotene maintenance treatment. None discontinued tazarotene lotion due to adverse events. 
 Conclusions: There is little guidance or research published on acne maintenance treatment after initial oral isotretinoin or other treatments are complete. Topical tazarotene 0.045% polymeric emulsion lotion has previously demonstrated good efficacy, safety, and tolerability with acne and PIH reductions in patients with moderate-to-severe acne, as well as dyspigmentation reductions in patients with melasma and/or PIH. The case reports presented here show that tazarotene 0.045% lotion may be an effective and safe treatment to prevent relapse after initial oral isotretinoin treatment for severe recalcitrant acne.
 Funding: Ortho Dermatologics

Prescribing Patterns of Oral Antibiotics and Isotretinoin for Acne in a Colorado Hospital System: Retrospective Cohort Study.

Guidelines established by the American Academy of Dermatology recommend oral antibiotics as first-line therapy for mild, moderate, and severe acne. However, it is recommended to minimize the duration of oral antibiotic use, and there is increasing support for other systemic agents for acne. We sought to characterize the use of oral antibiotics and isotretinoin for the treatment of acne in the pediatric and young adult population aged 10 through 20 years and the adult population aged 21 to 45 years from 2011 to 2019. We conducted a retrospective, observational cohort study using electronic data from the enterprise data warehouse of the University of Colorado Anschutz Medical Campus and its affiliates, with data in the format of the Observational Health Data Sciences and Informatics (OHDSI) Observational Medical Outcomes Partnership (OMOP) common data model. Categorical values (sex, race, and ethnicity) were compared using chi-square tests, and continuous variables (age) were compared using 2-tailed t tests. Our cohort of 15,704 patients was composed of mostly White (12,776/15,704, 81.4%), non-Hispanic or Latino (13,307/15,704, 84.7%), and female (11,093/15,704, 70.6%) patients. Among the 4605 male patients in the eligible cohort, 1810 (39%) received an oral antibiotic treatment, in comparison to 3109 (28%) of the 11,093 eligible women (P<.001). Among the 4605 men who were eligible for treatment with isotretinoin in this population, 988 (21.5%) received a course of isotretinoin, compared to only 10.4% (1159/11,093) eligible women (P<.001). Male patients were 1.67 times more likely to have received an antibiotic prescription(odds ratio [OR] 1.67, 95% CI 1.55-1.79) and over twice as likely to have received an isotretinoin prescription (OR 2.34, 95% CI 2.13-2.57) than female patients. Minocycline was the most frequently prescribed antibiotic for the treatment of acne in this study cohort. From 2015 to 2019, there was no significant change in the number of antibiotic prescriptions over time. Men were significantly more likely to receive both oral antibiotics and isotretinoin than female patients. Multiple factors could be contributing to this discrepancy, including the burden of iPLEDGE, additional systemic treatment options for female patients, and the difference in acne severity across sexes. We could not determine the difference in severity of acne between male and female patients in our cohort, and further research is needed to ascertain the variation across sexes.

