Isotretinoin versus placebo in the treatment of cystic acne. A randomized double-blind study

A practical approach for the use of oral isotretinoin for infantile acne

Infantile acne is a rare occurrence. It is more common in boys and predominately occurs on the cheeks in infants between the ages of 1 and 16 months. Clinically, the lesions range from comedones to inflammatory papulopustules to cysts. Successful therapies include topical tretinoin, benzoyl peroxide and topical and oral erythromycin. For more serious cases, oral isotretinoin (Accutane) has been reported to successfully treat recalcitrant infantile cystic acne. We describe two additional patients with infantile cystic acne treated successfully with oral isotretinoin. The dose of isotretinoin used ranged from 0.2 mg/kg/day to 1.5 mg/kg/day. The treatment duration varied from 5 to 14 months. Careful monthly monitoring is recommended because of the many side effects reported with isotretinoin. Practical tips for the administration of oral isotretinoin in infants are reviewed.

Effects of tazarotene 0.1 % cream in the treatment of facial acnevulgaris: Pooled results from two multicenter, double-blind, randomized, vehicle-controlled, parallel-group trials

BACKGROUND

Topical retinoids are one of the most effective classes of topical drugs used to treat acne vulgaris. The effects of the gel formulation of the topical retinoid tazarotene have been widely reported, but few data on the cream formulation are available.

OBJECTIVE

The primary aim of the 2 studies reported in this article was to determine the effects of tazarotene 0.1 % cream in patients with facial acne vulgaris.

METHODS

Two randomized, double-blind, parallel-group studies were performed. The first was conducted at 14 investigational sites across the United States, and the second took place at 15 sites, with 5 of these providing blood samples for analysis of tazarotenic acid. In both studies, patients aged > or =12 years with facial acne vulgaris were randomized to receive tazarotene or vehicle cream QD for 12 weeks. Lesion counts (noninflammatory, inflammatory, and total) and overall clinical and global assessments were made at weeks 0 (baseline), 4, 8, and 12. Adverse events (AEs) were monitored throughout the study In one of the studies, therapeutic drug monitoring was performed at weeks 4 and 8 in members of the study population who gave consent for blood withdrawal.

RESULTS

Eight hundred forty-seven patients were enrolled in the 2 studies (430 males, 417 females; mean age,19 years; age range, 11-52 years [1 patient was entered into the study at age 11 years, in violation of the protocol]). At 12 weeks, the median percentage changes from baseline in all 3 lesion counts were significantly lower with tazarotene than with vehicle (all, P < 0.001), as were the overall clinical and global responses (both, P < 0.001). Treatment-related AEs whose incidence was higher with tazarotene than with vehicle included desquamation, dry skin, erythema, a burning sensation on the skin, and skin irritation (all, P < 0.001) and pruritus (P < 0.01); most (83%-98%) were mild or moderate. Systemic exposure to tazarotenic acid was limited (mean, <0.1 ng/mL) and did not increase with time.

CONCLUSIONS

In these 2 studies in adolescent and adult patients with facial acne vulgaris, tazarotene 0.1%cream QD for 12 weeks was effective and well tolerated. Systemic exposure to tazarotenic acid was limited.

Oral retinoid therapy for dermatologic conditions in children and adolescents

The efficacy of systemic retinoid therapy in a number of dermatologic diseases is well established; however, concerns about potential side effects limit their use, especially in children. We review the efficacy and toxicity of oral retinoids in the pediatric population. The acute mucocutaneous toxicities commonly observed are typically well tolerated, readily treatable, and reversible. Systemic toxicities include teratogenicity and effects on the musculoskeletal, neurologic, and gastrointestinal systems. Children, like adults, generally tolerate short-term retinoid therapy without major complications. Concerns regarding serious systemic side effects are greater for those on high doses of oral synthetic retinoids for longer periods of time. Close patient monitoring and patient education can minimize the occurrence of complications. (J Am Acad Dermatol 2003;49:171-82.)Learning objective At the conclusion of this learning activity, participants should be familiar with use of oral retinoids for childhood dermatologic conditions such as psoriasis, acne, and ichthyoses as well as safety and risks associated with oral retinoid use in children and adolescents.

Acne: comparing hormonal approaches to antibiotics and isotretinoin

Acne is a common and disfiguring disease affecting a significant proportion of the general population. In milder cases topical therapy is sufficient. However, in more severe cases where papulopustular or nodulocystic acne is present, there is a need of systemic treatment. The latter include antibiotics, anti-androgens and retinoids. A systematic review of the literature was performed of systemic monotherapy using these drugs. Because of the significant methodological variability of the studies examined, it was not possible to make a meta-analysis. Instead the overall effects were assessed by calculating mean weighted effects across different reported effect variables. Isotretinoin scored 85 +/- 10% improvement compared with the baseline, whereas tetracyclines and cyproterone acetate plus ethinyloestradiol were less effective (54 +/- 3% versus 65 +/- 4% improvement compared with baseline, respectively). Moreover, studies suggested that isotretinoin reduces the risk of acne relapse in the few studies that included a follow-up period. A number of restrictions limit the general use of these drugs as monotherapy, e.g., potential teratogenicity. There is a continued need for effective drugs for the therapy of acne, although judicious combined use of existing topical and systemic therapies offers great relief to many patients. In addition, methodological problems in previous studies prevent adequate synthesis of existing knowledge within the framework of evidence-based medicine. There is therefore a demand for future standardisation of further acne studies to enable direct comparison of different treatment efficacies.

