Depression and Suicidal Behavior in Acne Patients Treated With Isotretinoin: A Systematic Review

The reliability and quality of YouTube videos about isotretinoin treatment and suicide

BACKGROUND

Seeking health information online has drastically increased. Isotretinoin is one of the agents used to treat acne.

OBJECTIVES

In this study, we aimed to investigate the reliability and quality of YouTube videos related to acne treatment. There is a misconception that use of isotretinoin increases risk of suicide.

METHODS

We used the terms 'isotretinoin suicide' and 'acne treatment suicide' to search YouTube videos. Videos that were not in English, were irrelevant, or were devoid of audio were not included. The information in the videos was primarily categorized as 'reliable' or 'unreliable' based on its scientific validation. DISCERN and the Global Quality Score were used to evaluate the videos' overall quality.

RESULTS

In total, 200 videos were examined and 112 videos were included in the study. Of these, 39 videos (34.8%) were found to be reliable, and 73 videos (65.2%) were found to be unreliable. The DISCERN values of videos uploaded by physicians or professional organizations, and health information websites were found to be significantly higher. There were statistically significant negative correlations between DISCERN score and both video length and the length of time the video was on YouTube, while a positive correlation was observed between DISCERN score and the number of subscribers.

CONCLUSIONS

Although videos created by dermatologists have become widespread in recent years, they are still insufficient. Patient experience videos mostly contain information that does not reflect reality, and they emphasize that isotretinoin increases the risk of suicide without evidence. As the number of dermatologists posting videos on YouTube increases, the chances of people accessing correct information will increase.

An update on the pharmacological management of acne vulgaris: the state of the art

INTRODUCTION

Acne vulgaris is a chronic inflammatory disease of the pilosebaceous unit that affects approximately 9.4% of the global population. Current treatment strategies aim to target as many pathogenic factors involved in the appearance of acne lesions and are centered on a systematic treatment escalation based on disease severity, extension, and treatment response, starting with topical treatments for mild cases and progressing over to systemic therapies in more severe cases. A literature search, which included clinical guidelines, clinical studies, and review articles on acne treatment and maintenance, was conducted to review the pharmacological approaches currently available to treat this disease.

AREAS COVERED

Topical therapies such as topical retinoids, benzoyl peroxide, azelaic acid, salicylic acid, topical antibiotics, and clascoterone, as well as systemic treatments such as oral antibiotics and isotretinoin are discussed in detail. Combined oral contraceptives and spironolactone will not be discussed in this article.

EXPERT OPINION

There is a need for a blockbuster acne drug that simultaneously targets the four main pathogenic factors involved in the appearance of acne lesions while presenting with minimal side effects. Until such a drug exists, combination therapy will remain the standard of treatment for most acne patients.

Guidelines of care for the management of acne vulgaris

BACKGROUND

Acne vulgaris commonly affects adults, adolescents, and preadolescents aged 9 years or older.

OBJECTIVE

The objective of this study was to provide evidence-based recommendations for the management of acne.

METHODS

A work group conducted a systematic review and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of evidence and formulating and grading recommendations.

RESULTS

This guideline presents 18 evidence-based recommendations and 5 good practice statements. Strong recommendations are made for benzoyl peroxide, topical retinoids, topical antibiotics, and oral doxycycline. Oral isotretinoin is strongly recommended for acne that is severe, causing psychosocial burden or scarring, or failing standard oral or topical therapy. Conditional recommendations are made for topical clascoterone, salicylic acid, and azelaic acid, as well as for oral minocycline, sarecycline, combined oral contraceptive pills, and spironolactone. Combining topical therapies with multiple mechanisms of action, limiting systemic antibiotic use, combining systemic antibiotics with topical therapies, and adding intralesional corticosteroid injections for larger acne lesions are recommended as good practice statements.

LIMITATIONS

Analysis is based on the best available evidence at the time of the systematic review.

CONCLUSIONS

These guidelines provide evidence-based recommendations for the management of acne vulgaris.

Managing Dermatologic Effects of Gender-Affirming Therapy in Transgender Adolescents

Transgender adolescents seek gender-affirming medical care to address gender identity and incongruence. Improved understanding of the dermatologic impact of gender-affirming medical care such as pubertal suppression, hormone therapy, and surgeries can enhance patient outcome. Pubertal suppression treats dysphoria associated with development of secondary sex characteristics, including androgen-driven acne. Gender-affirming hormone therapy influences acne and hair development in transgender adolescents. Dermatologists can help manage skin effects associated with chest binding and gender-affirming hormone therapy and surgery. Provision of patient-centered gender-affirming care in dermatologic and multidisciplinary settings is essential to improve skin and overall outcomes of gender-affirming therapy.