580 Factors which predict the need for multiple courses of isotretinoin

580 Factors which predict the need for multiple courses of isotretinoin

Facial rash with exuberant crusting in pregnancy

Case Summary A woman in her 20s with a history of systemic lupus erythematosus controlled with azathioprine and low-dose prednisone presented at ten weeks of pregnancy after developing pruritic, painful facial lesions over three weeks. She had no history of rosacea, topical corticosteroid use, or recent fevers, but was wearing masks frequently. On examination, she appeared non-toxic and had numerous coalescing erythematous papules and pustules with yellow-gray crusting around her nose, mouth, and glabella (Fig. 1). The vermilion border was spared. No comedones were present. Herpes simplex virus polymerase chain reaction (PCR), varicella zoster virus PCR, bacterial cultures, and fungal cultures were negative. Punch biopsy of a pustule showed intraepidermal neutrophilic spongiosis with subcorneal pustules, diffuse dermal neutrophilic inflammation, and dermal edema.Fig. 1.: Clinical presentation of the (A) frontal and (B) right face showing erythematous papules and pustules coalescing into plaques with thick, yellow-gray crust around the nose and mouth with sparing of the vermilion border and extension onto the glabella.Question 1 Which of the following is the most likely diagnosis? A. Pyoderma faciale B. Impetigo C. Acute lupus flare D. Pyostomatitis vegetans E. Amicrobial pustulosis associated with autoimmune disease (APAD) Correct answer: A. Pyoderma faciale. Disease is characterized by numerous erythematous nodules, papules, and pustules erupting on the central face. She was diagnosed with periorificial pyoderma faciale. With her obstetrician’s approval, we initiated a three-month course of cephalexin, in line with standard treatment durations for rosacea. At two months follow-up, there was near-resolution. Discussion Pyoderma faciale, also known as rosacea fulminans, is a rare inflammatory facial dermatosis most commonly affecting women between 20 and 40 years old with a history of flushing or rosacea.1 Approximately 10% of cases occur during pregnancy, and around 40% can be triggered by menopause, medication changes, or emotional stressors.1 Patients present suddenly with tender coalescing inflamed pustules, nodules, draining sinuses, and cysts/abscesses on the central face.2 Our patient presented with numerous pustules, with the additional and unique feature of thick, confluent, yellow-gray crusting. To our knowledge, prior reports of patients with crusted papulopustules have not shown such exuberant facial crusting.3 The reasons for our patient’s dramatic presentation are unclear. Possibly, her underlying systemic lupus erythematosus (SLE), stress and altered immunity during pregnancy, and mask wearing promoted vascular hyperreactivity and inflammation predisposing to development of pyoderma faciale.2 Pyoderma faciale can mimic infectious and inflammatory processes. In our patient with SLE on immunosuppression, the differential diagnosis included infections such as impetigo, an acute lupus flare, pyostomatitis vegetans, or an atypical facial presentation of amicrobial pustulosis associated with autoimmune disease (APAD). Given the patient’s pregnancy status, morphology of lesions with centrofacial distribution and sparing of the vermilion border, non-toxic appearance, stable SLE and negative infectious work-up, pyoderma faciale was felt to be the best diagnosis. Notably, the perioral and perinasal distribution of the rash resembled periorificial dermatitis, which is on the rosacea spectrum, much like pyoderma faciale. Typically, pyoderma faciale is treated initially with systemic corticosteroids to rapidly reduce inflammation, followed by longer courses of isotretinoin or tetracyclines to maintain improvement. In our patient, the latter 2 treatment options were contraindicated due to pregnancy. Beta-lactam antibiotics can improve pyoderma faciale, although they often fail to achieve resolution as monotherapy and are typically given in conjunction with corticosteroids or isotretinoin.1 Recently, erythromycin monotherapy has shown promising results in pregnant individuals.1 Our case provides evidence that a robust presentation of pyoderma faciale with a periorificial distribution can be treated safely and successfully with cephalexin monotherapy during pregnancy. Question 2 What dermatologic disorder is most associated with pyoderma faciale? A. Atopic dermatitis B. Acne C. Rosacea/flushing D. Impetigo E. Folliculitis Correct answer: C. Rosacea/flushing. Walsh et al.1 demonstrated that history of rosacea/flushing is present in 80% of cases of pyoderma faciale. Conflicts of interest None. Funding None. Author contributions Raymond Zhao contributed to the drafting of the manuscript, figure design, and background research. Severine Cao and Frank Wang contributed to the conception and overall planning of the project, supervision of the project, and critical revision of the manuscript. Study approval N/A.

