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

The role of current synthetic and possible plant and marine phytochemical compounds in the treatment of acne

Acne is a long-standing skin condition characterized by plugged hair follicles due to the accumulation of dead skin cells, sebum, and Propionibacterium acnes (P. acnes) bacteria, causing inflammation, and the formation of pimples or lesions. Acne was recognized in the ancient times by the ancient Egyptians, Greeks, and Romans. Since ancient times, folk medicine from different cultures have comprised herbal and natural products for the treatment of acne. Current acne medications include antibiotics, keratolytics, corticosteroids, in addition to hormonal therapy for women. However, these conventional drugs can cause some serious side effects. And therefore, seeking new safe treatment options from natural sources is essential. Plants can be a potential source of medicinal phytochemicals which can be pharmacologically active as antibacterial, antioxidant, anti-inflammatory, keratolytic and sebum-reducing. Organic acids, obtained from natural sources, are commonly used as keratolytics in dermatology and cosmetology. Most of the promising phytochemicals in acne treatment belong to terpenes, terpenoids, flavonoids, alkaloids, phenolic compounds, saponins, tannins, and essential oils. These can be extracted from leaves, bark, roots, rhizomes, seeds, and fruits of plants and may be incorporated in different dosage forms to facilitate their penetration through the skin. Additionally, medicinal compounds from marine sources can also contribute to acne treatment. This review will discuss the pathogenesis, types and consequences of acne, side effects of conventional treatment, current possible treatment options from natural sources obtained from research and folk medicine and possible applied dosage forms.

Acne treatment: research progress and new perspectives

Acne is a chronic inflammatory skin disease that primarily affects adolescents and is attributed to various factors, including hormonal changes, genetic predisposition, and environmental influences. It typically manifests in areas rich in sebaceous glands such as the face, chest, and back. Symptoms of acne can range from mild to severe and may present as pimples, pustules, nodules, cysts, and scarring. The appearance of acne can significantly impact both the physical and mental well-being of patients, potentially leading to feelings of anxiety, depression, and social withdrawal. The pathogenesis of acne is multifaceted involving genetic predisposition as well as environmental factors such as hormonal imbalances, inflammation, abnormal follicular sebaceous unit keratinization, proliferation of follicular microorganisms like Propionibacterium acnes, increased sebum production, and dietary influences. Traditional treatment methods for acne include topical drug therapy, oral drug therapy, photoelectric therapy, and chemical peeling. With ongoing research into the pathogenesis of acne, treatment methods are rapidly evolving with novel antibiotics, probiotics, biological agents, topical anti-androgen drugs, topical vitamin A acid metabolism blockers, antimicrobial peptides, immunotherapy, micro-needling, and micro-needling patches. This article aims to provide a comprehensive review of recent advancements in acne treatment.

Identification of Novel Protein Biomarkers and Drug Targets for Acne Vulgaris by Integrating Human Plasma Proteome with Genome-Wide Association Data

Background

Despite the availability of numerous therapies, the treatment of acne vulgaris remains challenging. Novel drug targets for acne vulgaris are still needed.

Methods

We conducted a Mendelian randomization analysis to explore possible drug targets for acne vulgaris. We utilized summary statistics obtained from the dataset of acne vulgaris, including 399,413 individuals of European ancestry. We gathered genetic instruments for 566 plasma proteins from genome-wide association studies. In order to strengthen the findings from Mendelian randomization, various methods were employed, including bidirectional Mendelian randomization analysis, Bayesian co-localization, phenotype scanning, and single-cell analysis. These methods facilitated the identification of reverse causality, the search for reported variant-trait associations, and the determination of the cell types that is the primary source of protein. Furthermore, using the plasma proteins in the deCODE cohort, we conducted a replication of the Mendelian randomization analysis as an external validation.

Results

At the significance level of Bonferroni (P < 8.83×10-5), a protein-acne pair was discovered through Mendelian randomization analysis. In plasma, increasing TIMP4 (OR = 1.15; 95% CI, 1.09-1.21; P = 1.01×10-7) increased the risk of acne vulgaris. The absence of reverse causality was observed in the TIMP4 protein. According to Bayesian co-localization analysis, TIMP4 shared the same variant with acne vulgaris (PPH4 = 0.93). TIMP4 was replicated in deCODE cohort (OR = 1.17; 95% CI, 1.10-1.24; P = 1.48×10-7). Single-cell analysis revealed that TIMP4 was predominantly detected in myeloid cells in blood, and was detected in almost all cell types in skin tissue.

Conclusion

The integrative analysis revealed that the level of plasma TIMP4 has a direct influence on the risk of developing acne vulgaris. This implies that TIMP4 protein could serve as a potential target for the development of drugs aimed at treating acne vulgaris.

[Translated article] Iberia Consensus on Strategies to Prevent and Manage Irritation by Topical Retinoids in Facial and Trunk Acne

OBJECTIVE

To assess the level of agreement on various prevention and management strategies for irritation caused by topical retinoids in facial and trunk acne in an attempt to alleviate it and minimize treatment discontinuations as much as possible.

METHOD

After reviewing the scientific medical literatura currently available, 4 different areas of uncertainty in the management of irritation caused by topical retinoids in acne were identified. A questionnaire with 34 recommendations was created and evaluated by a group of 133 dermatologists (Delphi methodology).

RESULTS

In 82.3% of the recommendations (28 out of 34), some level of agreement was reached (≥85% agreement in 22 recommendations and≥70% agreement in 6). The results with the highest level of agreement focused on specific patient education strategies (explaining that irritation is an expected reaction at the beginning of treatment and tends to decrease over time), gradual and/or spaced application of topical retinoids (at night time to prevent and/or reduce skin irritation), and the importance of using adjuvant products, specific for acne-prone skin, hydration, photoprotection, and skin cleansing. These recommendations reflect a comprehensive approach to managing irritation associated with topical retinoids and promoting long-term adherence.

CONCLUSIONS

Skin irritation caused by topical retinoids in facial and trunk acne is an expected, mild, and controllable reaction if proper prevention and management guidelines are followed, meaning that it should not be a reason for treatment discontinuation.