Retinoic acid reduces autoimmune renal injury and increases survival in NZB/W F1 mice

Retinoic acids, a group of natural and synthetic vitamin A derivatives, have potent antiproliferative and anti-inflammatory properties. Recently, retinoic acids were reported to inhibit Th1 cytokine production. We investigated the effects of retinoic acid on lupus nephritis in a model of NZB/NZW F(1) (NZB/W F(1)) mice. Three-month-old NZB/W F(1) mice were separated into two groups: one treated with all-trans-retinoic acid (ATRA; 0.5 mg i.p., three times weekly for 7 mo) and one with saline as a control. Compared with controls, ATRA-treated mice survived longer and exhibited a significant reduction of proteinuria, renal pathological findings including glomerular IgG deposits, and serum anti-DNA Abs. Splenomegaly was less marked in the treated mice than in controls. Transcripts encoding IFN-gamma, IL-2, and IL-10 in splenic CD4(+) T cells were significantly reduced in treated mice compared with controls. We conclude that treatment with ATRA in SLE-prone NZB/W F(1) mice significantly alleviates autoimmune renal disorder and prolongs survival; this may thus represent a novel approach to the treatment of patients with lupus nephritis.

Effects of all-trans-retinoic acid (atRA) on inducible nitric oxide synthase (iNOS) activity and transforming growth factor beta-1 production in experimental anti-GBM antibody-mediated glomerulonephritis

Sustained high output release of Nitric oxide (NO) as result of activation of inducible nitric oxide synthase (iNOS), and increased production of the antiproliferative/profibrotic cytokine transforming growth factor-beta1 (TGF-beta1) are well documented in glomerulonephritis. Modulation of iNOS activity and of TGF-beta1 production can therefore be viewed as anti-inflammatory strategies. The present study employed all-trans retinoic acid (atRA) which is known to have anti-inflammatory effects and to modulate expression of iNOS and TGF-beta1, in order to explore its effect on iNOS enzyme activity and TGF-beta1 production in anti-GBM antibody induced glomerulonephritis. Glomerulonephritis was induced in Lewis rats by injection of anti-GBM antibody. A group of nephritic rats were given daily administration of atRA for 14-16 days. Extent of proteinuria was assessed by measuring urine protein and creatinine excretion. iNOS enzyme activity was measured by calculating conversion of L[14C]arginine to L-[14C]citrulline in glomerular protein lysates. Levels of TGF-beta1 in glomerular protein lysates were measured by quantitative ELISA. Levels of proliferating nuclear antigen (PCNA), TGF-beta receptor II (TGFbeta-RII), and fibronectin were assessed by Western blot analysis. Glomerular iNOS activity in atRA treated nephritic animals was attenuated in comparison to that in nephritic controls that were not. Glomerular expression of PCNA was also reduced. Levels of TGF-beta1 were increased in glomeruli of atRA treated nephritic animals. In these animals, there was no change in glomerular levels of TGF-beta receptor II (TGFbeta-RII) or fibronectin. and there was no reduction in urine protein excretion. These results suggest that atRA attenuates iNOS activity and proliferation in glomeruli of nephritic animals. The failure of atRA treatment to reduce proteinuria could be due to the increase in TGF-beta1 levels and to inhibition of iNOS-driven NO production.

A randomized trial of the efficacy of a new micronized formulation versus a standard formulation of isotretinoin in patients with severe recalcitrant nodular acne

BACKGROUND

Isotretinoin is very frequently the drug of choice for the management of severe recalcitrant nodular acne. Recently, a new micronized and more bioavailable formulation of isotretinoin has been developed that permits once-daily administration in lower doses than usually used with standard isotretinoin (Accutane), regardless of whether it is taken with or without food.

OBJECTIVE

Our purpose was to determine whether micronized isotretinoin and standard isotretinoin are clinically equivalent.

METHODS

In this multicenter, double-blind, double-dummy study, 600 patients with severe recalcitrant nodular acne were treated with either 0.4 mg/kg of micronized isotretinoin once daily without food (n = 300) or 1.0 mg/kg per day of standard isotretinoin in two divided doses with food (n = 300). Lesion counts were monitored over 20 weeks.

