Oral Isotretinoin

Clinical practice Guidelines for 5-Aminolevulinic acid photodynamic therapy for acne vulgaris in China

A variety of evidence suggest that 5-Aminolevulinic acid-based photodynamic therapy (ALA-PDT) is clinically effective in management of acne vulgaris. Several clinical guidelines for acne recommend PDT as an alternative treatment modality for severe acne. However, there is a lack of detailed clinical guideline for PDT in acne treatment. To propose up-to-date, evidence-based and practical recommendations on application of ALA-PDT for acne vulgaris, dermatologists and PDT experts from the Photodynamic Therapy Research Center of the CMA and Photodynamic Therapy Rehabilitation Training Center of CARD achieved consensus and guidelines based on careful evaluation of published literature, expert opinions and experience. ALA-PDT plays a therapeutic role in all four major pathogenesis of acne, and is suitable for moderate to severe acne and scar-prone acne, especially for patients who cannot tolerate or refused systemic antibiotics and isotretinoin. The efficacy and adverse reactions of ALA-PDT are closely related to therapeutic parameters including ALA concentration, incubation time, light source and dosage. Proper pretreatment helps to improve transdermal absorption of ALA and enhances its efficacy. We reviewed and proposed recommended protocols for four PDT procedures including conventional PDT (C-PDT), modified painless PDT (M-PDT), intense pulsed light PDT (IPL-PDT) and daylight PDT (DL-PDT). M-PDT with lower ALA concentration (3-5%), shorter incubation time (30 mins), and lower dose but prolonged illumination (630nm, 40-60 mW/cm², 150 J/cm²) can improve lesions of moderate to severe acne vulgaris effectively with minimal pain and easier manipulation, and thus was recommended by Chinese dermatologists. Lastly, management of adverse reactions were addressed.

The immunomodulatory potential of phage therapy to treat acne: a review on bacterial lysis and immunomodulation

Background

Characterized by an inflammatory pathogenesis, acne is the most common skin disorder worldwide. Altered sebum production, abnormal proliferation of keratinocytes, and microbiota dysbiosis represented by disbalance in Cutibacterium acnes population structure, have a synergic effect on inflammation of acne-compromised skin. Although the role of C. acnes as a single factor in acne development is still under debate, it is known that skin and skin-resident immune cells recognize this bacterium and produce inflammatory markers as a result. Control of the inflammatory response is frequently the target for acne treatment, using diverse chemical or physical agents including antibiotics. However, some of these treatments have side effects that compromise patient adherence and drug safety and in the case of antibiotics, it has been reported C. acnes resistance to these molecules. Phage therapy is an alternative to treat antibiotic-resistant bacterial strains and have been recently proposed as an immunomodulatory therapy. Here, we explore this perspective about phage therapy for acne, considering the potential immunomodulatory role of phages.

Methodology

Literature review was performed using four different databases (Europe PubMed Central-ePMC, Google Scholar, PubMed, and ScienceDirect). Articles were ordered and selected according to their year of publication, number of citations, and quartile of the publishing journal.

Results

The use of lytic bacteriophages to control bacterial infections has proven its promising results, and anti-inflammatory effects have been found for some bacteriophages and phage therapy. These effects can be related to bacterial elimination or direct interaction with immune cells that result in the regulation of pro-inflammatory cytokines. Studies on C. acnes bacteriophages have investigated their lytic activity, genomic structure, and stability on different matrices. However, studies exploring the potential of immunomodulation of these bacteriophages are still scarce.

Conclusions

C. acnes bacteriophages, as well as other phages, may have direct immunomodulatory effects that are yet to be fully elucidated. To our knowledge, to the date that this review was written, there are only two studies that investigate anti-inflammatory properties for C. acnes bacteriophages. In those studies, it has been evidenced reduction of pro-inflammatory response to C. acnes inoculation in mice after bacteriophage application. Nevertheless, these studies were conducted in mice, and the interaction with the immune response was not described. Phage therapy to treat acne can be a suitable therapeutic alternative to C. acnes control, which in turn can aid to restore the skin's balance of microbiota. By controlling C. acnes colonization, C. acnes bacteriophages can reduce inflammatory reactions triggered by this bacterium.