Bidirectional Effect of Triphala on Modulating Gut-Brain Axis to Improve Cognition in the Murine Model of Alzheimer's Disease

SCOPE

The emerging role of gut microbiota and their metabolites in the modulation of the gut-brain axis has received much attention as a new hope for the treatment of hard-to-treat chronic neurodegenerative diseases like Alzheimer's disease. The naturally occurring polyphenols can restore the gut-brain axis by modulating gut microbiota and brain neurotransmitters. The Indian traditional medicine Triphala, a rich source of polyphenols, has been used on humans based on Prakriti or disease conditions for many years.

METHODS AND RESULTS

In this study, the dual mode (morning and evening) action of Triphala is used to provide scientific evidence of its superior preventive and therapeutic efficacy in C57BL/6 and 5xFAD, APP/PS1 transgenic mouse model of Alzheimer's disease. The study observes that Triphala treatment has significantly improved cognitive function, by modulating the APP pathway, reducing inflammation, and restoring the gut-brain axis by increasing the gut microbiota phyla of Bacteroides, Proteobacteria, Actinobacteria, etc., involved in maintaining the gut homeostasis.

CONCLUSIONS

The study paves a new path for using dual modes of Triphala alone or in combination to treat incurable AD.

Correlation between depression scores and serum NF-ĸB/NLRP3 axis, biotinidase, and HMGB1 after treatment with isotretinoin in patients with acne vulgaris

BACKGROUND

Acne vulgaris (AV) is an inflammatory skin disorder leading to scars and discomfort, its intensity has major psychological consequences such as depression.

AIM

To investigate the effect of isotretinoin (ISO) on NF-κB/NLRP3, biotinidase, and HMGB and correlation with depression.

PATIENTS AND METHODS

This was a case-control study that involved two groups. Group 1 is 20 healthy control, and group 2 is 20 patients diagnosed with AV according to Global Acne Grading System (GAGS) and received 20 mg ISO for 2 months. Before and after therapy, the Hamilton Depression Rating Scale (HDRS) was applied to assess each participant's level of depression. Nuclear factor kappa B (NF-ĸB), biotinidase, high mobility group box protein (HMGB1), nucleotide-binding domain, leucine-rich-containing family, and pyrin domain-containing-3 (NLRP-3) were measured in serum samples.

RESULTS

There was no significant difference in all measured markers of healthy group before and after 2 months. Regarding group 2, there was a statistically significant decrease in all measured markers after 2 months of treatment and significant correlations between GAGS, NF-ĸB, HMGB1, NLRP3, biotinidase, and depression score.

CONCLUSION

Increased GAGS, HMGB1, NLRP3, and biotinidase were associated with depression severity in AV patients and ISO treatment significantly reduced these parameters and reduced depressive symptoms.

Crystalline lens clarity in patients treated with isotretinoin

CLINICAL RELEVANCE

Isotretinoin has been the best treatment option for moderate and severe acne vulgaris since the 1980s. Some studies have shown evidence of subclinical anterior segment involvement of the eye in patients treated with isotretinoin.

BACKGROUND

This study aimed to evaluate lens clarity with the densitometry software of Scheimpflug tomography in patients treated with isotretinoin and to compare with healthy control subjects.

METHODS

Thirty-seven acnepatients treated with isotretinoin who met the inclusion criteria (24 males and 13 females, mean age 22.94 ± 4.21 years) and 39 healthy control subjects were included in the study. Clinical characteristics of the isotretinoin and control subjects were recorded. Lens density was evaluated with the densitometry software of the Scheimpflug tomography device (PentacamHR, Oculus, Wetzlar, Germany).

RESULTS

There was no statistically significant difference between the groups in age, gender distribution, spherical equivalent, or anterior segment parameters measured by the Pentacam system (p > 0.05 for all). Lens density values in zones 2 and 3 were significantly higher in the isotretinoin group (p = 0.042, p < 0.001) and positively correlated with cumulative isotretinoin dose (zone 2: r = 0.384, p = 0.032; zone 3: r = 0.384, p = 0.005).

CONCLUSION

Zone 2 and zone 3 lens density are higher in patients treated with isotretinoin when compared to healthy controls.

Knowledge, Attitude, and Risk Perception in Oral Isotretinoin Use: A Cross-Sectional Study from Jordan

The most prevalent skin condition is acne vulgaris. Recent clinical practice guidelines recommend oral isotretinoin to treat moderate-to-severe acne. The aim of this study is to assess the knowledge, attitude, and risk perception of oral isotretinoin for acne treatment. This is a cross-sectional descriptive study conducted in the country of Jordan. The study sample includes people resident in Jordan aged ≥14 years who have been treated with oral isotretinoin for acne. The study involved 373 participants who previously used oral isotretinoin for skin disorders. Most were Jordanian (89.3%), aged 19-25 (37.3%), and from the central region (82.8%). Mostly, they used isotretinoin for severe or mild acne (25.2% and 24.1%, respectively), rosacea (4.1%), or to alleviate acne scars. Surprisingly, 58.1% did not consult their specialist for side effects, and 20% shared their treatment. The average proper use score was 9.98 out of 16. A link was found between higher risk knowledge scores and proper use scores. Side effects such as nausea, irregular heartbeat, and pancreatitis affected some users (11.5%, 10.5%, 7.0%, and 3.2%, respectively). Knowledge about isotretinoin's risks varied, with percentages recognizing teratogenicity (57.7%), liver damage (52.6%), and lipid profile effects (37.2%), while 25% believed that they had no side effects. The study revealed partial adherence to oral isotretinoin guidelines, with gaps in monitoring and consultation. A positive correlation emerged between risk knowledge and proper usage, emphasizing the need for comprehensive education and monitoring strategies in isotretinoin therapy for skin disorders.

