Isotretinoin in dermatology

Efficacy and safety of low-level light therapy by delicate pulsed light combined with low-dose oral isotretinoin for the treatment of acne vulgaris: a randomized split-face study

Acne vulgaris (AV) is a common dermatosis that causes psychological problems. Isotretinoin is the first-line treatment for moderate-to-severe AV, but its onset of effect is delayed. Although light-based therapy is widely used in the treatment of AV, there is a lack of reports on delicate pulsed light (DPL) which has a narrow therapeutic spectrum (500-600 nm). Low-level light therapy (LLLT) has shown an emerging role in anti-inflammatory effects and skin repair. This study investigates the efficacy and safety of low-dose oral isotretinoin combined with LLLT using DPL in patients with moderate-to-severe AV. Thirty-six patients with moderate-to-severe AV were enrolled and received low-dose oral isotretinoin (10-20 mg/day). The two sides of the face were randomly assigned to receive DPL (6-9 J/cm²) or not at an interval of 2 weeks for 4 treatment sessions (weeks 0, 2, 4, 6). Photos, GAGS score, counts of papules, pustules, comedones, TEWL, melanin and erythema index, side effects, efficacy, and satisfactory score were recorded at each visit and at 4 weeks after the final treatment (week 10). Thirty-three patients completed the study. DPL and oral isotretinoin combined therapy exhibited significantly improved GAGS score as well as the number of the lesions from week 2 and maintained until week 10. At the end of the observation, the improvement of GAGS was 70.88% on the DPL and isotretinoin combined side versus 62.12% on the side with isotretinoin monotherapy (p = 0.0009). The improvement for papule number was 61.58% on the DPL combined side versus 43.33% on the control side (p < 0.0001), for comedone was 63.15% versus 43.30% (p = 0.0008). TEWL and indexes of melanin and erythema also had better outcomes with DPL combined therapy at week 10. All the side effects were temporary and tolerable; no adverse effects were observed. Oral low-dose isotretinoin combined with LLLT by DPL offers a combination with reduced side effects and better outcomes within a limited treatment duration, which advances the onset of effect of isotretinoin monotherapy and improves lesion clearance.

Co-delivery of isotretinoin and clindamycin by phospholipid-based mixed micellar system confers synergistic effect for treatment of acne vulgaris

BACKGROUND

The combination therapy of Isotretinoin (ITR) and antibacterial formulations administered through topical route suffer from several limitations including reduced therapeutic efficacy and low patient-compliance.

EXPERIMENT

The present study aimed to develop biocompatible lipid-based mixed micelles of ITR in combination with Clindamycin phosphate (CLIN) employing self-assembly method to improve its skin delivery, photostability, biocompatibility and pharmacodynamic efficacy.

RESULTS

The MTT assay and cellular uptake studies showed non-cytotoxic effect to HaCat cell lines. The zone of inhibition studies conducted in Propionibacterium acnes provides the first literature evidence to support the antimicrobial property of Isotretinoin and Tretinioin. The nano-sized carriers offered (19.3 ± 1.03 nm particle size with -3.12 mV zeta potential) enhanced permeation, skin retention, pre-clinical efficacy and significant skin biocompatibility. The testosterone-induced acne model proved superior pharmacodynamic efficacy of lab developed formulation vis-à-vis marketed products of both the drugs. The results were further confirmed by the histopathological studies of respective skin samples treated with different formulations.

CONCLUSION

The lab developed lipid-based micellar formulation of ITR and CLIN offers a better strategy for the combined delivery of unstable molecules like ITR and CLIN in acne management.

Effects of ısotretinoin on the growth rate and thickness of the nail plate

BACKGROUND

Isotretinoin has various effects on nails. However, the mechanism of how isotretinoin affects the nail plate is unknown. We aimed to investigate the effects of isotretinoin on morphology, growth rate, and thickness of the nail plate.

METHODS

A total of 70 acne vulgaris patients treated with isotretinoin and a control group consisting of 68 healthy volunteers were included in the study. Isotretinoin treatment was started at a dose of 0.5 mg/kg per day. Nail changes were noted; length and thickness of the nail plate were measured in all participants every month.

RESULTS

The medians of nail growth rates in the isotretinoin and control groups were 3.16 (2.87-3.57) mm/month and 2.89 (2.56-3.19) mm/month, respectively. The medians of nail thickness in the isotretinoin and control groups were 0.47 (0.38-0.53) mm and 0.50 (0.40-0.65) mm, respectively. Statistically significant differences were observed between the groups in terms of nail growth rate and thickness (P < 0.01, P = 0.02, respectively). Nail findings were observed in nine out of 70 patients (12.8%), mostly onychoschizia.

CONCLUSION

Isotretinoin gradually increases the nail growth rate and thins the nail plate over time during the course of isotretinoin treatment. Dermatologists prescribing isotretinoin should also consider the nail changes, which may impact the life quality of patients.

The effect of oral isotretinoin on visual contrast sensitivity and amount of lacrimation in patients with acne vulgaris

CONTEXT

Acne vulgaris is a puberty-onset chronic inflammatory disease of the pilosebaceous unit. Isotretinoin is a derivative of vitamin A commonly used for severe and nodulocystic acne. While isotretinoin has many side effects related to the eye, visual system and lacrimation, there is no information regarding isotretinoin's influence on contrast sensitivity.

AIM

To investigate the effect of isotretinoin on visual contrast sensitivity and the amount of lacrimation.