Isotretinoin‐induced inflammatory back pain and sacroiliitis in patients with moderate to severe acne vulgaris

INTRODUCTION

Isotretinoin has been reported to induce inflammatory back pain (IBP) and sacroiliitis in the patients with acne vulgaris. The aim of this study is to investigate the incidence of IBP and sacroiliitis in patients receiving isotretinoin treatment compared with oral antibiotics for acne vulgaris.

MATERIALS AND METHODS

A total of 201 patients with moderate-to-severe acne vulgaris who received isotretinoin (n = 100) or oral antibiotics (n = 101) were included in the study. All patients were monthly questioned for IBP symptoms during their treatment. Patients described IBP were also evaluated for sacroiliitis by c-reactive protein, sedimentation rate, HLAB27, and sacroiliac magnetic resonance imaging (MRI). Isotretinoin was discontinued in all patients diagnosed as sacroiliitis, and these patients were reevaluated after 3 months.

RESULTS

IBP was observed in 21 (10.4%), and sacroiliitis was detected in 11 (11%) patients on isotretinoin treatment; in oral antibiotic group, we did not observe IBP or sacroiliitis. The incidence of IBP and sacroiliitis differed significantly between the isotretinoin and oral antibiotic groups (p < 0.0001, p = 0.02). Complete regression was observed in the great majority of patients following cessation of isotretinoin.

CONCLUSIONS

Our study is the largest prospective controlled study that investigated the incidence of sacroiliitis in patients receiving isotretinoin and compared with patients using oral antibiotics.

Treatment challenges in adult female acne and future directions

Introduction: Acne is a chronic, inflammatory, and immune-mediated disease of the pilosebaceous unit, highly prevalent in adolescents. However, an increasing number of adults over 25 years old with facial acne, particularly women, have been observed. It is considered a different disease when compared to acne vulgaris. Face is the mainly involved area with inflammatory lesions and more sensitive skin, pointing out the need of a holistic approach.Areas covered: We performed a comprehensive literature search on PubMed database, up to January 2021, regarding adult female acne. We synthesized data about pathogenesis; differences compared to acne vulgaris; and treatment, with focus in the management challenges and perspectives.Expert opinion: It is essential to value the negative impact on quality of life of adult female acne, independently of severity. The disease has prolonged evolution, and patient might be resilient once the improvement, regardless of the treatment option, will just be noticeable after 3 months. Aggravating factors should be clearly discussed, such as the need of changing many habits, especially lesions manipulation. The therapeutic regimen includes make-up and tailored skin care (considering proneness to sensitivity), while anti-acne drugs should be chosen in accordance with desire to be pregnant, presence of pregnancy or breastfeeding.

Consensus on the use of oral isotretinoin in dermatology - Brazilian Society of Dermatology

BACKGROUND

Isotretinoin is a synthetic retinoid, derived from vitamin A, with multiple mechanisms of action and highly effective in the treatment of acne, despite common adverse events, manageable and dose-dependent. Dose-independent teratogenicity is the most serious. Therefore, off-label prescriptions require strict criteria.

OBJECTIVE

To communicate the experience and recommendation of Brazilian dermatologists on oral use of the drug in dermatology.

METHODS

Eight experts from five universities were appointed by the Brazilian Society of Dermatology to develop a consensus on indications for this drug. Through the adapted DELPHI methodology, relevant elements were listed and an extensive analysis of the literature was carried out. The consensus was defined with the approval of at least 70% of the experts.

RESULTS

With 100% approval from the authors, there was no doubt about the efficacy of oral isotretinoin in the treatment of acne, including as an adjunct in the correction of scars. Common and manageable common adverse events are mucocutaneous in nature. Others, such as growth retardation, abnormal healing, depression, and inflammatory bowel disease have been thoroughly investigated, and there is no evidence of a causal association; they are rare, individual, and should not contraindicate the use of the drug. Regarding unapproved indications, it may represent an option in cases of refractory rosacea, severe seborrheic dermatitis, stabilization of field cancerization with advanced photoaging and, although incipient, frontal fibrosing alopecia. For keratinization disorders, acitretin performs better. In the opinion of the authors, indications for purely esthetic purposes or oil control are not recommended, particularly for women of childbearing age.

CONCLUSIONS

Approved and non-approved indications, efficacy and adverse effects of oral isotretinoin in dermatology were presented and critically evaluated.

