Treatment Of Severe Cystic Acne Research Articles

Potential Neurologic Side Effects of Oral Isotretinoin: A Case of Peripheral Neuropathy

Oral isotretinoin is a well-known, effective medication used in the treatment of severe cystic acne. While efficacious, the potential side effects of isotretinoin are often discussed and may cause concern for patients. Although most side effects of this medication are mild, other more concerning adverse effects have been reported. Of note, isotretinoin has the potential to affect the central nervous system (CNS), causing headaches, pseudotumor cerebri, and fetal CNS malformations. In contrast, the effects on the peripheral nervous system are not well documented. The objective of this case report is to present an instance of oral isotretinoin leading to foot drop in an adolescent patient.

Awareness of isotretinoin use and Saudi FDA pregnancy prevention program in Riyadh, Saudi Arabia: A cross-sectional study among female patients

IntroductionOral isotretinoin is an effective agent for the treatment of severe cystic acne. Isotretinoin is a teratogen; there is an increased risk of congenital defects in infants exposed to the drug in the uterus. The Saudi Food and Drug Authority (SFDA) has implemented a pregnancy prevention program (PPP) to protect females from those teratogenic effects. ObjectivesTo investigate the awareness of women, of reproductive age who were using Isotretinoin or used it previously, about isotretinoin use and the SFDA-approved PPP in Riyadh, Saudi Arabia. MethodsThis cross-sectional study was conducted during the period from June to October 2019. A questionnaire was developed based on the published literature and the PPP recommendations. The study was carried out online among female patients who were on Isotretinoin therapy or have used it previously in Riyadh city. The Statistical Package for Social Sciences (SPSS for Windows, version 24) was used to analyze the study data. ResultsDuring the study period, 483 patients participated in the study. Among them, 97.3% reported that they used the drug based on a doctor’s prescription, 94.6% were aware of Isotretinoin’s teratogenic effect, and 30.6% confirmed their awareness of the PPP. Amongst the participants, 9.1% (n = 44) used Isotretinoin while being married or planning to get married within a one-month period after using it. Concerning the use of two contraceptive methods according to the PPP guidelines, of the participants, 43.2% reported that they have been informed by their healthcare providers to use two contraceptive methods before starting the medication. Also 43.2% reported that they have been informed to use two contraceptive methods while using the medication, and 50% reported that they have been informed to use two contraceptive methods for one month after stopping the medication. Regardless of the information they had, participants’ actual practice, was as follow: 15.9% used two contraceptive methods before starting the medication, 15.9% used two contraceptive methods during the treatment, and 13.6% used two contraceptive methods for one month after stopping the medication. ConclusionsAlthough this study revealed that the vast majority of participants were aware of isotretinoin’s teratogenic effect, still a considerable number of them had no idea about the PPP. This issue needs to greatly be addressed to minimize the risk of teratogenicity.

Trigeminal neuralgia associated with isotretinoin use: a very rare complication

Background: Trigeminal neuralgia (TN) is a term used in short-term acute pain in the trigeminal nerve distribution that feels like stabbing or electric shock. Isotretinoin (13-cis-retinoic acid) is a commonly used medication for the treatment of severe cystic acne that does not respond to other therapies. Isotretinoin treatment has been associated with rare but serious complications on multiple systems. Case Presentation: This case report presents a patient who developed TN while using oral isotretinoin therapy for acne vulgaris. This rare adverse event has not been well documented in the medical literature. Conclusion: The author want to emphasize with this case report that physicians should keep in mind that TN is one of the possible negative effects of isotretinoin.

AB0724 Isotretinoin Induced Bilateral Sacroiliitis: CASE Report

BackgroundIsotretinoin, a retinoid indicated for the treatment of severe cystic acne, has been associated with adverse effects,including musculoskeletal symptoms. Reported here is a case of bilateral sacroiliitis related to isotretinoin...