Metformin Therapy for Acne Vulgaris: A Meta-Analysis

Acne vulgaris is a common disease, which occurs in adolescents as well as adults and has a significant influence on the patient's quality of life (QoL) in every aspect. Due to resistance to standard therapies, it has become necessary to prospect for new treatment strategies. It is important to highlight that the diagnosis and treatment of the underlying cause of acne such as metabolic and hormonal disorders may significantly improve the effectiveness of acne treatment. The correlation between Insulin Resistance (IR) and acne has been proven. Both disorders share many common occurrence factors and activation pathways. Metformin, an antihyperglycemic agent, seems to be a possible therapy option, not only because of its insulin sensitizing ability but also via plenty of additional effects of this medicine. While the efficiency of metformin therapy in patients with acne and Polycystic Ovary Syndrome (PCOS) is well explored, it is still necessary to evaluate it in patients without any endocrinopathies. This meta-analysis aimed to estimate the effectiveness of oral metformin as a monotherapy in acne patients without PCOS or other endocrinopathies. Study selection was performed with included criteria such as no PCOS and other endocrinopathies diagnosed, oral administration of metformin, and metformin in monotherapy. Selected studies contained comparisons in the Global Acne Grading System (GAGS) before and after metformin therapy. Statistical analysis detected significant improvement in skin condition after treatment with metformin.

Exploring Acne Treatments: From Pathophysiological Mechanisms to Emerging Therapies

Acne vulgaris is a common dermatological condition that can present across different ages but predominantly affects adolescents and young adults. Characterized by various lesion types, the pathogenesis of acne is complex, involving genetic, hormonal, microbial, and inflammatory factors. This review comprehensively addresses current and emerging acne management strategies, emphasizing both topical and systemic treatments, procedural therapies, and dietary modifications. Key topical agents include retinoids, benzoyl peroxide, antibiotics, and other specialized compounds. Systemic options like antibiotics, hormonal therapies, and retinoids offer significant therapeutic benefits, particularly for moderate to severe cases. Procedural treatments such as laser devices, photodynamic therapy, chemical peels, and intralesional injections present viable alternatives for reducing acne symptoms and scarring. Emerging therapies focus on novel biologics, bacteriophages, probiotics, and peptides, providing promising future options. This review underscores the importance of personalized approaches to treatment due to the multifaceted nature of acne, highlighting the potential of innovative therapies for improving patient outcomes.

Structure-Activity Relationships and Therapeutic Applications of Retinoids in View of Potential Benefits from Drug Repurposing Process

Vitamin A, an essential micronutrient, is integral to various biological processes crucial for organismal development and maintenance. Dietary sources of vitamin A encompass preformed retinol, retinyl esters, and provitamin A carotenoids. Retinoic acid (RA), a key component, plays pivotal roles in vision, cell proliferation, apoptosis, immune function, and gene regulation. Drug repurposing, an effective strategy for identifying new therapeutic applications for existing drugs, has gained prominence in recent years. This review seeks to provide a comprehensive overview of the current research landscape surrounding retinoids and drug repurposing. The scope of this review encompasses a comprehensive examination of retinoids and their potential for repurposing in various therapeutic contexts. Despite their efficacy in treating dermatological conditions, concerns about toxicity persist, driving the search for safer and more potent retinoids. The molecular mechanisms underlying retinoid activity involve binding to retinoic acid receptors (RARs) and retinoid X receptors (RXRs), leading to transcriptional regulation of target genes. This review seeks to shed light on the possibilities for repurposing retinoids to cover a wider spectrum of therapeutic uses by exploring recent scientific progress. It also aims to offer a more comprehensive understanding of the therapeutic prospects of retinoids and the broader impact of drug repositioning in contemporary medicine.

Association Between Baseline Serum Lipids and Severity of Dry Eye Symptoms in Acne Patients Treated with Isotretinoin

BACKGROUND

Isotretinoin is a commonly prescribed medication for moderate-to-severe acne. Elevated triglycerides and total cholesterol, as well as eye dryness, are frequent side effects of isotretinoin.  Objective: This study aims to examine the association between serum baseline levels of triglycerides and total cholesterol with regards to the severity of dry eye symptoms in acne patients treated with isotretinoin.

METHOD

The study was a retrospective review of acne patients treated with isotretinoin for at least four months at the dermatology clinics of Qassim University Medical City, Saudi Arabia. Thirty patients were included in the study as they met the inclusion criteria. Baseline levels of triglycerides and total cholesterol were reviewed for these patients. The Ocular Surface Disease Index (OSDI) questionnaire was sent and filled out by the study participants to assess the severity of eye dryness.

RESULT

30 patients were included in the study, with 16 (53.3%) females and 14 (46.7%) males. The average age of participants was 22.1 years. The duration of treatment was between 120 and 140 days in 13 (43.3%) participants and 140 and 180 days in 17 (56.7%) participants. The mean ± 1 standard deviation (SD) was reported for each of the three variables, with an Ocular Surface Disease Index (OSDI) score of 27.6 ± 19.2, a baseline total cholesterol of 4.4 ± 0.9 mmol/L, and a baseline triglyceride level of 0.83 ± 0.4 mmol/L. Using a multiple linear regression model, baseline triglycerides and total cholesterol were used as predictors of the OSDI score. There was a significant dependent interaction between baseline total cholesterol and triglycerides and their effect on the OSDI score, with a higher OSDI score at higher levels of both triglycerides and cholesterol and a lower OSDI score at lower levels of both triglycerides and cholesterol. The study result showed that, in acne patients treated with isotretinoin for at least four months, a higher baseline level of both triglycerides and total cholesterol is associated with worse dry eye symptoms compared to those with lower baseline levels.

CONCLUSION

 The study concluded that baseline levels of triglycerides and total cholesterol are both significant predictors of the severity of dry eye symptoms in acne patients treated with isotretinoin. Despite study limitations due to the small sample size, we hope that, based on our findings, this will open the door to future studies with a larger sample size to further confirm our findings generalize the result, and apply it to clinical practice so that clinicians may identify those at higher risk of severe eye dryness before starting isotretinoin and subsequently be able to recommend specific measures to minimize symptoms of eye dryness.