RESULTS

Both treatment groups in this well-controlled clinical trial experienced an equivalent reduction in the number of total nodules (facial plus truncal). In addition, an equivalent proportion of patients achieved 90% clearance of the total number of nodules. Both formulations had similar results for other efficacy variables.

CONCLUSION

Once-daily use of the micronized and more bioavailable formulation of isotretinoin under fasted conditions is clinically equivalent to the standard twice-daily formulation under fed conditions in the treatment of severe recalcitrant nodular acne.

New oral chemotherapeutic agents for lung cancer

Anticancer treatment has recently shifted to include a broad range of antineoplastic therapies. Old agents are continuously being re-evaluated, and new mechanisms of treatment are rapidly being explored and developed. At the same time, the patient's perceived quality of life, adverse effects of therapy, time demands, and healthcare costs have become paramount in the treatment process. Lung cancer is the most common cause of cancer death in the USA, and because many of the patients are older or debilitated, these issues become all the more important. The oral administration of anticancer therapy offers both quality-of-life and healthcare cost advantages. Oral forms of 3 new cytotoxic agents and 2 novel oral therapies are discussed. Vinorelbine, a vinca alkaloid, has well documented activity in non-small cell lung cancer. Myelosuppression is dose limiting; neurotoxicity is rare. Satraplatin (JM-216), an oral platinum derivative, shows activity in lung cancer with a favourable adverse effect profile, with no neurotoxicity or nephrotoxicity. The oral topoisomerase I inhibitor topotecan may be ideal for obtaining long term low plasma drug concentrations, which appears to maximise efficacy. LGD-1069 is a retinoid X receptor agonist that modulates cell proliferation, and BAY-129566, a matrix metalloproteinase inhibitor, appears to interrupt both the processes of angiogenesis and metastasis. LGD-1069 and BAY-129566 are nontraditional anticancer agents which may be used in conjunction with chemotherapy, other modalities, or in prevention. These 5 agents will be discussed with particular reference to recent developments in the treatment of lung cancer.

Distribution, teratogenicity, and embryonic delivered dose of retinoid Ro 23-9223

Ro 23-9223 is a highly lipophilic aromatic retinoid with antiproliferative and sebum supressive effects in preclinical disease models of acne. To investigate the relation between Ro 23-9223 developmental toxicity, drug distribution, and transplacental transfer, groups of pregnant hamsters were given oral doses of 50-500 mg/kg Ro 23-9223 on days 8 and 9 of gestation. The teratogenic phenotype induced at doses greater than 125 mg/kg per day was similar to that found after exposure to doses of 13-cis-retinoic acid (isotretinoin, Accutane) greater than 37.5 mg/kg per day. Oral bioavailability of Ro 23-9223 was very low compared to 13-cis-retinoic acid. The highest concentrations of Ro 23-9223 were found in maternal liver, lung, adipose tissue, cardiac muscle, and placenta, whereas only little of the compound crossed the blood-brain barrier. Based on embryo AUC, Ro 23-9223 had a 30- to 50-fold greater embryo:maternal concentration ratio than 13-cis-retinoic acid plus its bioactive metabolites following similar doses of the two retinoids. In preclinical pharmacology studies, oral doses of Ro 23-9223 (5 mg/kg per day) and 13-cis-retinoic acid (10 mg/kg per day) produced comparable gland size reductions in the hamster ear sebaceous gland reduction assay. Under these conditions, Ro 23-9223 plasma AUC was 40 times smaller than that of 13-cis-retinoic acid plus its bioactive metabolites. Assuming that the near linear dose-exposure relationship of Ro 23-9223 extends beyond the dose range of this study, embryo AUCs of Ro 23-9223 and 13-cis-retinoic acid (plus metabolites) would be near identical following pharmacologically equivalent doses. A comparison of embryo retinoid AUCs suggests a 4-fold lower teratogenic potency of Ro 23-9223 compared to with 13-cis-retinoic acid. Despite high embryo levels in hamsters, the data suggest an improved therapeutic index for Ro 23-9223 compared with 13-cis-retinoic acid in a preclinical acne disease model.

Retinoic acids inhibit inducible nitric oxide synthase expression in mesangial cells

BACKGROUND

Nitric oxide (NO) release as a result of cytokine-mediated activation of inducible nitric oxide synthase (iNOS) in mesangial cells can be sustained and lead to oxidative injury in various forms of glomerular inflammation. Inhibition of iNOS expression and/or activity could therefore be an effective anti-inflammatory strategy. The present study was undertaken to explore whether retinoids, which are known to have anti-inflammatory and immuno-modulatory actions, can attenuate cytokine-stimulated iNOS expression and enzyme activity in murine mesangial cells.