Bilateral acute sacroiliitis due to isotretinoin therapy: a case report

We report here a case of a young female patient who developed sacroiliitis related to isotretinoin (13-cis-retinoic acid) use which completely resolved following discontinuation of the medication. Isotretinoin, a retinoid indicated for the treatment of severe cystic acne, has been associated with adverse effects, including musculoskeletal symptoms such as arthritis, arthralgia, myalgia and soft tissue calcification. Reactive sacroiliitis is a rare side effect. A small number of cases of sacroiliitis occurring in association with isotretinoin use have been described.1-3 A 20-year-old healthy woman was admitted to our department with complaints of myalgia, bilateral hip, pelvic and low back pain. She was not using any drugs except isotretinoin, which she had been using to treat acne for the previous 3 months (initial dose 30 mg/day for the first month, then increased to 40 mg/day for the following 2 months). Because of increased pain, the patient had stopped using the drug 15 days ago. On physical examination, sacroiliac joints were very painful and Gaenslen, Thigh Thrust, Patrick Faber and Mennel tests were strongly positive. Muscle power was normal (Medical Research Council scale 5/5). Laboratory examination showed that the erythrocyte sedimentation rate was 52 mm/h (normal range 0–20), C-reactive protein 2.75 mg/dL (0.0–0.5), creatine-kinase (CK) 43 U/L (30–200). Antinuclear antibodies, antineutrophil cytoplasmic antibodies, rheumatoid factor, C3, C4 were all negative. Blood chemistry, thyroid function tests and complete blood count were unremarkable. Screening for viruses and brucella was negative. Human leukocyte antigen (HLA)-B27 was positive. X-ray of pelvis and sacroiliac joint was normal. Magnetic resonance imaging (MRI) showed bilateral active inflammatory sacroiliitis with evidence of bone marrow edema adjacent to both sacroiliac joints. In dynamic contrast enhanced MRI, Fehn activity was measured 103% around the right sacroiliac joint and 75% around the left sacroiliac joint. These measures were compatible with prominent activity (Fig. 1). The patient was treated with prednisolone (15 mg daily slowly decreasing until suspension) and diclofenac sodium (75 mg daily) with gradual improvement over 2 months. After 6 weeks, the symptoms had completely resolved and the laboratory results had improved, so the treatment was stopped. There was no complaint and the laboratory results were normal on the sixth month of follow-up. The use of the Naranjo probability scale indicated a probable relationship between isotretinoin therapy and sacroiliitis.4 Isotretinoin is a retinoid that is used to treat cystic acne, comedonal acne and other diseases. Its most common side effects are mucocutaneous and ocular in nature (i.e., cheilitis, ocular sicca and decreased dark adaptation).5 Reactive sacroiliitis is a rare side effect. On physical examination and MRI findings, we see the symptoms related to sacroiliitis which are mentioned above in our patient. After isotretinoin treatment was stopped, the complaints in our patient vanished. Bilateral symmetrical sacroiliitis can be seen in seronegative spondyloarthropathies, although the presentation in this case is not characteristic of any of these disorders. The patient had no infectious conditions capable of initiating reactive arthritis and lacked both a history and symptoms of inflammatory bowel disease, psoriasis, uveitis, conjunctivitis or peripheral arthritis inconsistent with ankylosing spondylitis, enteropathic arthropathies or psoriatic arthropathy.6 The mechanisms underlying the induction of sacroiliitis by isotretinoin are not currently known. HLA-B27 was positive in our patient. It may be possible that patients with HLA-B27 could be more prone to developing sacroiliitis with isotretinoin use or sacroiliitis might have been triggered by isotretinoin.3 During isotretinoin treatment, patients may become colonized with Staphylococcus bacteria. Thus, it is reported in the literature that the frequency of incidence of perioral abscess formation, severe mucositis or angioedema, increase in patients having isotretinoin treatment.7 Cell-mediated autoimmunity which may develop with hypersensitivity reaction related to isotretinoin treatment may be responsible for multiple target involvement.5 We report here that isotretinoin treatment is usually used in acne treatment, may cause sacroiliitis development or trigger it in healthy people. We advise rheumatologists to be aware of this side effect. None.