The use of isotretinoin for acne - an update on optimal dosing, surveillance, and adverse effects

INTRODUCTION

Acne is a chronic, inflammatory, and immune mediated disease of pilosebaceous unit, highly prevalent in adolescents. It involves face, trunk, and back; may leave scars and affect quality of life. Early, effective, and safe treatment is the key for disease resolution. Oral isotretinoin is the unique treatment for cure or prolonged remission for moderate and severe acne, preventing psychosocial impact and scars. It inhibits sebaceous glands activity and has anti-inflammatory and immunoregulatory properties.

AREAS COVERED

We performed a comprehensive literature search on PubMed database, up to March 2020, regarding oral isotretinoin for acne treatment. We synthetized data about acne pathogenesis and mechanism of action, efficacy, and safety of isotretinoin.

EXPERT OPINION

This drug is effective, despite common, controllable, and reversible mucocutaneous side effects. Serious adverse events are rare and represent individual reactions. Teratogenicity is the most severe, requiring rigorous control. We believe that no other therapeutic option, even topicals combined to oral antibiotics accomplish same results. Recurrence after treatments other than isotretinoin is the rule, prolonging risk of scars, compromising skin appearance, and causing emotional distress in teenagers. If there is no absolute contraindication, isotretinoin should be the first line treatment for moderate to severe inflammatory acne.

Proper Counseling and Dispensing of Isotretinoin Capsule Products by Community Pharmacists in UAE: A Simulated Patient Study

PURPOSE

To evaluate the pharmacist's assessment of patient eligibility for safe use of isotretinoin and the quality of pharmacist's counseling.

PATIENTS AND METHODS

A covert simulated patient (SP) methodology was used in which a trained female researcher, who was 25 years old, played the patient's role through this cross-sectional study by visiting community pharmacies and requesting isotretinoin capsules through a controlled prescription. A data form was used to collect the information following each pharmacy visit by asking about medical/family history and providing comprehensive counseling about the most common adverse effects, proper use instructions, and the importance of adherence to medication. The pharmacists, who did not initiate counseling, were prompted by the SP.

RESULTS

The pharmacists in 400 pharmacies who agreed to participate were visited by the SP. Only 7 (2%) pharmacists provided a complete assessment of patient eligibility for using isotretinoin with comprehensive counseling. Most of the pharmacists (84%) provided incomplete assessment as indicated by the overall score. Only 11 (3%) pharmacists asked the six crucial questions for the assessment of patient eligibility. On prompting, only 6 (2%) pharmacists provided complete counseling about the expected adverse effects. The most frequently provided adverse effect was dry skin, specifically dry lips (71.8%). A minority of 108 (27%) pharmacists provided education about the importance of using contraception during isotretinoin therapy. A complete level of counseling was provided by 125 (31.3%) pharmacists regarding the lab tests that the SP needs to undergo during therapy. Female pharmacists were more likely to provide counseling about the pregnancy test (mean=134, p=0.001).

CONCLUSION

Suboptimal level of the patient's assessment was revealed with poor educational counseling by the community pharmacists. New strategies are needed to improve pharmaceutical care services in the UAE.

Onychocryptosis and asymptomatic external urethritis as complications of oral isotretinoin therapy

This case report presents a patient who, while undergoing oral isotretinoin therapy for acne vulgaris, developed onychocryptosis and asymptomatic external urethritis. These uncommon adverse events are not well-documented in medical literature. While his urethritis spontaneously resolved, his onychocryptosis symptoms necessitated surgical intervention. This report illustrates both cosmetic and functional adverse effects of isotretinoin and provides insight into the progression of these reactions over time.

Severe acne and risk of breast cancer

PURPOSE

Hormonal imbalance early in life is thought to be associated with breast cancer risk. Severe acne may arise from hormonal imbalance and could serve as an indicator of increased breast cancer risk. We explored whether severe acne was associated with incident breast cancer.

METHODS

We used data from the Sister Study, a large (n = 50,884) prospective cohort of women who had a sister diagnosed with breast cancer, but who were free of breast cancer themselves at baseline. Participants completed a structured questionnaire that included demographics, lifestyle factors, and medical history, including any diagnosis of severe acne. Adjusted Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the association of severe acne and breast cancer (invasive disease or ductal carcinoma in situ).

RESULTS

During an average of 8.4 years of follow-up, 3049 breast cancer cases were diagnosed. Ever being diagnosed with severe acne was associated with a higher risk of breast cancer (HR 1.23; 95% CI 0.98, 1.54), particularly in women who were diagnosed prior to age 18 years (HR 1.40; 95% CI 1.04, 1.90). Results were similar when limited to invasive cancers.