Treating Acne in Transgender Persons Receiving Testosterone: A Practical Guide

Transgender persons who undergo masculinizing hormone therapy experience a wide array of dermatologic effects as they initiate and maintain testosterone therapy. Acne is one of the most common adverse effects for many transmasculine patients receiving testosterone. Acne can worsen body image and mental health, with significant impact on quality of life in transgender patients. Specific training and awareness are needed for a clinically and culturally competent encounter while providing care for the transgender patient. This article provides a practical guide for the treatment of testosterone-induced acne in transmasculine patients. Recommendations on creating a welcoming clinical setting, taking a gender-inclusive history, and conducting a patient-centered physical examination relevant to acne care are provided. Assessment of reproductive potential and the appropriate contraceptive methods before prescribing acne treatment with teratogenic potential in transmasculine patients are examined. Interactions between acne treatments with gender-affirming therapies are explored. For patients with severe or treatment-refractory acne, indications, contraindications, and barriers to isotretinoin prescription, such as the US iPLEDGE program, are examined. Multidisciplinary approaches to acne care, involving mental health, reproductive health, gender-affirming hormone therapy and surgeries, are adopted to guide isotretinoin treatment.

Isotretinoin and neuropsychiatric side effects: Continued vigilance is needed

Background

Isotretinoin (13-cis-retinoic acid, marketed under the names Accutane, Roaccutane, and others) is an effective treatment for acne that has been on the market for over 30 years, although reports of neuropsychiatric side effects continue to be reported. Isotretinoin is an isomer of the active form of Vitamin A, 13-trans-retinoic acid, which has known psychiatric side effects when given in excessive doses, and is part of the family of compounds called retinoids, which have multiple functions in the central nervous system.

Methods

The literature was reviewed in pubmed and psychinfo for research related to isotretinoin and neuropsychiatric side effects including depression, suicidal thoughts, suicide, mania, anxiety, impulsivity, emotional lability, violence, aggression, and psychosis.

Results

Multiple case series have shown that successful treatment of acne with isotretinoin results in improvements in measures of quality of life and self esteem However, studies show individual cases of clinically significant depression and other neuropsychiatric events that, although not common, are persistent in the literature. Since the original cases of depression were reported to the United States Food and Drug Administration, numerous cases have been reported to regulatory agencies in the United Kingdom, France, Ireland, Denmark, Australia, Canada, and other countries, making isotretinoin one of the top five medications in the world associated with depression and other neuropsychiatric side effects. Clinicians are advised to warn patients of the risks of neuropsychiatric side effects with isotretinoin which may arise from the medication itself, and not just as a side effect of acne or youth.

Surgical and Nonsurgical Management of the Nasal Skin-Soft Tissue Envelope

Management of the skin-soft tissue envelope (SSTE) in rhinoplasty is challenging and critical for the overall outcome. The preoperative identification of patients with thick or thin skin and with preexisting skin conditions may contribute significantly to the postsurgical result. Most publications and textbooks focus on the management of the osseocartilaginous framework, but the SSTE management is often not addressed in detail. However, nonsurgical treatments, such as skin preconditioning, topical steroid-injections, oral isotretinoin, and topical vitamin A derivatives, may provide strong benefits. In this article, we reviewed the literature to present a comprehensive review on the available surgical and nonsurgical approaches pre-, intra-, and postoperatively dealing with SSTE in rhinoplasty.

Isotretinoin and the Kidney: Opportunities and Threats

Retinoids are one of the most effective drugs in inducing complete or prolonged remission of severe acne vulgaris, but the adverse reactions associated with the use of them are raising a concern about the potential effect of these drugs on internal organs function such as the kidney. The aim of this review is to comprehensively gather data about isotretinoin, both potential adverse and beneficial effects on the kidney based on the current experimental and clinical findings. Very few studies, including five case reports, described that systemic oral isotretinoin within usual doses (40 mg/day or 0.5 mg/kg⁄day) within 1 to 4 months of treatment might be associated with different types of renal dysfunctions. These include acute interstitial nephritis, nephrotic syndrome, and hematuria with dysuria. The adverse reactions of systemic isotretinoin on the kidney and urinary system are unlikely and rare. In contrast, six experimental studies demonstrated the beneficial effects of either oral or parenteral low- (2 or 5 mg/kg/day) or high- (10, 20, 25, 40 mg/kg/day) dose isotretinoin on the kidney in the rat models of glomerulonephritis, obstructive nephropathy or allograft nephropathy. The nephroprotective functions of isotretinoin in these studies were attributed to its anti-proliferative, anti-fibrotic, and anti-inflammatory actions. However, clinical studies are warranted to elucidate the possible beneficial effects of isotretinoin in preventing or attenuating kidney injury in different settings.

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.

Optimizing Isotretinoin Treatment of Acne: Update on Current Recommendations for Monitoring, Dosing, Safety, Adverse Effects, Compliance, and Outcomes

Acne vulgaris is the most common skin disease treated by dermatologists. It can be severe and result in permanent scars. Isotretinoin is the most effective treatment for acne and has the potential for long-term clearance. Prescribing and monitoring protocols can vary widely among prescribers. Recent studies, reports, and consensus statements help shed light on optimizing the use of isotretinoin for acne. A recent literature review is summarized in this article to help the practitioner optimize isotretinoin use for acne. The article outlines the advantages and disadvantages of standard, high-dose, and low-dose isotretinoin regimens; discusses the current status of controversies surrounding isotretinoin (including depression/suicide, pregnancy, and inflammatory bowel disease); reviews monitoring recommendations and treatment for hypertriglyceridemia and elevated transaminase levels; and discusses common adverse effects seen with isotretinoin, along with their treatment and prevention.