METHODS

Expression of iNOS was evaluated by NO production (nitrite analysis), protein (Western blot analysis) and mRNA (RT-PCR analysis) levels in mesangial cells stimulated by a combination of lipopolysaccharide (LPS) and interferon-gamma (IFN-gamma) in the presence and absence of all-trans-retinoic acid (ATRA) or its active metabolite, 13-cis-retinoic acid (13-cis-RA). Changes in iNOS enzyme activity were assessed by calculating conversion of L-[14C]arginine to L-[14C]citrulline. The levels of transcription factors nuclear factor-kappaB (NF-kappaB) and activated protein-1 (AP-1) in nuclear extracts prepared from mesangial cells stimulated by a combination of LPS and IFN-gamma in the presence and absence of ATRA was assessed by immunoblot analysis. The effect of both retinoids on transforming growth factor-beta1 (TGF-beta1) levels was also assessed by a quantitative enzyme immunoassay method.

RESULTS

The combination of LPS/IFN-gamma stimulated NO production, induced iNOS expression (mRNA and protein) and increased iNOS enzyme activity. ATRA and 13-cis-RA dose-dependently attenuated NO production. This effect was most pronounced at ATRA concentration of 10 microM. At this concentration, ATRA attenuated iNOS expression (mRNA and protein levels) and enzyme activity. ATRA also reduced nuclear levels of both subunits (p50 and p65) of NF-kappaB. TGF-beta1 levels in mesangial cells stimulated with LPS/IFN-gamma in presence of ATRA or 13-cis-RA were also reduced indicating that TGF-beta1 did not mediate the suppressive effect of retinoids on iNOS.

CONCLUSIONS

Our studies demonstrate that the retinoids ATRA and 13-cis-RA attenuate iNOS expression and activity in cytokine-stimulated murine mesangial cells. These retinoids may emerge as naturally occurring compounds for treatment of inflammatory glomerular diseases.

13-cis-retinoic acid in silicone-fluorosilicone copolymer oil in a rabbit model of proliferative vitreoretinopathy

The purpose of this study was to evaluate the effect of 13-cis-Retinoic Acid (RA) in Silicone-Fluorosilicone Copolymer Oil (SiFO) in a rabbit model of proliferative vitreoretinopathy (PVR). Rabbits underwent gas-compression vitrectomy. During gas-SiFO exchange, group 1 was injected with 1 ml (10 microg ml-1) 13-cis-RA in SiFO, group 2 with 1.5 ml (9 microg 1.5 ml-1) all-trans-RA in SiFO, group 3 with 1 ml SiFO alone, and group 4 with balanced salt solution (BSS). Groups 1-4 were also injected with 0.1 ml suspension of fibroblasts (75,000 0.1 ml-1) and 0.05 ml platelet rich plasma (70,000 0.1 ml-1), and were observed for 4 weeks. Group 5 was injected with SiFO alone, group 6 with 1 ml (10 microg ml-1) 13-cis-RA in SiFO, group 7 with 1.5 ml (9 microg 1.5 ml-1) all-trans-RA in SiFO, and group 8 with BSS. After 4 weeks, groups 5-7 underwent SiFO-BSS exchange. ERG and histopathology were performed to test for retinal toxicity in groups 5-8. The incidence of traction retinal detachment at 4 weeks was: group 1, 42.9%; group 2, 36.4%; group 3, 87.5%; and group 4, 88.9%. A significant difference in the incidence of PVR was noted between treated eyes (groups 1 and 2) and control eyes (groups 3 and 4) at 2, 3, and 4 weeks (P<0.05). No significant difference in the incidence of PVR was found between groups 1 and 2 during the same observation periods. ERG and histopathological studies showed no differences between the treated and the control fellow eyes (group 5-7) after 4 weeks. 13-cis-RA in SiFO (10 microg ml-1) is as effective as all-trans-RA in SiFO (9 microg 1.5 ml-1) in controlling the incidence of PVR when used for short term retinal tamponade and does not appear to be associated with retinal toxicity.

Isotretinoin for acne vulgaris

BACKGROUND

The clinical efficacy of oral isotretinoin in the treatment of severe acne is now well established and so are the clinical and laboratory adverse effects of the drug. Isotretinoin was first introduced in Saudi Arabia late in 1987. In this 7-year retrospective study, efficacy and side effects of isotretiunoin are reviewed in Saudi patients with acne vulgaris seen in a university skin clinic in Riyadh, Saudi Arabia.

MATERIALS AND METHODS

A total of 262 patients had been treated with isotretinoin. Their case records were studied with reference to demographic data, clinical findings, dosage of isotretinoin, response to the drug, and the prevalence and severity of clinical and laboratory adverse effects.