Isotretinoin update

AbstractBackgroundAcne is a common, chronic inflammatory condition seen in nearly all teenagers and many adult females, with a global lifetime prevalence between 70‐85%. While a majority of individuals with acne can be appropriately managed with a combination of topical therapies, oral antibiotics, and/or oral anti‐androgens, 10‐20% of individuals will have acne severe enough to warrant isotretinoin. When necessary, isotretinoin is highly effective and the only drug to offer the likelihood of a durable response.AimsTo review the literature regarding known adverse effects of isotretinoin therapy and nuances during and post‐isotretinoin therapy important to patient care.Materials and MethodsA literature search was conducted for original, English‐language case reports, case series, original studies and/or meta‐analyses published between 1982‐2021 on isotretinoin, related adverse effects, and laboratory assessment and treatment nuances during and after a course of isotretinoin.ResultsAdverse events categories include mucocutaneous (e.g., xerosis, cheilitis, epistaxis), ocular (xerophthalmia, nyctalopia, blepharitis, conjunctivitis), non‐specific gastrointestinal, musculoskeletal (myalgia, pre‐mature epiphyseal plate closure, DISH), neurologic (idiopathic intracranial hypertension, hearing loss, tinnitus). Most adverse events are mild, self‐limiting, and/or resolve with drug discontinuation. Teratogenicity is of utmost concern especially given the risk of patient nonadherence to iPLEDGE precautions. Laboratory testing at baseline and after month 2 of therapy or upon reaching maximum daily dose may be sufficient. Utilizing creatine kinase and gamma‐glutamyl transferase in lieu of aspartate aminotransferase and alanine aminotransferase may better assess hepatic function during treatment. Improved formulations of isotretinoin may improve absorption and decrease reliance on patient adherence to a high‐fat diet. Dermabrasion and fully ablative laser procedures should be avoided in the immediate post‐isotretinoin period.DiscussionAlthough adverse events associated with isotretinoin therapy are common, a majority of side effects are limited, self‐resolving (with completion of treatment course) without long‐term implications, and/or easily managed. Unfortunately, the advent of the internet and social media has given a platform to misleading law‐firm claims and medical pseudoscience inaccuracies that may frighten patients in need of treatment, ultimately delaying or even preventing therapy.ConclusionIt is important that physicians are knowledgeable about the nuances of isotretinoin therapy, including efficacy, real potential adverse events, and appropriate laboratory monitoring. By honing this expertise, physicians may confidently counsel and guide patients through a course of isotretinoin to achieve a more permanent solution for their acne and improve their quality of life.

17978 Analysis of factors associated with relapse in patients on their second course of isotretinoin for acne

Oral isotretinoin is commonly prescribed to treat nodulocystic acne and acne that is recalcitrant to standard treatments. Most patients treated with isotretinoin have remission of their acne; however, some patients relapse. Although extensive research has been done, the main factors associated with relapse of acne are still unclear, and the factor of duration of treatment after clearance has only recently been studied. The primary aim of this study was to identify factors strongly associated with the relapse of acne in patients receiving a second course of isotretinoin for treatment. Subjects were identified through a combination of EMR search and chart review. An EMR search was conducted using the ICD 9/10 diagnosis code for acne between the dates of January 2013 and June 2018 at UCLA dermatology. Patients who did relapse and required at least two courses of isotretinoin were compared with other patients in the same time period who were prescribed isotretinoin for acne and did not experience relapse. One-tailed t tests were utilized for statistical analysis. Overall, compared with 83 patients taking isotretinoin who required a second course, 220 patients taking isotretinoin without relapse had higher total cumulative isotretinoin doses (134.1 ± 48.0 vs 162.8 ± 45.5 milligrams/kg) and longer average durations of treatment after acne clearance (0.8 ± 1.2 vs 1.4 ± 1.3 months), P < .001 and P = .005, respectively. Our data suggest that treating acne at a higher cumulative dose and for longer after acne clearance is associated with lower rates of relapse.

Analysis of factors associated with relapse in patients on their second course of isotretinoin for acne vulgaris

Analysis of factors associated with relapse in patients on their second course of isotretinoin for acne vulgaris

Quality of Life Assessed Using Skindex-16 Scores Among Patients With Acne Receiving Isotretinoin Treatment

Acne is a common dermatologic condition and significantly affects psychosocial health and quality of life. An international task force recommended routine use of quality-of-life measures for clinic visits associated with acne management, but this has yet to translate into clinical practice. To assess mean Skindex-16 scores over time among patients with moderate to severe acne receiving isotretinoin treatment. A longitudinal, retrospective case series study of Skindex-16 data collected at monthly visits from 57 consecutive patients with acne receiving isotretinoin; data were collected and evaluated between November 23, 2016, and January 22, 2019. Continuous variables were compared using quantile regression. Multivariable linear mixed models evaluated mean (95% CI) score trajectory over time. Skindex-16 scores, including normalized scores for the emotional, symptomatic, and functional aspects of having skin disease as well as an overall score. Fifty-seven patients (31 [54.4 %] males, with median [interquartile range] age of 17.2 [15.9-18.1] years) in this case series study completed the Skindex-16 at baseline and at least once during follow-up. Baseline Skindex-16 scores were similar by sex but worse with increasing age. Emotional impact was more bothersome to patients with acne requiring isotretinoin treatment than either symptoms or functioning. Improvements of greater than 50% in overall and Emotional domain scores were seen by month 2 of receiving isotretinoin treatment (eg, overall scores decreased from 39.4 to 17.5 by month 2; a decrease of 22.0; P < .001). Qualitatively, Skindex-16 scores reached their nadir between months 3 and 5; at month 4, overall Skindex-16 scores showed a 4.4-fold improvement (from 39.4 at baseline to 8.9; P < .001) and Emotional domain scores showed a 4.8-fold improvement (from 57.7 at baseline to 11.9; P < .001). The findings of this case series suggest that patients receiving isotretinoin treatment achieve greater than a 50% improvement in quality of life by month 2 and can expect approximately 4-fold to 5-fold improvements from baseline with a full course of isotretinoin. This study shows the potential of routine administration of quality of life measures to assess patient care in dermatology.