Dermatologic Problems Commonly Seen by the Allergist/Immunologist

Allergists/immunologists see a variety of skin disorders, some of which have a known immunologic basis whereas others do not. We review the prevalence, etiology, clinical presentation, and effective and low-cost care of common dermatologic conditions seen in outpatient practices. Conditions discussed include pityriasis alba, seborrheic dermatitis, rosacea, acne, tinea infections, intertrigo, lichen planus, tinea versicolor, lichen simplex chronicus, scabies, pityriasis rosea, keratosis pilaris, and seborrheic keratosis. An understanding of frequently encountered cutaneous diseases and their therapies will help provide immediate access to treatment and improve the experience for both the affected patient and the clinician.

Oral isotretinoin for acne

BACKGROUND

Acne vulgaris, a chronic inflammatory disease of the pilosebaceous unit associated with socialisation and mental health problems, may affect more than 80% of teenagers. Isotretinoin is the only drug that targets all primary causal factors of acne; however, it may cause adverse effects.

OBJECTIVES

To assess efficacy and safety of oral isotretinoin for acne vulgaris.

SEARCH METHODS

We searched the following databases up to July 2017: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO and LILACS. We updated this search in March 2018, but these results have not yet been incorporated in the review. We also searched five trial registries, checked the reference lists of retrieved studies for further references to relevant trials, and handsearched dermatology conference proceedings. A separate search for adverse effects of oral isotretinoin was undertaken in MEDLINE and Embase up to September 2013.

SELECTION CRITERIA

Randomised clinical trials (RCTs) of oral isotretinoin in participants with clinically diagnosed acne compared against placebo, any other systemic or topical active therapy, and itself in different formulation, doses, regimens, or course duration.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 31 RCTs, involving 3836 participants (12 to 55 years) with mild to severe acne. There were twice as many male participants as females.Most studies were undertaken in Asia, Europe, and North America. Outcomes were generally measured between eight to 32 weeks (mean 19.7 weeks) of therapy.Assessed comparisons included oral isotretinoin versus placebo or other treatments such as antibiotics. In addition, different doses, regimens, or formulations of oral isotretinoin were assessed, as well as oral isotretinoin with the addition of topical agents.Pharmaceutical companies funded 12 included trials. All, except three studies, had high risk of bias in at least one domain.Oral isotretinoin compared with oral antibiotics plus topical agentsThese studies included participants with moderate or severe acne and assessed outcomes immediately after 20 to 24 weeks of treatment (short-term). Three studies (400 participants) showed isotretinoin makes no difference in terms of decreasing trial investigator-assessed inflammatory lesion count (RR 1.01 95% CI 0.96 to 1.06), with only one serious adverse effect found, which was Stevens-Johnson syndrome in the isotretinoin group (RR 3.00, 95% CI 0.12 to 72.98). However, we are uncertain about these results as they were based on very low-quality evidence.Isotretinoin may slightly improve (by 15%) acne severity, assessed by physician's global evaluation (RR 1.15, 95% CI 1.00 to 1.32; 351 participants; 2 studies), but resulted in more less serious adverse effects (67% higher risk) (RR 1.67, 95% CI 1.42 to 1.98; 351 participants; 2 studies), such as dry lips/skin, cheilitis, vomiting, nausea (both outcomes, low-quality evidence).Different doses/therapeutic regimens of oral isotretinoinFor our primary efficacy outcome, we found three RCTs, but heterogeneity precluded meta-analysis. One study (154 participants) reported 79%, 80% and 84% decrease in total inflammatory lesion count after 20 weeks of 0.05, 0.1, or 0.2 mg/kg/d of oral isotretinoin for severe acne (low-quality evidence). Another trial (150 participants, severe acne) compared 0.1, 0.5, and 1 mg/kg/d oral isotretinoin for 20 weeks and, respectively, 58%, 80% and 90% of participants achieved 95% decrease in total inflammatory lesion count. One RCT, of participants with moderate acne, compared isotretinoin for 24 weeks at (a) continuous low dose (0.25 to 0.4 mg/kg/day), (b) continuous conventional dose (0.5 to 0.7 mg/kg/day), and (c) intermittent regimen (0.5 to 0.7 mg/kg/day, for one week in a month). Continuous low dose (MD 3.72 lesions; 95% CI 2.13 to 5.31; 40 participants; one study) and conventional dose (MD 3.87 lesions; 95% CI 2.31 to 5.43; 40 participants; one study) had a greater decrease in inflammatory lesion counts compared to intermittent treatment (all outcomes, low-quality evidence).Fourteen RCTs (906 participants, severe and moderate acne) reported that no serious adverse events were observed when comparing different doses/therapeutic regimens of oral isotretinoin during treatment (from 12 to 32 weeks) or follow-up after end of treatment (up to 48 weeks). Thirteen RCTs (858 participants) analysed frequency of less serious adverse effects, which included skin dryness, hair loss, and itching, but heterogeneity regarding the assessment of the outcome precluded data pooling; hence, there is uncertainty about the results (low- to very-low quality evidence, where assessed).Improvement in acne severity, assessed by physician's global evaluation, was not measured for this comparison.None of the included RCTs reported birth defects.