MATERIALS AND METHODS

The study included 25 patients (16 females and 9 males) who underwent isotretinoin treatment. The treatment duration ranged from 4 to 7 months. Patients were examined both before the start and at the end of treatment using the Schirmer test in each eye. The contrast sensitivity measurement was performed both individually for each eye and in a binocular fashion using the Pelli-Robson Sensitivity Chart.

RESULTS

The results of the Schirmer test before treatment were 19.74 ± 3.63 mm for the right eye and 19.66 ± 3.63 mm for the left eye. Post-treatment measurement results were 17.24 ± 3.5 mm for the right eye and 16.68 ± 3.73 mm for the left eye. There was a statistically significant difference between the before and after treatment measurements (p < 0.000). Before treatment, contrast sensitivity was 1.45 ± 0.19 for the right eye and 1.42 ± 0.2 for the left eye. The binocular measurement was 1.54 ± 0.14. After treatment, the right eye was 1.47 ± 0.19, the left eye was 1.46 ± 0.18, and the binocular measurement was 1.54 ± 0.18. There were no statistically significant differences between before and after treatment (p > 0.05).

DISCUSSION

There are contradicting reports on the results of the Schirmer test. The only similar study that has evaluated contrast sensitivity used the drug acitretin, the results of which are consistent with those the present study.

CONCLUSION

Our study is significant in that it is the first to investigate the effects of isotretinoin on visual contrast sensitivity that is closely associated with real-world performance. Our results need to be supported by future studies.

Psoriasis treatment: Unconventional and non-standard modalities in the era of biologics

Psoriasis is a potentially debilitating inflammatory dermatosis affecting 0.2%-4.8% of the population worldwide causing a significant occupational, personal or psychosocial morbidity to these patients for life. The basic aim of psoriasis therapy is to control the disease to maximum possible extent and improve the patient’s quality of life. Management of triggers for flare-ups, lifestyle modifications, and dietary supplements are often recommended. Intermittent or rotational therapy with frequent alterations in treatment options is usually needed to reduce toxicity of anti-psoriatic drugs in the absence of safer alternatives. Currently, several biological agents categorized as either T-cell targeted (e.g., Alefacept, Efalizumab) or cytokine modulating (e.g., Adalimumab, Infliximab, Etanercept) are available for treating severe psoriasis. However, their high cost is often precluding for most patients. The usefulness of systemic (methotrexate, cyclosporine, acitretin or several other therapeutic agents) or topical (tar, anthralin, corticosteroids or calcipotriol ointments, phototherapy with or without psoralens) therapies has been well established for the management of psoriasis. The literature is also replete with benefits of less used non-standard and unconventional treatment modalities (hydroxycarbamide, azathioprine, leflunomide, mycophenolate mofetil, isotretinoin, fumarates, topical calcineurin inhibitors, peroxisome proliferator-activated receptors agonists, statins, sulfasalazine, pentoxifylline, colchicine, grenz ray therapy, excimer laser, climatotherapy and balneophototherapy, peritoneal dialysis, tonsillectomy, ichthyotherapy, etc.). These can be used alternatively to treat psoriasis patients who have mild/minimal lesions, are intolerant to conventional drugs, have developed side effects or achieved recommended cumulative dose, where comorbidities pose unusual therapeutic challenges, or may be as intermittent, rotational or combination treatment alternatives.

The use of isotretinoin in acne

Systemic isotretinoin remains the most efficacious treatment for severe acne as well as many cases of more moderate disease that are unresponsive to other treatment modalities. The current chapter outlines the mechanisms behind the excellent efficacy, describes how to optimize treatment, reviews the recommended guidelines for monitoring and summarizes adverse effects.

Low-dose isotretinoin in the treatment of acne vulgaris

BACKGROUND

The efficacy of isotretinoin at 0.5 to 1.0 mg/kg per day in the treatment of acne is well established and considered safe, although it is sometimes not easily tolerated because of its cutaneous side effects.

OBJECTIVE

The purpose of this study was to determine the efficacy of low-dose isotretinoin in the treatment of acne.

METHODS

In this prospective, noncomparative, open-label study, 638 patients, both male and female, with moderate acne were enrolled and treated with isotretinoin at 20 mg/d (approximately 0.3-0.4 mg/kg per day) for 6 months. The patients were divided into two age groups: 12 to 20 and 21 to 35 years old. Patients were evaluated at 2-month intervals by means of clinical and laboratory examinations. A 4-year follow-up was also carried out.

RESULTS

At the end of the treatment phase, good results were observed in 94.8% of the patients aged 12 to 20 years, and in 92.6% of the patients aged 21 to 35 years. Failure of the treatment occurred in 5.2% and 7.4% of the two groups, respectively. Twenty-one patients dropped out of the study because of lack of compliance, and another patient discontinued participation because of a laboratory side effect. During the 4-year follow-up period, relapses of the acne occurred in 3.9% of the patients aged 12 to 20 years and in 5.9% of the patients aged 21 to 35 years. Elevated serum lipid levels (up to 20% higher than the upper limit of normal value) were found in 4.2% of the patients and abnormal (<twice the upper limit of normal values) liver tests were observed in 4.8%.

LIMITATIONS

This was a noncomparative, open-label study.

CONCLUSION

Six months of treatment with low-dose isotretinoin (20 mg/d) was found to be effective in the treatment of moderate acne, with a low incidence of severe side effects and at a lower cost than higher doses.