Simplifying contraception requirements for iPLEDGE: A decision analysis

For persons of childbearing potential prescribed isotretinoin, the iPLEDGE program requires use of 2 simultaneous methods of contraception or commitment to abstinence. To model the relative effectiveness of a variety of contraception strategies for patients taking isotretinoin, including those that are acceptable according to iPLEDGE. We performed a decision analysis modeling the estimated rate of pregnancy with various contraception strategies during a typical 6-month course of isotretinoin. Tier 1 contraception options (eg, subdermal hormonal implant, intrauterine devices) each had effectiveness of >99.5% alone. When combined with a secondary form of contraception, tier 2 contraception options (eg, depot medroxyprogesterone injections, combined oral contraceptives) each had effectiveness >99%. Sensitivity analyses were conducted to evaluate the impact of uncertain parameters on the results. There may be opportunities to simplify iPLEDGE by recognizing the high effectiveness of tier 1 contraception options and increasing use of secondary forms of contraception among those using tier 2 contraception options as their primary form of contraception. Future studies are needed to understand the most effective strategies in clinical practice to prevent unintended pregnancy for patients taking isotretinoin to improve outcomes and provide patient-centered care.

Isotretinoin and risk factors for suicide attempt: apopulation-based comprehensive case series and nested case-control study using 2010-2014 French Health Insurance Data.

Although the causal role of isotretinoin in suicidal behaviour is controversial, suicide attempts (SA) do occur among patients taking isotretinoin. To describe patient profiles and the management of isotretinoin among patients who committed or attempted suicide under treatment. To assess the risk factors for SA under isotretinoin. We performed a comprehensive case series of suicides and SAs under isotretinoin, and a case-control study, using Nationwide French Health Insurance database. The main analysis compared cases (subjects with a SA during a course of isotretinoin) to controls, individually matched for age, gender and rank of the current course; controls were to be exposed to isotretinoin at the index date (date of SA for the corresponding cases). The patients' psychiatric history at isotretinoin initiation was studied. In a secondary analysis, patients who continued their isotretinoin treatment after their SA were compared to patients who discontinued it. In all, 328018 subjects started a course of isotretinoin between 1 January 2010 and 31 December 2014 and 184 patients were hospitalized for a SA; half of them had a psychiatric history at initiation. In the multivariate analysis, psychiatric history and history of anxiety alone were risk factors for SA [Odds ratio (OR), 18.21; 95% confidence interval (CI), 9.96-33.30 and 4.78; 95% CI, 2.44-9.33, respectively]. Among 176 cases of SA with sufficient follow-up, 103 (58.5%) carried on with their treatment after their SA. Treatment initiation by a dermatologist was inversely associated with the continuation of the treatment after a SA (OR, 0.38; 95% CI, 0.18-0.80). Suicide attempts under isotretinoin are rare events, and our results suggest that most of the patients concerned have a risk-prone profile detectable at the time of treatment initiation. The risk-benefit ratio of continuing isotretinoin after a SA warrants further careful evaluation.

A Comprehensive Safety Trial of Chimeric Antibody 14.18 With GM-CSF, IL-2, and Isotretinoin in High-Risk Neuroblastoma Patients Following Myeloablative Therapy: Children's Oncology Group Study ANBL0931.