AUTHORS' CONCLUSIONS

Evidence was low-quality for most assessed outcomes.We are unsure if isotretinoin improves acne severity compared with standard oral antibiotic and topical treatment when assessed by a decrease in total inflammatory lesion count, but it may slightly improve physician-assessed acne severity. Only one serious adverse event was reported in the isotretinoin group, which means we are uncertain of the risk of serious adverse effects; however, isotretinoin may result in more minor adverse effects.Heterogeneity in the studies comparing different regimens, doses, or formulations of oral isotretinoin meant we were unable to undertake meta-analysis. Daily treatment may be more effective than treatment for one week each month. None of the studies in this comparison reported serious adverse effects, or measured improvement in acne severity assessed by physician's global evaluation. We are uncertain if there is a difference in number of minor adverse effects, such as skin dryness, between doses/regimens.Evidence quality was lessened due to imprecision and attrition bias. Further studies should ensure clearly reported long- and short-term standardised assessment of improvement in total inflammatory lesion counts, participant-reported outcomes, and full safety accounts. Oral isotretinoin for acne that has not responded to oral antibiotics plus topical agents needs further assessment, as well as different dose/regimens of oral isotretinoin in acne of all severities.

Guidelines of care for the management of acne vulgaris

Acne is one of the most common disorders treated by dermatologists and other health care providers. While it most often affects adolescents, it is not uncommon in adults and can also be seen in children. This evidence-based guideline addresses important clinical questions that arise in its management. Issues from grading of acne to the topical and systemic management of the disease are reviewed. Suggestions on use are provided based on available evidence.

Adherence to acne treatment guidelines in the military environment - a descriptive, serial cross-sectional study

BACKGROUND

Acne vulgaris, a common skin disease, affects up to 80 % of the population. Moderate to severe acne requires treatment with a combination of topical and oral drugs such as antibiotics, hormones and retinoids. Retinoids have many contraindications and adverse effects requiring close monitoring. The study's objectives were to describe prescribing trends in acne medication over time in a military setting, and assess physician adherence to guidelines for acne treatment, including drug precautions, clinical monitoring, and treatment progression.

METHODS

We conducted a descriptive, serial cross-sectional study of acne drugs prescribed in the Israel Defense Forces (IDF) in the years 2002-2007, analyzing the classes of drugs prescribed and patient characteristics. In addition, the clinical quality of the medical encounter was assessed by examining physician adherence to IDF guidelines.

RESULTS

Between 2002 and 2007, 64,281 patients were treated for acne. Treatment courses generally persisted for 1-2 months. Over 70 % of female patients receiving oral retinoids were not concomitantly receiving oral contraceptives.

CONCLUSION

This study provides a unique perspective of acne treatment in a military setting, overall displaying good adherence to general guidelines. The common prescription of oral retinoids to young females without concomitant contraception is alarming.

Retinoids for prevention and treatment of actinic keratosis

Actinic keratosis is a common cause of dermatological consultations and it presents a strong association with squamous cell carcinoma. Many substances are used for treatment and prevention, such as retinoids. Nevertheless, many studies on retinoids emphasize their application in treating and preventing non melanoma skin cancers. In this article, we reviewed studies about systemic and topical retinoids used with immunocompetent patients and organ transplant recipients with actinic keratosis, as primary or secondary outcomes. The majority of these papers pointed to a reduction in actinic keratosis count after treatment with retinoids. However, studies need to be better-defined in order to address the lack of a standardized dose, the absence of control groups, the low number of patients and short follow-up periods. Blind, randomized and controlled clinical trials with adequate sample sizes, specifically focused on actinic keratosis, are needed to clarify the real benefit of topical and/or oral retinoids. Comparison of efficacy and safety between oral and topical retinoids in the prevention and treatment of non-melanoma skin cancers and actinic keratosis is an essential pre requisite to establish new strategies to control these conditions.

Isotretinoin: update on controversial issues

Acne vulgaris is a commonly seen dermatologic condition that plagues millions and can be very psychosocially disabling. Severe and recalcitrant acne is typically treated with isotretinoin. Isotretinoin is a synthetic vitamin A derivative that has been available since 1982.This therapeutic option has been the most effective at putting severe and recalcitrant acne vulgaris into remission. Despite its effectiveness,it has been associated with inflammatory bowel disease, depression, suicidality, and teratogenicity. We review the current literature on isotretinoin's role in inflammatory bowel disease, depression, and suicidality. In addition, we review whether or not the iPledge program has been successful at reducing pregnancy rates while on isotretinoin.