Psychiatric reactions to isotretinoin in patients with bipolar disorder

Background Isotretinoin (Accutane®) has been available for the treatment of severe cystic acne for about twenty-five years. There have been several reports of adverse psychiatric reactions to isotretinoin, including depressive symptoms and suicide. However, there have been only three case reports of patients with bipolar disorder (BD) who experienced an untoward psychiatric side effect while receiving isotretinoin treatment. In this study, the psychiatric side effects from isotretinoin were assessed in a larger group of BD patients than has previously been reported. Methods A retrospective chart review of 300 BD outpatients identified ten patients treated with isotretinoin. Results Nine of these ten patients experienced a significant worsening of mood symptoms, and three developed suicidal ideation. Eight experienced a reversal of the relapsed mood symptoms when the isotretinoin was discontinued, whether prematurely or after a full course. Limitations The limitations of this study include small sample size, retrospective data collection, absence of double-blind controlled design, and inability to control for spontaneous mood episodes in patients with BD. Conclusions These results indicate that BD patients treated with isotretinoin for acne are at risk for clinically significant exacerbation of mood symptoms, including suicidal ideation, even with concurrent use of psychiatric medicines for BD. The clinical implications of this study are especially relevant to the treatment of patients with BD because acne usually occurs during adolescence, which is often the age of onset of BD and because a common side effect of lithium (a standard treatment for BD) is acne.

Retinoic acid as a neurobehavioral teratogen

Animal research on retinoic acids (RA) has helped to establish a principle of neurobehavioral teratology: embryonic exposure to a CNS teratogen produces a continuum of outcomes, ranging from death, to malformation, to subtle functional alterations. Demonstrating this principle in human studies was problematic prior to the introduction in 1982 of 13‐cis RA (Accutane, Hoffman‐LaRoche) for the treatment of severe cystic acne. 13 cis RA is a potent human teratogen that causes a 40% rate of spontaneous abortion, and, among liveborn infants, a 35% rate of major malformation (Lammer et al, 1985; 2001). The characteristic pattern includes hindbrain, craniofacial, cardiac, and thymic abnormalities. Longitudinal follow‐up of this original cohort and the matched controls has focused on neuropsychological characteristics at 5 and 10 years of age, and the relationships between malformation and cognitive status. Of 35 children exposed to RA between postconception days 14 and 60 and tested at age 5, 46% scored in the below average range of general mental ability, as compared to 10% of the controls. Boys were more frequently affected than girls with respect to major malformations and reduced intelligence. Presence of a major malformation was associated with reduced intellectual performance, however, 6 of 16 children scoring in the below average range had no detectable malformations. Thus, as in the animal studies, features at birth, such as major malformations, do not fully characterize the adverse consequences of embryonic RA exposure. Likewise, the effects cannot be fully characterized by examining only reduced intelligence. As compared to control children, RA exposed children with average mental ability were three times more likely to have a specific, non‐verbal learning disability and boys were again over‐represented.

Effects of certain prenatal drugs on the fetus and newborn.

1. Robert J. Boyle, MD* 1. *Professor of Pediatrics, University of Virginia Health System, Charlottesville, VA. After completing this article, readers should be able to: 1. Describe the short- and long-term effects of moderate-to-severe alcohol use in pregnancy. 2. List the risks and long-term effects of smoking relative to pulmonary disease, sudden infant death syndrome, and infant intelligence. 3. Characterize the range of anomalies associated with antiepileptic drug use during pregnancy. 4. Describe the risk of Ebstein anomaly following lithium exposure. 5. Describe the effect of angiotensin-converting enzyme inhibitors in the newborn period. Many pregnant women use multiple prescription, over-the-counter, and recreational drugs during their pregnancies. Questions frequently arise from the mother, the mother’s clinician, and the physician caring for the newborn about the potential risks of these agents for the fetus and newborn. Few of these agents have been evaluated prospectively in pregnant women prior to licensure and marketing. Our knowledge of potential risks to the fetus and newborn, therefore, is based on case reports, epidemiologic surveys of exposed individuals, and animal studies. Multiple factors may influence whether a specific drug may affect an individual fetus or newborn and the magnitude of that effect (Table 1). Clearly, not every infant exposed to an individual drug is affected. Likewise, it is important to note that many of these agents are critical to the mother’s health, and discontinuing the drug may place the mother and fetus at higher risk than continuing the drug. The physician also must acknowledge that patients often take medications that were not prescribed specifically for them. These may include over-the-counter medications that the patient does not recall taking, does not understand the active ingredients, or even does not consider a “medication” or “drug.” Or they may be taking medications that they are reluctant to disclose or that were prescribed to another individual. Reluctance to disclose exposures may be especially true of drugs that carry negative social stigmas in …

Oral retinoids and pregnancy.