Acne treatment challenges - Recommendations of Latin American expert consensus

BACKGROUND

Acne is a chronic inflammatory disorder of the pilosebaceous unit that is associated with a negative impact on quality of life, causing anxiety, depression, and poor self-esteem. The treatment of acne is not simple and presents some new challenges. This article addresses important issues faced by dermatologists on their daily, some of them specific for Latin America.

OBJECTIVE

To discuss daily practice recommendations when managing acne patients.

METHODS

A literature review was conducted by a group of eight experts with extensive experience in the field of acne. The results of the data review were presented at an initial kick-off meeting to align the consensus topics. Two e-surveys using the Delphi methodology and an interim group webinar meeting were held.

RESULTS

The expert panel reached a consensus on all proposed key statements, providing scientific support to help dermatologists and healthcare providers make acne management decisions on topics that can be challenging in the everyday practice of dermatology, such as the characteristics of Generation Z or the importance of the maintenance phase of adult acne treatment.

CONCLUSION

This article provides current recommendations for managing acne patients. The high level of agreement achieved based on the latest evidence supports the best acne therapeutic choices in both established topics and new important issues that have emerged in recent years, such as the impact of social media, Generation Z characteristics, and transgender male patient specifics.

Iberia Consensus on Strategies to Prevent and Manage Irritation by Topical Retinoids in Facial and Trunk Acne

OBJECTIVE

To assess the level of agreement on various prevention and management strategies for irritation caused by topical retinoids in facial and trunk acne in an attempt to alleviate it and minimize treatment discontinuations as much as possible.

METHOD

After reviewing the scientific medical literatura currently available, 4 different areas of uncertainty in the management of irritation caused by topical retinoids in acne were identified. A questionnaire with 34 recommendations was created and evaluated by a group of 133 dermatologists (Delphi methodology).

RESULTS

In 82.3% of the recommendations (28 out of 34), some level of agreement was reached (≥85% agreement in 22 recommendations and≥70% agreement in 6). The results with the highest level of agreement focused on specific patient education strategies (explaining that irritation is an expected reaction at the beginning of treatment and tends to decrease over time), gradual and/or spaced application of topical retinoids (at night time to prevent and/or reduce skin irritation), and the importance of using adjuvant products, specific for acne-prone skin, hydration, photoprotection, and skin cleansing. These recommendations reflect a comprehensive approach to managing irritation associated with topical retinoids and promoting long-term adherence.

CONCLUSIONS

Skin irritation caused by topical retinoids in facial and trunk acne is an expected, mild, and controllable reaction if proper prevention and management guidelines are followed, meaning that it should not be a reason for treatment discontinuation.

Isotretinoin-unresponsive acne as a sign of a congenital disorder: a case of 21-hydroxylase deficiency

Acne is a multifactorial and common disorder among young people and a frequent reason for dermatology consultation. When moderate-to-severe acne is not responsive to conventional treatments, oral isotretinoin is a very effective solution. However, there are cases in which this treatment fails to produce the expected results. In this case, an 18-year-old male patient with acne, unresponsive to traditional acne therapies, experienced only a partial benefit from oral isotretinoin. Endocrinology consultation and hormonal work-up revealed androgen metabolism anomalies suggestive of a non-classical form of congenital adrenal hyperplasia due to 21-hydroxylase deficiency. In this case report, the authors discuss when to suspect, how to diagnose, and how to manage similar cases.

Effect of isotretinoin on CYP2D6 and CYP3A activity in patients with severe acne

AIMS

Previously, retinoids have decreased CYP2D6 mRNA expression in vitro and induced CYP3A4 in vitro and in vivo. This study aimed to determine whether isotretinoin administration changes CYP2D6 and CYP3A activities in patients with severe acne.

METHODS

Thirty-three patients (22 females and 11 males, 23.5 ± 6.0 years old) expected to receive isotretinoin treatment completed the study. All participants were genotyped for CYP2D6 and CYP3A5. Participants received dextromethorphan (DM) 30 mg orally as a dual-probe substrate of CYP2D6 and CYP3A activity at two study timepoints: pre-isotretinoin treatment and with isotretinoin for at least 1 week. The concentrations of isotretinoin, DM and their metabolites were measured in 2-h postdose plasma samples and in cumulative 0-4-h urine collections using liquid chromatography-mass spectrometry.

RESULTS

In CYP2D6 extensive metabolizers, the urinary dextrorphan (DX)/DM metabolic ratio (MR) (CYP2D6 activity marker) was numerically, but not significantly, lower with isotretinoin administration compared to pre-isotretinoin (geometric mean ratio [GMR] [90% confidence interval (CI)] 0.78 [0.55, 1.11]). The urinary 3-hydroxymorphinan (3HM)/DX MR (CYP3A activity marker) was increased (GMR 1.18 [1.03, 1.35]) and the urinary DX-O-glucuronide/DX MR (proposed UGT2B marker) was increased (GMR 1.22 [1.06, 1.39]) with isotretinoin administration compared to pre-isotretinoin.

CONCLUSIONS

Administration of isotretinoin did not significantly reduce CYP2D6 activity in extensive metabolizers, suggesting that the predicted downregulation of CYP2D6 based on in vitro data does not translate into humans. We observed a modest increase in CYP3A activity (predominantly CYP3A4) with isotretinoin treatment. The data also suggest that DX glucuronidation is increased following isotretinoin administration.