Mood changes, depression and suicide risk during isotretinoin treatment: a prospective study

BACKGROUND

Depression and mood changes appear as potentional side effects of isotretinoin in the Summary of Product Characteristics. There have been many studies treating this topic but in most cases not identifying any significant depression or suicide risk. To further investigate this issue, we conducted a prospective, uncontrolled study to evaluate mood changes and suicidal ideations in patients receiving isotretinoin therapy.

METHODS

One-hundred patients were included in our single center, no-blind, and no controlled prospective study. All patients completed the Beck's Depression Inventory, Version II (BDI-II) before the treatment, following the first month of the treatment and then every third month until finishing the isotretinoin therapy. All questionnaires were checked by a psychiatrist. Suicidal ideations were monitored. Statistical analysis of BDI-II scores was performed.

RESULTS

All patients completed the study. Before the treatment, six percent of the patients had suffered from depressive symptoms. During the isotretinoin treatment, we did not find any deterioration of depression problems in any of these patients. On the contrary, in most patients the depressive symptoms disappeared. Symptoms of depression occurred in two patients, in which case coexisting situational factors were found to be the cause. No occurrence of suicidal ideations was found.

CONCLUSIONS

We did not find any depressive symptoms or suicide risk caused by isotretinoin. On the contrary, a statistically significant improvement of BDI-II scores was found. In our opinion, patients have to be informed about the risk of depression but emphasizing the fact that it is very rare.

Suicide risk in skin disorders

Suicide accounts for about 1,000,000 deaths worldwide every year and is among the leading causes of death in young adults. Reports of high prevalence of suicidal ideation and increased suicide risk in several skin diseases raised concerns about deliberate self-harm in dermatological patients. The literature consistently points to an increased suicide risk in patients with psoriasis, atopic dermatitis, and acne, with higher risk in patients in whom the skin condition is associated with clinically significant emotional distress, changes in body image, difficulties in close relationships, and impaired daily activities. Other risk factors for suicide include a history of suicide attempts, severe mental or physical disorders, alcoholism, unemployment, bereavement or divorce, and access to firearms or other lethal means. Dermatologists may play an important role in recognizing suicidal ideation and preventing fatal self-harm in their patients. Increasing dermatologists' awareness of the issue of suicide and developing mental health consultation-liaison services within dermatology settings would be instrumental in contributing to suicide prevention in this population.

Evidence on acne therapy

Among the current treatments available for acne vulgaris, many widely practiced options lack support from studies at the best level of scientific evidence. The aim of this narrative review was to present the very latest information on topical and systemic treatments for acne vulgaris. Information from systematic reviews and well-designed clinical trials, obtained through a systematic search of the major medical databases, is emphasized. There are important issues regarding the clinical management of acne that still lack consistent grounding in scientific evidence. Among these are the optimum dose and duration of treatment with oral antibiotics that can be given without inducing bacterial resistance, and the safety of oral isotretinoin.

Acne vulgaris

Acne is a chronic inflammatory disease of the pilosebaceous unit resulting from androgen-induced increased sebum production, altered keratinisation, inflammation, and bacterial colonisation of hair follicles on the face, neck, chest, and back by Propionibacterium acnes. Although early colonisation with P acnes and family history might have important roles in the disease, exactly what triggers acne and how treatment affects the course of the disease remain unclear. Other factors such as diet have been implicated, but not proven. Facial scarring due to acne affects up to 20% of teenagers. Acne can persist into adulthood, with detrimental effects on self-esteem. There is no ideal treatment for acne, although a suitable regimen for reducing lesions can be found for most patients. Good quality evidence on comparative effectiveness of common topical and systemic acne therapies is scarce. Topical therapies including benzoyl peroxide, retinoids, and antibiotics when used in combination usually improve control of mild to moderate acne. Treatment with combined oral contraceptives can help women with acne. Patients with more severe inflammatory acne usually need oral antibiotics combined with topical benzoyl peroxide to decrease antibiotic-resistant organisms. Oral isotretinoin is the most effective therapy and is used early in severe disease, although its use is limited by teratogenicity and other side-effects. Availability, adverse effects, and cost, limit the use of photodynamic therapy. New research is needed into the therapeutic comparative effectiveness and safety of the many products available, and to better understand the natural history, subtypes, and triggers of acne.

Retinoic acid and affective disorders: the evidence for an association

OBJECTIVE

Isotretinoin (13-cis-retinoic acid), approved by the US Food and Drug Administration for the treatment of acne, carries a black box warning related to the risk of depression, suicide, and psychosis. Retinoic acid, the active form of vitamin A, regulates gene expression in the brain, and isotretinoin is its 13-cis isomer. Retinoids represent a group of compounds derived from vitamin A that perform a large variety of functions in many systems, in particular the central nervous system, and abnormal retinoid levels can have neurologic effects. Although infrequent, proper recognition and treatment of psychiatric side effects in acne patients is critical given the risk of death and disability. This article reviews the evidence for isotretinoin's relationships with depression and suicidality.