RESULTS

Only 156 case records (69.9% women) could be evaluated. Most patients received 0.60 to 0.75 mg of isotretinoin per kg per day for a period ranging from 16 to 35 weeks (mean +/- SD: 21.2 +/- 3.3 weeks); a total cumulative dose of 75 to 146 mg per kg (mean +/- SD: 104 +/- 10.6 mg per kg). Approximately 56% of the patients had therapy-resistant moderate acne and only 14% had nodulocystic acne. Of the patients, 90.4% had an excellent response and 3.8% were poor responders. Adverse effects occurred in 99% of the patients, but in no case did they lead to discontinuation of the drug. Except for minor differences in prevalence, the clinical side effects were similar to those reported in the literature. Elevation of plasma triglyceride levels was the most significant laboratory adverse effect.

CONCLUSIONS

This is the first report on the experience with isotretinoin in the treatment of acne in the Middle East. Moderate doses of isotretinoin are well tolerated and produce excellent results in Saudi patients with acne.

A double-blind evaluation of topical isotretinoin 0.05%, benzoyl peroxide gel 5% and placebo in patients with acne

A double-blind, randomized study comparing isotretinoin gel (Isotrex), its vehicle base, and benzoyl peroxide was performed on 77 patients with mild to moderate acne vulgaris. The effect of treatment was assessed by acne grade and lesion count. The vehicle base had no effect, but both active groups produced significant improvements. Benzoyl peroxide and isotretinoin significantly reduced non-inflamed lesions at 4 (P < 0.05), 8 (P < 0.01), 12 (P < 0.01) weeks. Benzoyl peroxide had a more rapid effect on inflamed lesions, their being significant reductions at 4, 8 and 12 weeks (P < 0.01), whereas with isotretinoin there was a significant improvement at 12 weeks (P < 0.01). In addition, compared to placebo, both active treatments significantly reduced inflamed and non-inflamed lesions. Acne grade had improved significantly in the benzoyl peroxide group by 4 weeks (P < 0.01) and in the isotretinoin group by 8 weeks (P < 0.05). No significant change in haematological or biochemical parameters occurred. An irritant dermatitis occurred equally with both treatments but was well tolerated by the patients. This data confirms the clinical benefit of benzoyl peroxide in acne. The initial effect of isotretinoin on non-inflamed lesions in this study suggests that the prime mode of action is on comedone formation or separation whereas benzoyl peroxide has an effect on both comedones and inflammation.

Facial pyogenic granuloma-like lesions under isotretinoin therapy

A male patient with severe cystic acne was treated with 13-cis-retinoic acid in a dosage of 1 mg/kg/day. Early flare-up of his acne and multiple pyogenic-like lesions on his face appeared during the second week of isotretinoin treatment. Histologic study of the lesions revealed granulation tissue. Possible etiologies for this phenomenon are discussed.

Human biliary metabolites of isotretinoin: identification, quantification, synthesis, and biological activity

1. The metabolites of isotretinoin (13-cis-retinoic acid, Accutane) were investigated in the bile of two patients with biliary T-tube drainage after administration of a single, oral, 80-mg dose of 14C-isotretinoin. Radioactivity measurements showed that the two patients excreted 22.7 and 17.1% of the dose in their bile in 4 days. 2. The two major drug-related components in the bile were identified as the glucuronide conjugates of 4-oxo-isotretinoin and 16-hydroxy-isotretinoin. Two minor components were identified as the glucuronide conjugates of isotretinoin and 18-hydroxy-isotretinoin. 3. H.p.l.c. analyses of Glusulase-treated bile samples indicated that the glucuronides of isotretinoin and the two major metabolites accounted for about 48% and 44% of the total radioactivity in the bile of the two patients. 4. Racemic 16-hydroxy-isotretinoin was synthesized and evaluated for its effect on human sebocytes in vitro. This metabolite and the other major metabolites of isotretinoin were less active than isotretinoin in inhibiting the proliferation of the sebocytes.

Isotretinoin therapy for acne vulgaris: results in an Irish population

The results of treatment of cystic and antibiotic-resistant acne vulgaris in 96 consecutive patients with the oral retinoid isotretinoin (13-cis-retinoic acid; Roacentane) are reported retrospectively. The results show that the drug, while toxic in the short term, is highly effective in clearing acne.

Comparison of the stability of topical isotretinoin and topical tretinoin and their efficacy in acne

After 4 hours of exposure to incandescent light, 80% of 0.05% topical isotretinoin and 60% of 0.05% topical tretinoin preparations remained in their original form. In contrast, after 2 hours of exposure to fluorescent light only 25% of topical tretinoin and possibly 60% of topical isotretinoin remained in their original forms. Longer exposure to fluorescent light did not result in further breakdown, and the final breakdown of both preparations was similar. A 12-week, double-blind clinical trial comparing isotretinoin (0.05%) with tretinoin (0.05%) applied topically to patients with moderate acne was carried out. Both preparations caused significant reductions in papules and pustules. However, neither treatment was significantly superior to the other in the reduction of acne lesions. This may be because both preparations are rapidly broken down to similar products when exposed to fluorescent light.