Alterations in Alanine Transaminase, Aspartate Transaminase, Gamma-Glutamyl Transpeptidase, and Creatine Kinase in Acne Patients Undergoing Isotretinoin Treatment: A Retrospective Evaluation of Laboratory Tests

Background Isotretinoin therapy is a commonly prescribed medication by dermatologists for the treatment of acne. Regular laboratory assessments are recommended throughout the treatment period to detect any potential complications. Objectives This study aims to present the alterations in laboratory parameters throughout the course of isotretinoin therapy and identify required diagnostic testing. Methods This study involved 136 patients undergoing isotretinoin treatment at doses of 0.3-0.5 mg/kg/day, with ages ranging from 18 to 41 years. A retrospective evaluation was conducted on biomarkers including aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transpeptidase (GGT), creatine kinase (CK), triglycerides, total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), hemoglobin, white blood cells, and thrombocytes. Levels of these parameters were analyzed prior to treatment and at the third month of treatment from the records of patients and the data were compared statistically. Moreover, the parameters of ALT, AST, CK, and GGT were graded objectively, and any alterations were noted in the patients. Results The levels of ALT, AST and GGT, along with triglycerides, total cholesterol, LDL-C, and thrombocyte levels showed significant elevation (p=0.001, p<0.001, p<0.001, p=0.001, p<0.001, p<0.001, and p=0.003, respectively). A significant decrease in HDL-C with hemoglobin was also noted (p=0.022, p=0.006, respectively). One patient (0.73%) exhibited grade 1 elevations in ALT, AST, and CK. One patient (0.73%) displayed grade 1 elevations in ALT and AST. One patient (0.73%) exhibited grade 1 elevations in AST and CK, while another patient (0.73%) had grade 1 elevation in AST and grade 3 elevation in CK. Furthermore, one patient (0.73%) had a grade 1 elevation exclusively in ALT, two patients (1.47%) had a grade 1 elevation exclusively in AST, and six patients (4.41%) exhibited a grade 1 elevation in CK only. No grade changes were observed in the GGT levels in the patients. Conclusion During isotretinoin treatment, changes in ALT and AST levels were more frequently associated with the muscle enzyme CK, while GGT levels remained unaffected. Therefore, GGT can be considered a reliable parameter for evaluating liver function in patients undergoing isotretinoin treatment.

Practices, Efficacy, and Reported Side Effects Associated with Isotretinoin Treatment in Palestine

Background

Isotretinoin is a commonly prescribed medication for the treatment of acne. It is associated with serious side effects that require monitoring and adherence by patients and healthcare providers. No studies have been conducted in Palestine to explore isotretinoin prescribing and utilization.

Objective

This study aims to evaluate the current clinical practices, adherence to clinical guidelines, efficacy, and reported side effects associated with Isotretinoin treatment in Palestine.

Methods

A descriptive cross-sectional online questionnaire-based study using social media platforms (eg, Facebook and Telegram) was conducted among Birzeit University students in April 2023. This study included participants aged ≥ 18 years with a history of isotretinoin treatment; subjects with incomplete data were excluded. Statistical significance was set at P < 0.05. SPSS version 27 was used for data analysis.

Results

A total of 548 participants were included in the study, the majority of most of whom were female (96%). The most predominant side effects were cracked, dry lips and xeroderma (96.2%). Moreover, 12% of participants had depression. Most respondents were educated about medication side effects and only 39.1% were counseled about blood donation. Of the 59 sexually active women, only 4 (6.8%) were asked for a recent pregnancy test. A total of 60.2% of dermatologists adhered to the American Academy of Dermatology (AAD) guidelines, and 48.7% ordered the required laboratory tests before initiating isotretinoin treatment. Only 1.7% of pharmacists followed the FDA-suggested protocols for dispensing isotretinoin to childbearing females.

Conclusion

Adherence to isotretinoin safety prescribing protocols to provide patient education, monitoring, and ordering of laboratories to ensure patient safety can be improved by adapting policies and protocols in pharmacy and medical practice in Palestine to monitor and enforce adherence when prescribing, dispensing, or taking high-risk medications.

Use of Oral Supplements and Topical Adjuvants for Isotretinoin-Associated Side Effects: A Narrative Review

Acne is a chronic inflammatory disease of the pilosebaceous unit with a multifactorial etiology and is one of the most common conditions treated by dermatologists and primary care physicians. Within an extensive and evolving treatment landscape, oral isotretinoin has demonstrated efficacy for treatment of severe, recalcitrant acne. Several side effects of isotretinoin have been reported, including laboratory abnormalities, mucocutaneous, and musculoskeletal effects, which may reduce compliance and patient satisfaction with treatment. In this narrative review, we aim to review the efficacy and safety profile of oral supplements or topical adjuvant therapies in mitigating isotretinoin-associated mucocutaneous and musculoskeletal side effects. Oral supplements reviewed include omega-3 fatty acids, vitamin E, folic acid and vitamin B12, antihistamines, l-carnitine, biotin, and combined oral supplements. Topical adjuvants include a hyaluronic acid, biosaccharide gum-2, and glycerine gel-cream; a nongreasy, noncomedogenic, fragrance-free moisturizing cream; dexpanthenol; trichloroacetic acid; and a combination cream. Most of the supplements and topical adjuvants demonstrated efficacy with an adequate level of supporting evidence and no reported adverse events, indicating an adequate safety profile. Patients on isotretinoin may benefit from using oral supplements and topical adjuvants to minimize primarily mucocutaneous side effects, increase adherence to treatment, and thereby improve overall outcomes.

Evaluation of the protective effects of curcumin-rich turmeric (Curcuma longa) extract against isotretinoin-induced liver damage in rats

AIM

The aim of this study was to evaluate the protective effect of curcumin-rich turmeric (CRT) extract against isotretinoin (ISO)-induced liver damage through routine biochemical parameters and oxidative stress parameters that indicate liver damage.

MATERIAL AND METHOD

42 albino Wistar rats of 200 g were randomly grouped as Group I: Healthy control, Group II: Sunflower oil, Group III: Curcumin 200 mg/kg, Group IV: ISO control groups (7.5 mg/kg), Group V: Curcumin 50 mg/kg + ISO 7.5 mg/kg, Group VI: Curcumin 100 mg/kg + ISO 7.5 mg/kg, Group VII: Curcumin 200 mg/kg + ISO 7.5 mg/kg. At the end, after the rats were killed, their blood and liver tissues were collected. ALT and AST levels in serum; superoxide dismutase activity (SOD), GSH, and MDA levels in liver tissue were determined.

RESULTS

Our results showed that ALT, AST, and MDA levels increased, and SOD and GSH levels decreased in the ISO-administered group compared to the healthy control group. CRT 50, 100, and 200 mg/kg groups were compared to ISO group. A dose-dependent increase in protective effect was observed. A decrease in ALT, AST, and MDA levels, and an increase in SOD and GSH levels were determined. A protective effect was found at all doses. The best protective effect was in the CRT 200 mg/kg group.