CONCLUSIONS

Our study supports a non-significant positive association between severe acne-a potential marker of hormonal imbalance-and breast cancer risk. These findings suggest that severe acne, when considered along with other risk factors, could help to identify women who may be at a higher risk of breast cancer.

Algorithm for acne treatment: Ibero-Latin American consensus

Acne is a chronic, immune-mediated, inflammatory disease with high prevalence among adolescents. By compromising face, thorax and back, with the risk of permanent scars, it has a negative impact on the quality of life. Effective, safe and early treatment is the key to remission, while decreasing the risk of physical and/or emotional sequelae. The Iberian-Latin American Group of Acne Studies joined professionals with expertise and developed a practical therapeutic algorithm, adapted to the reality of Latin American countries, Spain and Portugal. This article intends to disseminate it with an updated review on a rational, safe and effective acne treatment.

Eruptive milia during isotretinoin therapy

Isotretinoin (13-cis-retinoic acid) is a synthetic vitamin A derivative that is effective in the treatment of recalcitrant, nodulocystic acne. To our knowledge, there are no reports in the medical literature of milia as a side effect of isotretinoin. We report a case of eruptive facial milia in the setting of isotretinoin treatment for acne.

Eosinophilic tubulointerstitial nephritis on treatment with isotretinoin

Drug-related acute tubulointerstitial nephritis is one of the most common causes of childhood acute renal failures which originate from kidneys. Sixteen-year old male patient with the history of isotretinoin use for the last 3 months was admitted with acute renal failure. Renal function parameters were measured as follows: blood urea nitrogen 21 mg/dL, serum creatinine 1.68 mg/dL, cystatin C 1.15 mg/L, and estimated glomerular filtration rate based on cystatin C 56.5 mL/min/1.73 m2. The patient whom pathological signs of renal biopsy sections revealed interstitial mononuclear cell and eosinophilic infiltration was diagnosed with acute tubulointerstitial nephritis.

CONCLUSION

Isotretinoin is a vitamin A-derived agent which is commonly used in the treatment of acne and may cause drug-related acute tubulointerstitial nephritis. What is Known: •Drug-related acute tubulointerstitial nephritis (ATIN) is one of the most common causes of childhood acute renal failures. What is New: •Isotretinoin may cause drug-related acute tubulointerstitial nephritis.

The prevalence of sacroiliitis in patients with acne vulgaris using isotretinoin

BACKGROUND/OBJECTIVE

Acne vulgaris is a chronic inflammatory disease affecting the pilosebaceous unit in the skin. Isotretinoin is a synthetic vitamin A derivative regarded as the most effective agent in the treatment of acne. There have recently been increasing reports of adverse effects of isotretinoin on the skeletal system. Our aim in this study was to evaluate the rheumatic side-effects triggered by this drug, and particularly the prevalence of sacroiliitis.

MATERIALS AND METHODS

A total of 73 patients receiving isotretinoin due to moderate or severe acne vulgaris were included. All patients were questioned about inflammatory low back pain and musculoskeletal pains during the treatment process. Inflammatory low back pain was evaluated using Assessment of Spondyloarthritis International Society (ASAS) criteria. Patients meeting ASAS criteria were evaluated with radiography and when necessary with sacroiliac magnetic resonance.

RESULTS

The dose range for isotretinoin was between 0.4 and 0.8 mg/kg/day (mean 0.53 mg/kg/day). Treatment lasted for 6-8 months (mean 6.8 months). Lethargy was determined in 37 (50.7%) patients, myalgia in 31 (42.5%) and low back pain in 36 (49.3%). Mechanical low back pain symptoms were present in 20 of the patients describing low back pain and inflammatory low back pain in 16. Acute sacroiliitis was determined in six patients (8.2%) following a sacroiliac magnetic resonance imaging (MRI). Five (83.3%) of the patients with sacroiliitis were female and one (16.7%) was male. No statistically significant difference was determined between male and female patients in terms of prevalence of sacroiliitis (p = 0.392).

CONCLUSION

The incidence of sacroiliitis in patients using isotretinoin is quite high. Patients using isotretinoin must be questioned about sacroiliitis findings and must be subjected to advanced assessment when necessary. Further studies regarding the development of sacroiliitis under isotretinoin therapy are now needed.