A phase 3 randomized study (COG ANBL0032) demonstrated significantly improved outcome by adding immunotherapy with ch14.18 antibody to isotretinoin as post-consolidation therapy for high-risk neuroblastoma (NB). This study, ANBL0931, was designed to collect FDA-required safety/toxicity data to support FDA registration of ch14.18. Newly diagnosed high-risk NB patients who achieved at least a partial response to induction therapy and received myeloablative consolidation with stem cell rescue were enrolled to receive six courses of isotretinoin with five concomitant cycles of ch14.18 combined with GM-CSF or IL2. Ch14.18 infusion time was 10-20 h per dose. Blood was collected for cytokine analysis and its association with toxicities and outcome. Of 105 patients enrolled, five patients developed protocol-defined unacceptable toxicities. The most common grade ≥ 3 non-hematologic toxicities of immunotherapy for cycles 1-5, respectively, were neuropathic pain (41, 28, 22, 31, 24%), hypotension (10, 17, 4, 14, 8%), allergic reactions (ARs) (3, 10, 5, 7, 2%), capillary leak syndrome (1, 4, 0, 2, 0%), and fever (21, 59, 6, 32, 5%). The 3-year event-free survival and overall survival were 67.6 ± 4.8% and 79.1 ± 4.2%, respectively. AR during course 1 was associated with elevated serum levels of IL-1Ra and IFNγ, while severe hypotension during this course was associated with low IL5 and nitrate. Higher pretreatment CXCL9 level was associated with poorer event-free survival (EFS). This study has confirmed the significant, but manageable treatment-related toxicities of this immunotherapy and identified possible cytokine biomarkers associated with select toxicities and outcome. EFS and OS appear similar to that previously reported on ANBL0032.

Non-antibiotic Isotretinoin Treatment Differentially Controls Propionibacterium acnes on Skin of Acne Patients.

Emergence and potential transfer of antibiotic resistance in skin microorganisms is of current concern in medicine especially in dermatology contexts where long term treatment with antibiotics is common. Remarkably, non-antibiotic therapy in the form of isotretinoin – a non-antimicrobial retinoid is effective at reducing or eradicating the anaerobe Propionibacterium acnes which is causally involved in the complex pathogenesis of Acne vulgaris. This study measured the extent of colonization of P. acnes in patients with primary cystic or severe acne from three defined skin sites in ‘non-lesion’ areas before, during and after treatment with isotretinoin. Patients attending acne clinics were investigated using standardized skin sampling techniques and the recovery of anaerobic P. acnes from 56 patients comprising 24 females and 32 males (mean age 22 years, age range 15–46 years) who were given a standard course of isotretinoin (1 mg/kg/day) are reported. P. acnes cultured from the external cheek surface of patients following treatment showed a significant reduction (1–2 orders of magnitude) compared with their pre-treatment status. Interestingly, other distinct sites (nares and toe web) failed to show this reduction. In addition, high levels of antibiotic-resistant P. acnes were recorded in each patients’ skin microbiota before, during and after treatment. In this study, microbial composition of the skin appears substantially altered by isotretinoin treatment, which clearly has differential antimicrobial effects on each anatomically distinct site. Our study confirmed that orally administered isotretinoin shows good efficacy in the resolution of moderate to severe acne that correlates with reductions in the number of P. acnes on the skin, including resistant isolates potentially acquired from previous treatments with antibiotics. Our study suggests that the role of tetracycline’s and macrolides, which are currently first line treatments in dermatology, might be reserved for severe or life-threatening infections since current antibiotic stewardship guidelines from medical departments no longer prescribe these antibiotics for routine use.

Adult female acne treated with spironolactone: a retrospective data review of 70 cases.

The prevalence of acne in the adult population is increasing, particularly in women. Spironolactone regulates sebaceous gland activity by blocking androgen receptor. To evaluate retrospectively the efficacy of spironolactone in women with acne. Data from 70 women of at least 20 years, treated for their acne between 2010 and 2015 with low-dose spironolactone (≤150mg/day), were analysed. Remission was defined by the number of retentional lesions inferior or equal to five and inflammatory lesions inferior or equal to two on the face. Variables influencing the response were studied using the Cox model. The mean age was 31.3 years; 39 (56%) women had prior courses of isotretinoin and 53 (76%) had an oral contraception prior to treatment. Remission data from a median treatment period of six months (95%CI: 4-9) were obtained from 47 (71%) women. Markers for a positive response to spironolactone were a high number of inflammatory lesions at inclusion (OR: 1.08; 95%CI: 1.03-1.13; p=0.001) and relapse with previous isotretinoin (OR: 2.46; 95%CI: 1.09-5.54; p=0.03). The marker for a negative response was an association with oral contraceptives containing first or second-generation progestin (OR: 2.77; 95%CI: 1.35-5.71; p=0.005). This retrospective data analysis confirms that the use of low doses of spironolactone is a valuable alternative in women with acne in whom oral isotretinoin has failed. Moreover, the analysis shows that first and second-generation oral contraceptives decrease the efficacy of spironolactone, confirming the interest of using two third or fourth-generation oral contraceptives.