CONCLUSION

CRT extract can be considered a candidate herbal medicine for the elimination of liver damage in individuals using ISO. However, further experimental and clinical validation should be studied.

Emodin exhibits anti-acne potential by inhibiting cell growth, lipogenesis, and inflammation in human SZ95 sebocytes

Emodin, a natural anthraquinone derivative, possesses anti-proliferative and anti-inflammatory properties in skin diseases. However, little information is available on the efficacy of emodin in treating acne vulgaris (acne). This study aims to investigate the protective effects and potential mechanisms of emodin as an anti-acne agent. In vitro, SZ95 sebocytes was chose to establish an acneigenic cellular model. We found that emodin effectively inhibited proliferation, induced cell cycle arrest and apoptosis of SZ95 sebocytes in a dose-dependent manner. To evaluate the lipid-lowering potential of emodin, we examined the levels of lipid contents and lipogenic transcription factors, and found that both lipid production and protein expression of PPARγ, LXR α/β, and SREBP-1 were decreased after treatment with emodin. Furthermore, our results revealed that emodin inhibited sebaceous lipogenesis induced by insulin-like growth factor 1 (IGF-1), which was accompanied by a potent inhibition of the phosphoinositide-3-kinase (PI3K)/Akt/forkhead box protein O1 (FoxO1) pathway. In detail, emodin augmented the inhibitory effect of isotretinoin and PI3K inhibitor LY294002, while attenuating the activation of IGF-1 on PI3K/Akt/FoxO1 pathway. In addition, emodin could decrease the secretion of pro-inflammatory cytokines IL-6 and IL-8, and suppress the expression of NLRP3, capase-1, IL-1β, and IL-18 in SZ95 sebocytes exposed to Cutibacterium acnes. Overall, our study provides preliminary evidence supporting the anti-growth, anti-lipogenic and anti-inflammatory properties of emodin, indicating the potential therapeutic application of emodin for acne treatment.

Effect of systemic isotretinoin therapy on semen parameters

PURPOSE

Vitamin A has multiple functions in the human body, being involved in growth, epithelial differentiation, vision, immune function and reproduction. While normal spermatogenesis is influenced by several factors, it requires vitamin A. Systemic isotretinoin is a vitamin A derivative that is used in the treatment of many dermatological diseases, especially acne vulgaris (AV). There is limited research on the changes in semen parameters after systemic isotretinoin therapy in humans. Our study investigates the presence of varicoceles in patients undergoing systemic isotretinoin therapy for AV and examines whether there were any changes in the semen parameters before and after treatment.

METHODS

Included in the study were 46 men patients who were scheduled for systemic isotretinoin therapy for AV. Before treatment, the patients underwent a physical examination and ultrasonography for varicoceles assessment. The patients underwent spermiogram before treatment and after 6 months of treatment. The spermiogram assessments included semen volume, sperm concentration, total sperm count, progressive motility, viability and sperm morphology.

RESULTS

After treatment, there was an increase in semen volume, sperm concentration, total sperm count, progressive motility and vitality from the pre-treatment values, but a deterioration in the sperm morphology (p < .05). Comparing patients with and without varicoceles revealed more changes in semen parameters after treatment in those with varicoceles. There was a statistically significant difference in sperm concentration (p < .001).

CONCLUSIONS

Systemic isotretinoin therapy negatively affects sperm morphology, but has positive effect on other semen parameters, and these changes in semen parameters occur more frequently in patients with varicoceles.KEY MESSAGESAcne vulgaris is a very common disease and systemic isotretinoin is used as the most effective agent in its treatment.Systemic isotretinoin positively affects semen parameters except sperm morphology.Changes in semen parameters are more common in patients with varicocele.

A new perspective on isotretinoin in pregnancy: Pregnancy outcomes, evaluation of complex phenotypes, and importance of teratological counselling

OBJECTIVES

Teratogens are responsible for 5% of all known causes of congenital anomalies. Isotretinoin, a retinoic acid-derived agent, leads to congenital anomalies in 21-52% of cases when exposure occurs during pregnancy according to studies conducted before 2006. However, rates of congenital anomalies were much lower in later studies. The purpose of this study was to investigate the rates of congenital anomalies in isotretinoin exposure during pregnancy, isotretinoin exposure before pregnancy, and a control group unexposed to any teratogenic agents.

STUDY DESIGN

In this cohort study, we divided pregnant women admitted to our center between 2009 and 2020 into two groups: isotretinoin exposure before and during the pregnancy (n = 77) and isotretinoin exposure before the pregnancy (n = 75). We selected the control group from among the non-teratogen exposed pregnant women with a simple random sampling method. Obstetricians calculated the ages of all pregnancies via ultrasound (USG) (crown-rump diameter for the first trimester; biparietal diameter and femur length for the second trimester). After birth, a pediatric genetics specialist examined all babies. Whole-exome sequencing (WES) was conducted on the babies who displayed complex phenotypes.

RESULTS

Among the isotretinoin exposure before and during the pregnancy, isotretinoin exposure before the pregnancy, and the control groups, there were statistically significant differences in live births (respectively, 64.3 %, 88 %, 93.3 %), congenital anomalies (respectively, 28.6 %, 6.1 %, 1.4 %), miscarriages (respectively, 13 %, 2.7 %, 4 %), terminations (respectively, 32.5 %, 9.3 %, 2.7 %), and premature births (11.9 %, 16.7 %, 2.9 %) (respectively, p < 0.001, p < 0.001, p = 0.014, p < 0.001). We detected novel phenotypical features in five patients.

CONCLUSIONS

Our study demonstrated that study design, long-term follow-up, teratological counseling, and implementation of advanced molecular analysis in complex phenotypes with novel phenotypical features are beneficial for understanding the association of congenital anomalies with isotretinoin exposure. While evaluating congenital anomalies, we detected statistically significant differences between isotretinoin exposure before and during the pregnancy vs control, but we did not detect any statistically significant differences between isotretinoin exposure before the pregnancy and controls. Another finding of the study is that WES might be an efficient way to evaluate complex phenotypes in isotretinoin-exposed babies; however, further research is required.