Sebum-suppressing activity of the nonpolar arotinoid Ro 15-0778 in rodents

Retinoids are known to modulate sebaceous gland activity in humans and animals. The nonpolar arotinoid Ro 15-0778 [(E)-1,2,3,4-tetrahydro-1,1,4,4-tetramethyl-6-(1-methyl-2-phenylethen yl) naphthalene] does not contain a polar end group and is devoid of the classical retinoid side effects of hypervitaminosis A. The favorable toxicological profile stimulated the evaluation of this arotinoid in animal models of sebum production. In castrated, testosterone-stimulated male rats, Ro 15-0778 is 50 times more potent than 13-cis-retinoic acid in inhibiting the production and subsequent secretion of sebum. The oral ED50 value of Ro 15-0778 is 30 micrograms/kg, while an oral dose of 0.5 mg/kg inhibited sebum secretion nearly 100%. In testosterone-stimulated female rats, Ro 15-0778 inhibits sebum secretion significantly with an oral ED50 of 140 micrograms/kg and an s.c. ED50 of 75 micrograms/kg. Ro 15-0778 was also evaluated for its ability to prevent testosterone induction of the immature hamster flank organ. The topical ED50 is 0.53 mg/kg and the oral ED50 is 38 mg/kg. This arotinoid is similarly active in mature male hamsters without testosterone treatment. In addition, the retinoid is active topically and orally in reducing the size of the gerbil abdominal sebaceous gland. The compound exhibits no antiandrogenic activity when tested in ventral prostrate and seminal vesicle assays in rats. Additionally, the compound does not have estrogenic activity when tested in the rat uterine weight assay. High doses of Ro 15-0778 in humans did not demonstrate significant sebum-suppressing activity.(ABSTRACT TRUNCATED AT 250 WORDS)

Reduced anxiety and depression in cystic acne patients after successful treatment with oral isotretinoin

We evaluated the psychiatric morbidity and mood characteristics of a group (n = 72) of patients with cystic acne before and after treatment with one of three dosage schedules of isotretinoin. Although no excess psychiatric morbidity was observed, substantial evidence of psychologic distress was noted before treatment. Significant reductions in anxiety were observed on several measures of anxiety after treatment, with mitigation of anxiety and depression most robust in those patients with the greatest dermatologic improvement with isotretinoin.

Solid facial edema as a complication of acne vulgaris: treatment with isotretinoin

A case of persistent solid facial edema is described in a 17-year-old boy with moderate papulocystic acne. After a 20-week course of isotretinoin, the acne vulgaris resolved, and there was a moderate reduction in the facial edema.

Organisms associated with gram-negative folliculitis: in vitro growth in the presence of isotretinoin

Isotretinoin has been found to be effective in the treatment of Gram-negative folliculitis. We investigated the direct in vitro antibacterial activity of isotretinoin against Gram-negative species. The concentrations of isotretinoin tested were two and ten times greater than the maximal levels attained in the sera of patients receiving oral isotretinoin. Regardless of the inoculum size, each organism tested grew as well in isotretinoin-containing media as it did in the control medium. These findings suggest that the efficacy of isotretinoin in patients with Gram-negative folliculitis is due to mechanisms other than direct antimicrobial action.

In vitro effect of isotretinoin on monocyte chemotaxis

The effect of isotretinoin on the chemotaxis of human monocytes was studied in an in vitro system using a Nucleopore chamber. The chemoattractant used was zymosan-activated serum. Inhibition of monocyte chemotaxis was achieved with isotretinoin in concentrations of 1 X 10(-3) M and 5 X 10(-4) M. It is felt that the improvement seen in patients with inflammatory skin diseases such as cystic acne and acne conglobata who are treated with isotretinoin may in part be a result of this anti-inflammatory action.

Changes in plasma lipids and lipoproteins during isotretinoin therapy for acne

Abnormalities in plasma lipids are a recognized side effect of isotretinoin therapy for nodulocystic acne. We studied 60 patients during 20 weeks of isotretinoin therapy, to measure changes in plasma lipids and lipoproteins, to compare plasma lipid responses in men and women, and to determine whether there are alterations in levels of lipoprotein lipase or hepatic triglyceride lipase that could explain the development of isotretinoin-induced hypertriglyceridemia. Mean triglyceride levels rose in men and women, with maximum mean increases of 46.3 mg per deciliter (P less than 0.0001) and 52.3 mg per deciliter (P less than 0.002), respectively. The maximum level was reached by 4 weeks of therapy in men but not until the 12th week in women. Nine of 53 patients (17 per cent) completing 20 weeks of isotretinoin therapy acquired hypertriglyceridemia, with values of 200 to 600 mg per deciliter. Both men and women had significant increases in mean plasma levels of cholesterol and low-density-lipoprotein cholesterol and decreases in mean levels of high-density-lipoprotein cholesterol. There were no significant changes in mean levels of lipoprotein lipase or hepatic triglyceride lipase. Plasma lipid and lipoprotein levels returned to base line by eight weeks after discontinuation of the drug. If sustained over a long period, the change in the ratio of low-density-lipoprotein cholesterol to high-density-lipoprotein cholesterol that we observed, from 2.4 to 3.0 (P less than 0.0001), would predict an increased risk of cardiovascular disease.