DATA SOURCES

The PsycINFO, MEDLINE, and PubMed searchable database indexes were searched for articles published in the English language from 1960 to June 2010 using the key words isotretinoin, retinoids, retinoic acid, depression, depressive disorders, and vitamin A. Evidence examined includes (1) case reports; (2) temporal association between onset of depression and exposure to the drug; (3) challenge-rechallenge cases; (4) class effect (other compounds in the same class, like vitamin A, having similar neuropsychiatric effects); (5) dose response; and (6) biologically plausible mechanisms.

STUDY SELECTION

All articles in the literature related to isotretinoin, depression, and suicide were reviewed, as well as articles related to class effect, dose response, and biologic plausibility.

DATA EXTRACTION

Information from individual articles in the literature was extracted, including number of episodes of depression, suicidality, suicide, psychosis, violence and aggression, past psychiatric history, time of onset in relation to isotretinoin usage, medication dosage, duration of treatment, and dechallenge and challenge history.

RESULTS

The literature reviewed is consistent with associations of isotretinoin administration with depression and with suicide in a subgroup of vulnerable individuals.

CONCLUSIONS

The relationship between isotretinoin and depression may have implications for a greater understanding of the neurobiology of affective disorders.

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

BACKGROUND

Assessment of adverse effects in pediatric patients on oral isotretinoin has not been standardized and the exact incidence is unknown.

OBJECTIVE

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.

METHODS

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.

RESULTS

The charts of 102 patients, representing 123 courses of isotretinoin and 760 treatment-months, were reviewed. A total 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 21 years. Impaired night vision, nosebleeds, and dry/bloodshot eyes were more common in the older age group.

LIMITATIONS

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.

CONCLUSIONS

The isotretinoin symptom survey appears to be an effective screening tool to standardize monitoring of isotretinoin side effects in the pediatric population.

A prospective trial of the effects of isotretinoin on quality of life and depressive symptoms

BACKGROUND

Isotretinoin is an efficacious treatment for acne, but has been controversially linked with depression.

OBJECTIVES

This study aimed to examine the effects of isotretinoin on quality of life(QoL) and depression using a prospective design.

METHODS

The WHOQOL-BREF QoL measure and Centre for Epidemiological Studies Depression Scale were administered to consecutive outpatients with acne who were prescribed either isotretinoin (n = 65) or antibiotic treatment (n = 31).Patients and physicians rated acne severity independently. Groups were compared at baseline with a matched community sample (n = 94) and measurements repeated at 3 months for treatment groups.

RESULTS

There were no differences between the three groups at baseline in terms of age, gender, depression or overall QoL. Acne was more severe in the treatment groups (P < 0·001). Depression was negatively correlated with QoL (P < 0·001)and hence was included as a covariate in repeated-measures analyses of QoL.Acne improved over time in both treatment groups (F = 48·2, P < 0·001). There was no detectable deterioration in depression score in either group (F = 1·1, not significant). QoL in the physical and social domains improved (P < 0·001) while psychological and environmental QoL was unchanged over time. The improvement in social QoL was greater in the isotretinoin group (P < 0·05). Those patients with higher baseline depression scores showed greater improvements in physical, psychological and social QoL (P < 0·001).

CONCLUSIONS

Treatment of acne improves QoL, particularly in those with more depressive symptoms at the outset. Mood deterioration was not detected, but the possibility of subtle or rare mood effects of isotretinoin cannot be ruled out.

Therapeutic considerations for severe nodular acne

Severe nodular acne, defined as grade 4 or 5 acne on the Investigator's Static Global Assessment scale, is a skin condition characterized by intense erythema, inflammation, nodules, cysts, and scarring. Both the well known risk of physical scarring and the more recent recognition that acne can be a chronic, psychologically distressing disease with significant adverse effects on a patient's quality of life, have prompted earlier, more aggressive treatment with more effective medications, in the hope of preventing progression to more severe, nodular forms of the disease. Oral antibacterials, primarily tetracyclines, have long been the first-line therapy for severe nodular acne, which frequently remained refractory to therapy. However, concerns of antibacterial adverse effects, patient adherence, and antimicrobial resistance prompted the search for alternate therapies and combinations thereof in order to target the multifactorial pathogenesis of the disease. Isotretinoin, an oral retinoid introduced in 1982, has since become the gold standard therapy in severe acne and has revolutionized its treatment. Several adjunctive agents exist. Oral antibacterials are indicated as an alternative for patients with severe acne who cannot tolerate oral retinoids, or for whom a contraindication exists. In order to prevent bacterial resistance, antibacterials should always be used in combination with benzoyl peroxide, a nonantibiotic antimicrobial agent with anti-inflammatory activity. Topical retinoids are often added to this regimen. In women, hormonal agents, which include oral contraceptives, spironolactone, and oral corticosteroids, and, in Europe, cyproterone acetate, may be used as monotherapy or concomitantly with isotretinoin. For rapid treatment of inflammatory nodules, intralesional corticosteroids are effective. These treatment modalities have been studied, refined, and combined in novel ways in order to target the multifactorial pathogenesis of the disease, and in this article we review each of their roles.