Acne Transcriptomics: Fundamentals of Acne Pathogenesis and Isotretinoin Treatment

This review on acne transcriptomics allows for deeper insights into the pathogenesis of acne and isotretinoin's mode of action. Puberty-induced insulin-like growth factor 1 (IGF-1), insulin and androgen signaling activate the kinase AKT and mechanistic target of rapamycin complex 1 (mTORC1). A Western diet (hyperglycemic carbohydrates and milk/dairy products) also co-stimulates AKT/mTORC1 signaling. The AKT-mediated phosphorylation of nuclear FoxO1 and FoxO3 results in their extrusion into the cytoplasm, a critical switch which enhances the transactivation of lipogenic and proinflammatory transcription factors, including androgen receptor (AR), sterol regulatory element-binding transcription factor 1 (SREBF1), peroxisome proliferator-activated receptor γ (PPARγ) and signal transducer and activator of transcription 3 (STAT3), but reduces the FoxO1-dependent expression of GATA binding protein 6 (GATA6), the key transcription factor for infundibular keratinocyte homeostasis. The AKT-mediated phosphorylation of the p53-binding protein MDM2 promotes the degradation of p53. In contrast, isotretinoin enhances the expression of p53, FoxO1 and FoxO3 in the sebaceous glands of acne patients. The overexpression of these proapoptotic transcription factors explains isotretinoin's desirable sebum-suppressive effect via the induction of sebocyte apoptosis and the depletion of BLIMP1(+) sebocyte progenitor cells; it also explains its adverse effects, including teratogenicity (neural crest cell apoptosis), a reduced ovarian reserve (granulosa cell apoptosis), the risk of depression (the apoptosis of hypothalamic neurons), VLDL hyperlipidemia, intracranial hypertension and dry skin.

Combining superpulse dynamic CO2 laser and supramolecular salicylic acid in the treatment of dense comedones with higher clearance in a shorter time: A prospective, randomized, split-face clinical trial

OBJECTIVES

Dense comedones are common in patients with acne vulgaris, and promoting treatment can prevent the progression of acne lesions. However, the efficacy-time conflict makes the treatment challenging and the medication options are limited by the side effects.

MATERIALS AND METHODS

Thirty-five patients with symmetrical dense comedones were enrolled and the two sides of the face were randomly assigned to receive 30% supramolecular salicylic acid (SSA) combined with CO2 laser or CO2 laser monotherapy at an interval of 2 weeks for six treatment sessions. Comedones count, porphyrin index (PI), texture index (TI), melanin index, erythema index, hydration index (HI), transepidermal water loss (TEWL), and side effects were recorded at each visit till the 12th week.

RESULTS

Thirty-one patients completed the study. Comedones on the combined-SSA side were reduced more after six treatments, that the mean reduction rate of the combined-SSA side was 85.76%, and that of the CO2 laser-treated side was 62.32% (Pbetween  < 0.001). Combining SSA also showed a better effect on reducing PI and TI than CO2 laser singly (Pbetween  < 0.001). TEWL and HI between the two sides showed no significant differences after treatments. No permanent or severe side effects were observed on both side.

CONCLUSIONS

The treatment combined CO2 laser with 30% SSA dealt with the efficacy-time conflict while significantly reducing comedones and improving skin texture in 12 weeks and no serious adverse reactions occurred.

LIMITATIONS

It is a single-center study and the number of subjects was small.

Treatment of mild to severe acne with 1726 nm laser: A safe alternative to traditional acne therapies

INTRODUCTION

Acne is the most common reason for dermatology consultation in adolescents and young adults. Consultation is often delayed despite unsuccessful self-treatment. Postponing effective treatment places acne sufferers at higher risk for permanent acne scars and post-inflammatory pigment changes.

AIM

This review discusses clinical challenges with present therapeutic options for acne treatment and the role of a 1726 nm laser for acne.

METHODS

Current acne treatment guidelines were reviewed. A literature review was conducted for trials of light-based acne therapy. The selectivity of previous light-based therapies was reviewed.

RESULTS

Available acne therapy is effective, but treatment-related side effects are common. Acne treatment guidelines do not include recommendations for light-based treatments. Different types of light-based treatments have been tried but until now no wavelength specifically targeted sebaceous glands.

CONCLUSION

The 1726 nm laser is safe and effective for treating mild to severe acne in all Fitzpatrick skin types. Acne resolution is apparent within the first month and improves for up to 2 years beyond treatment.

Study on Antibacterial Activity and Mechanism of Improved Dian Dao San Against Cutibacterium acnes (C. acnes)

Purpose

The hyperproliferation of C. acnes has long been regarded as a primary etiological factor in the development of acne vulgaris (AV). Antibiotics targeting C. acnes have been the mainstay in AV treatment. Meanwhile, C. acnes has developed resistance to numerous antibiotics. IDDS, as traditional Chinese medicine, exhibits potent antibacterial activity against C. acnes. However, the mechanism of IDDS against C. acnes remains unclear.

Methods

In this study, we conducted a systematic investigation in vitro to determine the minimal bactericidal concentration (MBC) and time-kill curves. The MBC and time-kill curves were assessed by quantifying Colony Forming Units countsIn order to establish an in vivo rat ear model of acne, a single intradermal injection of 100μL C. acnes suspension was administered, and oleic acid was applied to the right ear pinna for a duration of 14 days. The intervention involved the utilization of IDDS medications. Additionally, the levels of inflammatory mediators tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and interleukin-10 (IL-10) were assessed using respective ELISA kits, while Hematoxylin and eosin (HE) staining was employed to visualize the rat ear model. The antimicrobial mechanism was investigated through the analysis of mRNA levels using real-time, quantitative PCR. ELISA analysis was performed according to the protocols outlined for energy metabolism and antioxidant system.