The oral retinoids isotretinoin and etretinate are uniquely effective in the treatment of severe cystic acne and keratinisation disorders. Because of their known teratogenicity, there are strict prescription guidelines, but exposure during pregnancy still occurs. A dedicated effort by women and their clinicians is required, involving patient selection, education and informed consent, detailed contraceptive counselling, and careful monitoring and management, including pregnancy testing before commencement of therapy.

Historical aspects of the oral use of retinoids in acne.

A number of investigations of the effects of vitamin A deficiency in animals and man and its treatment with natural products containing vitamin A were carried out in the twenties and thirties. In 1942, a clinical study in patients with acne treated with vitamin A yielded encouraging results. Further trials in the forties and fifties, trying to confirm the beneficial effect of oral vitamin A in acne, met with equivocal success. In the sixties, all-trans retinoic acid (tretinoin) became clinically available, and its topical efficacy in acne could be demonstrated. In 1971, oral tretinoin also was shown to be active in patients with acne. Coincidentally, the efficacy of oral 13-cis retinoic acid (isotretinoin) became evident in a series of unpublished studies in Europe. Then, in 1978, a trial carried out at the NIH, Bethesda, Maryland, yielded convincing evidence that isotretinoin is a potent new drug for the treatment of severe cystic acne. In 1982, isotretinoin was registered in the United States and one year later in Europe for the treatment of severe, recalcitrant, cystic acne. Since then, many thousands of patients suffering psychologically and physically from the severity of their disease have been treated successfully with this drug. However, the main concern of physicians prescribing isotretinoin has to focus on its potentially severe side effects, particularly its teratogenicity.

Retinoid Therapy for Severe Dermatological Disorders

This Policy Statement was retired January 2006. Isotretinoin is approved for the treatment of severe recalcitrant cystic acne, and etretinate is approved for the treatment of severe recalcitrant psoriasis. Women of childbearing age place their infants at risk should these compounds be used during pregnancy and, in the case of etretinate, even before pregnancy. The purpose of this statement is to describe the indications for the use of these drugs and to advise physicians of their common side effects and their teratogenic potential. Isotretinoin, 13-cis-retinoic acid (Accutane, Hoffmann-LaRoche), is a vitamin A derivative that is effective in the treatment of severe cystic acne. This type of acne, affecting adolescents and young adults, is severe, nodular, cystic, and conglobate—a scarring disease that resists treatment with topical or systemic antibiotics, benzoyl peroxide, all-trans-retinoic acid, and intralesional corticosteroids. Adolescents with less severe forms of acne who learn about the therapeutic triumphs of isotretinoin in severe recalcitrant nodular and cystic acne may assume that the drug also would be beneficial for them. Physicians should explain to these adolescents why isotretinoin is not indicated in the treatment of typical acne. Another retinoid, etretinate (Tegison, Hoffmann-La Roche), is now available for the treatment of severe psoriasis that is unresponsive to standard therapies (topical tar with UVB light, anthralin, UVA light and psoralens, systemic corticosteroids and methotrexate). Etretinate is used for severe psoriasis of both the erythrodermic and generalized pustular types. Individualization of etretinate dosage is important. Most patients are started at a dosage of 0.75 to 1.0 mg/kg of body weight per day in divided doses.

When a Uniquely Effective Drug is Teratogenic

Isotretinoin is a uniquely effective oral agent for the treatment of severe cystic acne.1 Typically a patient uses the medicine for 20 weeks, and in most cases enters a prolonged remission. First m...

Isotretinoin in lacrimal gland fluid and tears.