Suicidal ideation, mental health problems, and social impairment are increased in adolescents with acne: a population-based study

We performed a cross-sectional, questionnaire-based study to explore the relationship of suicidal ideation, mental health problems, and social functioning to acne severity among adolescents aged 18-19 years. A total of 4,744 youth were invited and 3,775 (80%) participated. In all, 14% reported having substantial acne (a lot and very much). Among those with very much acne, as compared those with no/little acne, suicidal ideation was twice as frequently reported among girls (25.5 vs. 11.9%) and three times more frequently reported among boys (22.6 vs. 6.3%). Suicidal ideation remained significantly associated with substantial acne (odds ratio 1.80, 95% confidence interval 1.30-2.50) in a multivariate model including adjustments of symptoms of depression, ethnicity, and family income. Mental health problems, as assessed by the Strengths and Difficulties Questionnaire (2.25, 1.69-3.00), low attachment to friends (1.52, 1.21-1.91), not thriving at school (1.41, 1.12-1.78), never having had a romantic relationship (1.35, 1.05-1.70), and never having had sexual intercourse (1.51, 1.21-1.89) were all associated with substantial acne in a multivariate model. Acne is frequently found in late adolescence and is associated with social and psychological problems. Adverse events including suicidal ideation and depression that have been associated with therapies for acne may reflect the burden of substantial acne rather than the effects of medication.

Isotretinoin is not associated with inflammatory bowel disease: a population-based case-control study

OBJECTIVES

There is anecdotal evidence that isotretinoin use is associated with development of colitis. We aimed at determining whether there is an association between isotretinoin use and development of inflammatory bowel disease (IBD).

METHODS

The population-based University of Manitoba IBD Epidemiology Database and a control group matched by age, sex, and geographical residence were linked to the provincial prescription drug registry, a registry that was initiated in 1995. The number of users and duration of isotretinoin use were identified in both IBD cases and controls.

RESULTS

We found that 1.2% of IBD cases used isotretinoin before IBD diagnosis, which was statistically similar to controls (1.1% users). This was also similar to the number of IBD patients who used isotretinoin after a diagnosis of IBD (1.1%). There was no difference between isotretinoin use before Crohn's disease compared with its use before ulcerative colitis.

CONCLUSIONS

Patients with IBD were no more likely to have used isotretinoin before diagnosis than were sex-, age-, and geography-matched controls. Although there may be anecdotes of isotretinoin causing acute colitis, our data suggest that isotretinoin is not likely to cause chronic IBD.

On the association between low resting heart rate and chronic aggression: retinoid toxicity hypothesis

Low resting heart rate is a strong and consistent predictor of conduct disorder and chronic aggression. Explanations such as fearlessness and low arousal-induced stimulus-seeking have been offered, assuming a causal association between the phenomena, but the origin of low heart rate and its significance for understanding aggression and violence remain obscure. Retinoids (vitamin A and its congeners) play important roles in embryogenesis and neural development. Several lines of evidence also suggest a causal role of retinoids in aggression as well as cognitive and mood disorders. The hypothesis is proposed that retinoid overexpression in utero induces, via a noradrenergic-to-cholinergic switch, alterations in cardiac functioning and hemodynamics resulting in low resting heart rate, brain structural and functional changes, minor physical anomalies, and persistent aggression. Retinoid toxicity occurring early in pregnancy could represent a final common pathway by which various prenatal challenges result in conduct disorder and chronic aggression (e.g., maternal cigarette smoking, alcohol consumption, drug use, exposure to environmental chemicals, stress, trauma or infection). Implications of the model for understanding related aspects of chronic aggression are discussed, as well as strategies for prevention and treatment.

Chronic 13-cis-retinoic acid administration disrupts network interactions between the raphe nuclei and the hippocampal system in young adult mice

Previously, we showed that chronic administration of 13-cis-retinoic acid (13-cis-RA) induces depression-related behaviors in mice and that 13-cis-RA alters components of the serotonergic system in vitro. Work by others has shown that 13-cis-RA reduces hippocampal neurogenesis in mice and orbitofrontal cortex metabolism in humans. In the current study, we measured cytochrome oxidase activity, a metabolic marker that reflects steady state neuronal energy demand, in various regions of the brain to determine the effects of 13-cis-RA on neuronal metabolic activity and network interactions between the raphe nuclei and the hippocampal system. Brain cytochrome oxidase activity in young adult male mice was analyzed following 6 weeks of daily 13-cis-RA (1 mg/kg) or vehicle injection and behavioral testing. Chronic 13-cis-RA administration significantly decreased cytochrome oxidase activity only in the inferior rostral linear nucleus of the raphe. However, covariance analysis of interregional correlations in cytochrome oxidase activity revealed that 13-cis-RA treatment caused a functional uncoupling between the dorsal raphe nuclei and the hippocampus. Furthermore, a path analysis indicated that a network comprising lateral habenula to dorsal raphe to hippocampus was effectively uncoupled in 13-cis-RA treated animals. Finally, cytochrome oxidase activity in the dentate gyrus of 13-cis-RA treated mice was inversely correlated with depression-related behavior. Taken together, these data show that 13-cis-RA alters raphe metabolism and disrupts functional connectivity between the raphe nuclei and the hippocampal formation, which may contribute to the observed increase in depression-related behaviors.