Can oral isotretinoin be safely initiated and monitored in primary care? A case series.

Oral isotretinoin has traditionally been prescribed only in secondary care for severe or resistant acne. To explore whether this drug can be safely initiated and monitored in primary care by a GP with extra training in dermatology. One hundred consecutive patients who were started on oral isotretinoin therapy in a primary care centre were retrospectively reviewed. One hundred percent of the patients with acne who completed their course of isotretinoin were cleared at the end of treatment. Twenty-three of the eighty-one patients (28%) who were followed-up after a mean of 5years relapsed and eighteen (22%) had to have at least one more course of isotretinoin. Seventy-four of seventy-seven (96%) patients who had long-term follow-up were satisfied with the level of care they received in primary care. This study suggests that oral isotretinoin can be safely initiated and monitored by a GP with a special interest in dermatology and experience in prescribing systemic retinoids.

Standardized laboratory monitoring with use of isotretinoin in acne

Laboratory monitoring for adverse effects to isotretinoin occurs with variability. Standardization of laboratory monitoring practices represents an opportunity to improve quality of care. We sought to develop an evidence-based approach to laboratory monitoring of patients receiving isotretinoin therapy for acne. We reviewed laboratory data from 515 patients with acne undergoing 574 courses of isotretinoin from March 2003 to July 2011. Frequency, timing, and severity of abnormalities were determined. Clinically insignificant leukopenia or thrombocytopenia occurred in 1.4% and 0.9% of patients, respectively. Elevated liver transaminases were detected infrequently and not significantly increased compared with baseline detection rates (1.9% vs 1.6% at baseline). Significant elevations occurred with triglyceride (19.3%) and cholesterol (22.8%) levels. The most severe abnormalities were grade 2 (moderate). Mean duration of treatment before abnormalities were detected was 56.3days for hypertriglyceridemia, 61.9days for alanine transaminitis, and 50.1days for hypercholesterolemia. This was a single-center experience examining variable isotretinoin laboratory monitoring practices. In healthy patients with normal baseline lipid panel and liver function test results, repeated studies should be performed after 2months of isotretinoin therapy. If findings are normal, no further testing may be required. Routine complete blood cell count monitoring is not recommended.

High-Dose Isotretinoin Treatment and the Rate of Retrial, Relapse, and Adverse Effects in Patients With Acne Vulgaris

Isotretinoin is the most effective treatment for acne. The ideal dosing regimen is unknown. To determine the rates of relapse of acne vulgaris and retrial of isotretinoin after high cumulative-dose treatment and the changes to the adverse effect profile. A prospective, observational, intervention study was conducted from August 1, 2008, to August 31, 2010, in a single academic tertiary care center with multiple providers. A total of 180 patients with acne resistant to other treatments were enrolled. Of these, 116 participated in the 12-month follow-up survey, for a response rate of 64.4%. Patients received isotretinoin, with dosing based on the providers' judgment. Patients were divided into 2 groups on the basis of cumulative dosing (<220 mg/kg and ≥ 220 mg/kg). Relapse (treatment with a prescription topical or oral acne medication after a course of isotretinoin) or retrial (retreatment with isotretinoin) at 12-month follow-up and adverse effects experienced during and after 12 months of treatment. RESULTS The mean age of the participants was 19.3 years, 51.9% were female, and 74.1% were white. At 12 months' follow-up, 97.4% of the patients reported that their acne was improved. Overall, acne in 32.7% of patients in the study relapsed at 12 months, and 1.72% of the patients required a retrial. In the lower-dose treatment group (<220 mg/kg), the relapse rate was 47.4% (95% CI, 32.3%-63.0%) compared with 26.9% (95% CI, 18.3%-37.8%) in the high-dose group (P = .03). Almost 100% of the patients in both treatment groups developed cheilitis and xerosis during treatment. Retinoid dermatitis was significantly more common in the high-dose treatment group (53.8% vs 31.6%; P = .02). None of the other adverse effects was significantly different between the 2 groups. The dosing regimen used in the present study is considerably higher than that used in previous studies of isotretinoin. At 1 year after completion of isotretinoin treatment, we found that patients receiving 220 mg/kg or more had a significantly decreased risk of relapse. Rash was the only adverse effect that was significantly more common in the high-dose group during treatment. This study suggests that significantly higher doses of isotretinoin are effective for treating acne and decreasing relapse rates without increasing adverse effects.