Isotretinoin (13-cis-retinoic acid) is used in the treatment of severe cystic acne. Adverse ocular reactions, including blepharoconjunctivitis and dry eye symptoms, are frequent side effects of this drug. Our previous observation that retinol is present in tears and lacrimal gland fluid suggests that isotretinoin may also be secreted by the lacrimal gland. Rabbits were treated with isotretinoin, and lacrimal gland fluid was collected from the cannulated lacrimal gland duct. Tears were collected from patients who were being treated with isotretinoin. Lacrimal gland fluid and tears were analyzed by reverse-phase high-pressure liquid chromatography and a peak eluted from each sample, which was identified as isotretinoin. We conclude that the lacrimal gland is able to secrete isotretinoin in addition to retinol and that, in animals and patients treated systemically with isotretinoin, the ocular surface is exposed to the drug via the tear film.

Adverse Ocular Reactions Possibly Associated With Isotretinoin

A total of 261 adverse ocular reactions occurred in 237 patients who received isotretinoin, a commonly used drug in the treatment of severe cystic acne. Blepharoconjunctivitis, subjective complaints of dry eyes, blurred vision, contact lens intolerance, and photodermatitis are reversible side effects. More serious ocular adverse reactions include papilledema, pseudotumor cerebri, and white or gray subepithelial corneal opacities; all of these are reversible if the drug is discontinued. Reported cases of decreased dark adaptation are under investigation. Isotretinoin is contraindicated in pregnancy because of the many reported congenital abnormalities after maternal use (including microphthalmos, orbital hypertelorism, and optic nerve hypoplasia).

Isotretinoin: a reappraisal.

Isotretinoin is remarkably effective in the treatment of severe cystic acne, however, many complications have been observed during treatment and new toxic effects have been reported. Hypertriglyceridemia associated with decreases in high density lipoprotein (HDL) cholesterol has occurred in 25 percent of patients and requires monitoring during treatment. Painful erosions with granulation tissue recently have been reported in patients with severe acne. Other complications have included corneal opacities, pseudotumor cerebri, hypercalcemia, photosensitivity reactions, abnormal liver function tests, and skeletal hyperostosis. Isotretinoin is teratogenic and should be avoided during pregnancy. With the increasing acceptance and use of isotretinoin for cystic acne, as well as related disorders (inflammatory papulopustular acne with scarring, gram-negative folliculitis, and acne rosacea), a reevaluation of isotretinoin aimed at reducing complications is in order. Patient selection criteria and guidelines directed at reducing these complications are presented.

Inflammatory Neovascular Nodules Associated With Oral Isotretinoin Treatment of Severe Acne

Isotretinoin is extremely effective in the treatment of severe cystic acne.^1,2We have recently noted the occurrence of inflammatory neovascular nodules See also p 808. (INNs), or exuberant nodular granulation tissue, in two of 12 patients with severe acne who were treated with oral isotretinoin. <h3>Report of Cases</h3><h3>Case 1.—</h3> A 17-year-old boy with severe acne was entered into the Hoffmann-La Roche Isotretinoin Study. His acne had progressed while he was receiving conventional topical, intralesional, and oral therapy all of which were discontinued several weeks prior to entry into the study. Physical examination of the patient revealed numerous, crusted, draining, inflammatory nodulocystic lesions associated with sinus tracts, pustules, comedones, and mild scarring involving the face, neck, upper aspect of the trunk, and proximal, upper part of the arms. According to the study protocol, the patient began receiving a moderately low dose (1 mg/kg/day) of oral isotretinoin, which was increased

The treatment of severe cystic acne with 13- cis-retinoic acid : Evaluation of sebum production and the clinical response in a multiple-dose trial

Fourteen patients with severe, treatment-resistant, nodulocystic acne have been treated with 13-cis-retinoic acid in a double-blind study. The patients were treated with either 0.1, 0.5, or 1.0 mg/kg/day of 13-cis-retinoic acid for 12 weeks. A marked dose-related decrease in sebum production, which was usually evident within 2 weeks of the onset of therapy, was observed in all patients. At a dose of 1.0 mg/kg/day of 13-cis-retinoic acid, sebum production was decreased to about 10% of the pretreatment value. Clinical improvement, as judged by counting the nodulocystic lesions and measuring their greatest diameters, was noted in all three groups. The most common clinical side effects were cheilitis, desquamation of the skin, and pruritus, but the side effects were not severe enough to require interruption of treatment. Laboratory abnormalities during therapy were minimal and also did not necessitate the cessation of therapy.