Acne through the ages: case-based observations through childhood and adolescence

Acne vulgaris is a common disorder that affects more than 17 million individuals in the United States. Knowledge of the disease is an important part of clinical practice, particularly for the pediatric practitioner. Contrary to common belief, acne is not a disease limited to adolescents and young adults but can occur at any stage of life. This article is a case-based review of acne during childhood and adolescence. Workup is based on age and concurrent physical findings, whereas therapy depends on the type of skin lesions along with patient characteristics and preferences.

New insights into adolescent acne

PURPOSE OF REVIEW

Acne vulgaris remains one of the most common conditions affecting adolescents. The pediatric practitioner is the first to evaluate adolescent acne, making familiarity with the condition and its management essential. This review covers some of the recent literature regarding acne to help practitioners stay current on the issues regarding this topic.

RECENT FINDINGS

The pathogenesis of acne is multifactorial and complex, but recent advances in molecular genetics have provided additional information on the actions of Proprionibacterium acnes. Nutritional studies have reevaluated a possible role for diet and lifestyle factors in acne development. Many therapies are available to control acne and to limit associated scarring. Their appropriate use requires an understanding of not only the benefits but also the possible risks and adverse effects involved. Recent concerns regarding the use of antibiotics and isotretinoin will be addressed.

SUMMARY

This study reviews the recent literature regarding teenage acne, focusing on pathogenesis, associations, and controversies and considerations in therapy.

[Suicidal behavior in dermatology]

Even in dermatology one can potentially encounter suicidal patients. A risk of suicide can be preexisting, appear as complication of skin disorders or be triggered by medications such as interferons. Patients at risk must be specifically asked about suicidal ideations and tendencies. Acute suicide risk requires immediate crisis intervention. In dermatology suicide risk has been described in severe acne conglobata (especially men) and metastatic melanoma. Patients with chronic or potentially fatal disease or severe pain may be suicidal. In addition patients with depression, alcohol dependency, substance abuse, schizophrenia or borderline personality disorder are at special risk. We review psychodermatological diseases with risk of suicide and point out treatment strategies. More attention should be focused on the early recognition of a possible risk of suicide in dermatology patients.

The neurobiology of retinoic acid in affective disorders

Current models of affective disorders implicate alterations in norepinephrine, serotonin, dopamine, and CRF/cortisol; however treatments targeted at these neurotransmitters or hormones have led to imperfect resolution of symptoms, suggesting that the neurobiology of affective disorders is incompletely understood. Until now retinoids have not been considered as possible contributors to affective disorders. Retinoids represent a family of compounds derived from vitamin A that perform a large number of functions, many via the vitamin A product, retinoic acid. This signaling molecule binds to specific retinoic acid receptors in the brain which, like the glucocorticoid and thyroid hormone receptors, are part of the nuclear receptor superfamily and regulate gene transcription. Research in the field of retinoic acid in the CNS has focused on the developing brain, in part stimulated by the observation that isotretinoin (13-cis retinoic acid), an isomer of retinoic acid used in the treatment of acne, is highly teratogenic for the CNS. More recent work has suggested that retinoic acid may influence the adult brain; animal studies indicated that the administration of isotretinoin is associated with alterations in behavior as well as inhibition of neurogenesis in the hippocampus. Clinical evidence for an association between retinoids and depression includes case reports in the literature, studies of health care databases, and other sources. A preliminary PET study in human subjects showed that isotretinoin was associated with a decrease in orbitofrontal metabolism. Several studies have shown that the molecular components required for retinoic acid signaling are expressed in the adult brain; the overlap of brain areas implicated in retinoic acid function and stress and depression suggest that retinoids could play a role in affective disorders. This report reviews the evidence in this area and describes several systems that may be targets of retinoic acid and which contribute to the pathophysiology of depression.

Pharmacologic Modulation of Sebaceous Gland Activity: Mechanisms and Clinical Applications

Acne vulgaris is a common skin condition seen by physicians. It primarily affects adolescents, but can continue into adulthood. A key factor in the pathogenesis of acne is sebum production. Typical therapy includes combinations of topical retinoids and antimicrobials for mild acne, with the addition of oral antibiotics for moderate to severe disease. In the most recalcitrant cases or for nodulocystic acne, oral retinoids are indicated. In women who fail to respond to conventional treatment, hormonal therapy is often used adjunctively. Only isotretinoin and hormonal therapy improve acne via their action on the sebaceous glands. This article focuses on the mechanisms by which these treatment modalities act on the sebaceous glands and their clinical use in the practice of medicine.