Grover's disease treated with isotretinoin. Report of four cases

Grover's disease (transient acantholytic dermatosis; TAD), a disorder of unknown etiology, may resemble Darier's disease and frequently resists conventional therapies. The lesions can be extensive and pruritus can be a prominent feature. Four patients with Grover's disease were treated with isotretinoin. Three patients with relatively acute disease responded with remissions of up to 10 months after treatment. One patient with disease of 8 months' duration obtained partial relief but experienced a relapse when medication was stopped.

Isotretinoin and tetracycline in the management of severe nodulocystic acne

Thirty patients with treatment-resistant cystic and conglobulate acne entered a randomized double-blind protocol, testing the efficacy of isotretinoin versus tetracycline. After 16 weeks of isotretinoin treatment, the mean number of cysts decreased by 64% and the mean sum of the longest diameters was reduced by 68%. After 16 weeks of tetracycline therapy, the total number of cysts showed a mean decrease of 52%, and the mean sum of the longest diameters decreased by 60%. The reduction in the number of cysts and the sum of their longest diameters that occurred after 16 weeks of treatment was statistically significant for each of the treatment groups, but there was no statistically significant difference between the treatment groups at the end of therapy. Eight weeks after the discontinuation of treatment in the isotretinoin group, there was an overall reduction from baseline of 82% in the cyst count and 88% in the sum of the longest diameters. In the tetracycline treatment group, the overall reduction from baseline in the cyst count was 54% and in the sum of the longest diameters, 60%. This led to a statistically significant difference in the two treatment groups at 24 weeks. All patients on isotretinoin experienced side effects that were primarily related to the integumentary system but necessitated discontinuation of the drug for a short period of time in only one patient. Long-term follow-up, 8 months after discontinuation of the study, showed a prolonged significant remission of acne in the isotretinoin group but not in the tetracycline group.

Oral isotretinoin therapy for familial Muir-Torre syndrome

Two representative cases of familial Muir-Torre syndrome are presented. Multiple benign sebaceous neoplasms in both cases and a solitary keratoacanthoma in one were successfully treated with oral isotretinoin. Low-dose maintenance therapy has stabilized the cutaneous manifestations in the two patients, and no new epithelial neoplasms have appeared. This report emphasizes (1) the rationale for the use of isotretinoin in the Muir-Torre syndrome and (2) the potential for a familial pattern of inheritance and a possible association with the cancer family syndrome. It speculates on the prevention of future internal malignancies in Muir-Torre syndrome patients by maintenance oral isotretinoin treatment.

13-Cis-retinoic acid: pharmacology, toxicology, and clinical applications for the prevention and treatment of human cancer

Retinoids, particularly 13-cis-retinoic acid, have shown great promise against a number of benign, but serious dermatological conditions. In animal models, 13-cis-retinoic acid functions is a potent antipromoter whether a cancer has been initiated by chemical, physical, or viral agents. Additionally, substantial antiproliferative activity of this compound has been demonstrated in vitro in many culture systems. Clinical activity noted against several types of skin malignancies has led to several investigations to determine the anticancer activity of 13-cis-retinoic acid. Response of a variety of preneoplastic and neoplastic lesions of epithelial histology has been demonstrated. The toxicity of 13-cis-retinoic acid largely reflects its tissue distribution with skin and subcutaneous side-effects limiting dose escalation. The pharmacology and pharmacokinetics of 13-cis-retinoic acid has been explored in a number of patients and a long terminal half-life demonstrated. This review will discuss 13-cis-retinoic acid as a good model for a biological response modifier.

Effect of topical application of 13-cis retinoic acid on skin of hairless rats and hairless mice

The potential effectiveness of topical 13-cis retinoic acid (13-cis RA) as a sebosuppressive agent was evaluated in hairless ("fuzzy") rats and hairless mice. At nontoxic dosages (i.e., concentrations which induced no weight loss), topical 13-cis RA had no detectable sebosuppressive effects in either of these species. In hairless rats, the topical application of 0.2% 13-cis RA induced more severe symptoms of toxicity than was induced by the administration of equivalent amounts of the drug by either oral or subcutaneous routes. Due to variability in species sensitivity to 13-cis RA, the potential effectiveness of the topical use of this retinoid can probably only be evaluated in human volunteers.

Premature sebaceous gland hyperplasia: successful treatment with isotretinoin

Hyperplasia of sebaceous glands is a common cause of papulonodular facial lesions that occur in middle-aged and older patients. Recently, several cases of premature sebaceous gland hyperplasia have been reported. In these patients the lesions had persisted despite vigorous attempts at therapy. We present a case of premature sebaceous gland hyperplasia that was successfully treated with isotretinoin.