High‐dose isotretinoin in acne vulgaris: improved treatment outcomes and quality of life

Isotretinoin, for acne treatment, is associated with high rates of permanent remission. However, at recommended doses of 0.5-1.0 mg/kg/day for 5-6 months [average cumulative dose: 120-150 mg/kg], more than 20% of patients experience a relapse within two years that requires further medical management. To examine outcomes of high-dose isotretinoin in a cohort with cystic acne, as well as measuring its impact on quality of life (QOL). A single dermatologist, single institution investigation within an academic tertiary care center in Bronx, NY. Eighty patients with nodulocystic acne, maintained on oral isotretinoin at a dose of 1.3 mg/kg/day or greater, were studied from 2006-2009 while additionally participating in a QOL survey. Main outcome measures included documented events, acne clearance, presence of relapse, and quality of life parameters. The mean daily dose of isotretinoin was 1.6 mg/kg/day for an average time course of 178 days [cumulative dose: 290 mg/kg]. No side effects or laboratory abnormalities led to discontinuation of treatment. There were no psychiatric symptoms. One-hundred percent (100%) of patients were disease-free upon completion of treatment. During the three-year study period, 10 patients (12.5%) developed a relapse that required an additional course of isotretinoin. Analysis of QOL domains (self-perception, role-social, symptoms) revealed significant improvement following isotretinoin therapy (p = 0.0124, p = 0.0066, p = 0.0265, respectively). Isotretinoin prescribed at 1.5 mg/kg/day or greater for 5-6 months [cumulative total dose of 290 mg/kg] is safe and effective compared to current standard dosing practices. We propose the use of high-dose isotretinoin (>1.3 mg/kg/day) as a treatment option in severe nodulocystic acne and encourage larger, prospective, multicenter studies into this therapeutic approach.

Dichotomous Long‐Term Response to Isotretinoin in Two Patients with Fordyce Spots

Fordyce spots are benign, enlarged sebaceous glands that commonly present as tiny yellow papules on a variety of body surfaces, including the lips. Although these lesions are asymptomatic, in some patients, they are abundant and conspicuous, leading to concerns regarding their cosmetic appearance. The response of Fordyce spots to isotretinoin therapy is poorly documented in the literature, which contains only one case report of an affected patient treated with a short course of isotretinoin (35 mg/kg in total). Herein, we report dichotomous long-term response to a standard course of isotretinoin in two patients with Fordyce spots of the lips and concomitant acne.

Effective monitoring of isotretinoin safety in a pediatric dermatology population: A novel “patient symptom survey” approach

Assessment of adverse effects in pediatric patients on oral isotretinoin has not been standardized and the exact incidence is unknown. Our goal was to determine the usefulness of an isotretinoin symptom survey as a screening tool for assessment and quantification of adverse effects, including psychiatric symptoms, during isotretinoin treatment in a pediatric population of different age groups. We performed a retrospective chart review on a random sample of patients treated with isotretinoin at a tertiary pediatric dermatology clinic where patients completed an isotretinoin symptom survey at each visit. Responses were stratified by age group and psychiatric history. The charts of 102 patients, representing 123 courses of isotretinoin and 760 treatment-months, were reviewed. Atotal of 722 (95.0%) symptom surveys were complete and 38 (5.0%) were incomplete/missing. Recorded side effects were similar to published adult data; dry lips/dry skin were reported in 94.25% and 72.13% of treatment-months of isotretinoin, respectively. Psychiatric symptoms were reported in 1.65%, with no statistical difference between patients with or without a mental health history. Patients aged 11 to 15 years had similar side-effect profiles to those aged 16 to 21years. Impaired night vision, nosebleeds, and dry/bloodshot eyes were more common in the older age group. This was a retrospective chart review, with known limitations. The study was performed at a tertiary referral center for pediatric dermatology, possibly allowing patient selection bias. The isotretinoin symptom survey appears to be an effective screening tool to standardize monitoring of isotretinoin side effects in the pediatric population.

Academic branding: erythema ab igne and use of laptop computers

A 20-year-old female university student presented with a two-month history of asymptomatic pigmentation in a net-like distribution, isolated to the front thighs ([Figure 1][1]). She was otherwise healthy, apart from having recently completed a six-month course of isotretinoin for acne. She had no