Topical and systemic effects of retinoids on horn-filled utriculus size in the rhino mouse. A model to quantify "antikeratinizing" effects of retinoids

A method was developed to quantify the "antikeratinizing" effects of various retinoids (all-trans-retinoic acid, 13-cis-retinoic acid, motretinide, etretinate) in rhino mouse skin, which contains many keratinized pilosebaceous structures or horn-filled utriculi. Mean utriculus diameters in whole mount epidermis were determined and dose-response relationships were constructed after topical or oral administration of test retinoids. All-trans-retinoic acid was 3.7x, 12.5x, and 50x more potent than 13-cis-retinoic acid, etretinate, and motretinide, respectively, after topical administration. Administered orally, all-trans-retinoic acid was 2.3x more potent than 13-cis-retinoic acid. At 5 mg/kg, each retinoid produced a significant reduction in utriculus size. The rhino mouse model represents a novel and useful assay to quantify antikeratinizing activity and potency differences of biologically active retinoids.

13-cis-retinoic acid in conglobate acne. A follow-up study of 14 trial centers

A follow-up was done on the patients of the German multicenter study with severe conglobate acne who had been treated with different dosages of 13-cis-retinoic acid. Eighty-seven patients were monitored from 12 to 21 months. Optimal long-term therapeutic effects were obtained with an initial dose of 1.0 mg/kg body weight, for 3 months, followed by another 3-month-treatment period with 0.2 mg/kg body weight. Six months after the termination of therapy 96% of the patients were still in remission and 81% after 12 months. Comparative figures for the administration of doses were 84% as opposed to 47% (0.5----0.2 mg/kg body wt.) and 74% as opposed to 37% (0.2----0.2 mg/kg body wt.), respectively. It is suggested from the present data that a high initial dosage of 13-cis-retinoic acid be chosen in order to obtain optimal long-term therapeutic effects. Transiently elevated lipid levels as well as other tolerable side effects return to normal within 3 months at the latest after discontinuation of treatment.

Isotretinoin therapy for acne: results of a multicenter dose-response study

One hundred fifty patients with treatment-resistant nodulocystic acne were entered into a double-blind clinical study. Three different dosing levels (0.1, 0.5, 1.0 mg/kg/day) were used in equal-sized groups. In addition to the clinical response, the clinical side effects, the laboratory abnormalities, and the duration of the induced remissions were evaluated with each dose of the drug. There was a highly significant clinical response to treatment with all three dosages of isotretinoin. There was no significant difference in the clinical response between dosages. However, 42% of the patients who received 0.1 mg/kg/day of isotretinoin required retreatment with the drug. This finding, coupled with only minor differences in the clinical side effects and the laboratory abnormalities, indicates that higher dose levels of isotretinoin are indicated for treatment of nodulocystic acne.

Cellular retinoic acid-binding proteins in human epidermis and sebaceous follicles

Evidence suggests that some of the effects of retinoids on sensitive target tissues are mediated by specific cellular binding proteins. This study demonstrated the presence of cellular retinoic acid-binding proteins (cRABP) in human skin. The approximate concentration and affinity of cRABP was determined independently in epidermal and sebaceous follicle cytosol, using both tritiated retinoic acid (RA) and tritiated 13-cis-retinoic acid (13-cis-RA) as radiolabeled ligands. Scatchard analysis suggested that on the basis of binding per mg of cytosol protein, the binding capacities by epidermal and sebaceous follicle cytosol were similar for RA and 13-cis-RA. However, the dissociation constants of binding of 13-cis-RA by sebaceous follicle cRABP was more than 9-fold the Kd for RA (1096 nM compared to 117 nM). The Kd for binding 13-cis-RA by epidermal cRABP was 31-fold the Kd for binding RA (3582 nM compared to 114 nM). Thus the affinity for 13-cis- RA by epidermal and sebaceous follicle cRABP is significantly less than for RA. It appears that the specificity of response of human sebaceous glands to 13-cis-RA is dependent on factors other than the concentration or affinity of cRABP in these structures.

How I Manage Acne in Athletes

In brief: Athletes aggravate acne by coming in contact with other competitors, rubbing against sports equipment and tight clothing, and sweating excessively. Another factor is the psychological stress involved in competition. However, these aggravations are part of sports, so it is impossible to avoid them. Athletes should wear clean, dry, loose-fitting, absorbent, cotton clothing and change wet clothing as soon as possible. They should work out with minimal clothing and equipment in a cool, well-ventilated environment whenever practical. Systemic and topical antimicrobial drugs are the most effective, dependable form of acne treatment, although some side effects exist. If these drugs do not control a patient's acne, he or she should be referred to a dermatologist.