Results

Our research has demonstrated that IDDS possesses antibacterial activity against C. acnes both in vitro and in vivo. The mechanisms underlying these effects involve energy metabolism and antioxidant systems.

Conclusion

The data has provided further insights into the mechanism of IDDS against C. acnes, which establishes a robust foundation for the clinical application of IDDS.

Treatment of Acne with Isotretinoin Should Be Avoided in Patients with Hidradenitis Suppurativa "Conglobata Phenotype"

BACKGROUND

Acne conglobata (AC) and nodulocystic acne have long been confused clinically, despite the presentation and the response to treatment being different. AC and hidradenitis suppurativa (HS) resemble each other; a subtype of HS called "conglobata phenotype" has recently been reported in a large Dutch cohort. Acne vulgaris and HS are often associated. Isotretinoin is typically ineffective in treating HS and may even aggravate it, but it is often indispensable in treating acne vulgaris.

OBJECTIVE

The aim of the study was to assess whether isotretinoin may be used safely in adults with both HS and acne vulgaris and when it might be contraindicated.

MATERIALS AND METHODS

Belgian HS patients from the European Registry for Hidradenitis Suppurativa Registry (ERHS) reporting a history of severe acne of the face and/or the back, and who have ever used isotretinoin for their acne, were all selected. Patients whose acne worsened on isotretinoin were compared to patients whose acne did not worsen (improvement or no change).

RESULTS

Among the 82 selected patients, 10 (12.2%) report that their acne was aggravated while taking isotretinoin, while 72 (87.8%) report that their acne was not aggravated on isotretinoin. Of the 10 HS patients whose acne worsened with isotretinoin, 9 (90%) were men (p = 0.04) and 8 (80%) were HS "conglobata phenotype" (p < 0.001). In contrast, 47 (65.3%) of the 72 patients whose acne did not worsen on isotretinoin belonged to the HS "regular phenotype" (p = 0.01). On multivariate analysis, the item most strongly associated with poor response to isotretinoin was the HS "conglobata phenotype," followed by body mass index (BMI) (worse response to isotretinoin if BMI >25 kg/m2). Additionally, of 26 patients who received isotretinoin while their HS had already started, only 6 (23.1%) reported isotretinoin effectiveness on their HS.

CONCLUSION

Subject to confirmation by larger studies, our study suggests that isotretinoin should be avoided in the treatment of acne in HS patients with the HS "conglobata phenotype," as it may worsen the acne, likewise being male or having a BMI above 25 seems to increase this risk of a bad therapeutic outcome. Patients with an HS "regular phenotype" appear to be at a reduced risk of isotretinoin treatment worsening their acne.

Markers of Oxidative Stress in Patients with Acne: A Literature Review

Acne vulgaris is a chronic inflammatory skin disease of the pilosebaceous unit. Its pathogenesis is multifactorial and involves the overlap between four main processes: alteration of the keratinization, increased sebum production, colonization with Cutibacterium acnes, and inflammation. The role of oxidative stress (OS) has been intensively studied in inflammatory skin conditions such as psoriasis, vitiligo, or atopic dermatitis. However, the involvement of OS in the pathogenesis of acne is less known. The evidence accumulated over the last decade suggests that in the case of acne patients, there is an imbalance between oxidants and antioxidants. In this review, we analyzed studies that evaluated markers of OS in patients with acne, published in the last ten years, with the aim of providing new insights into the pathogenesis of acne.

Skin Pigmentation Types, Causes and Treatment-A Review

Human skin pigmentation and melanin synthesis are incredibly variable, and are impacted by genetics, UV exposure, and some drugs. Patients' physical appearance, psychological health, and social functioning are all impacted by a sizable number of skin conditions that cause pigmentary abnormalities. Hyperpigmentation, where pigment appears to overflow, and hypopigmentation, where pigment is reduced, are the two major classifications of skin pigmentation. Albinism, melasma, vitiligo, Addison's disease, and post-inflammatory hyperpigmentation, which can be brought on by eczema, acne vulgaris, and drug interactions, are the most common skin pigmentation disorders in clinical practice. Anti-inflammatory medications, antioxidants, and medications that inhibit tyrosinase, which prevents the production of melanin, are all possible treatments for pigmentation problems. Skin pigmentation can be treated orally and topically with medications, herbal remedies, and cosmetic products, but a doctor should always be consulted before beginning any new medicine or treatment plan. This review article explores the numerous types of pigmentation problems, their causes, and treatments, as well as the 25 plants, 4 marine species, and 17 topical and oral medications now on the market that have been clinically tested to treat skin diseases.

A Young Patient Presenting with Dilated Cardiomyopathy and Renal Infarction during Treatment with Isotretinoin: Mere Coincidence or Serious Side Effect of a Drug Commonly Used in Adolescence?

Isotretinoin or 13-cis-retinoic acid (RA) is one of the most effective and widely used drugs for the treatment of severe acne vulgaris. Despite being deemed safe, no definite consensus has been reached on the cardiovascular risk of RA derivatives. We report a case of heart failure due to dilated cardiomyopathy (DCM) and concomitant renal infarction occurring after 5 months of isotretinoin use in a previously healthy 18-year-old male. The patient, with a history of acne vulgaris, presented to our emergency department with left iliac fossa pain and effort dyspnea. A trans-thoracic echocardiogram showed DCM and severely reduced left ventricle ejection fraction (LVEF: 29%). During hospitalization, a total body computed tomography (CT) showed an ischemic lesion in the left kidney. Ischemic, autoimmune, infective, and heritable causes of DCM were ruled out. Cardiac magnetic resonance (CMR) evidenced LV circumferential mid-wall late gadolinium enhancement. Heart failure therapy was promptly started and up-titrated, but only poor LVEF improvement was detected overtime. Our case aims to raise awareness on rare life-threatening cardiovascular events possibly associated with isotretinoin use. To the best of our knowledge, this is the first described case of renal thromboembolism and severe DCM leading to implantable cardioverter-defibrillator (ICD) implantation occurring during isotretinoin treatment.

Efficacy and safety of low-dose oral isotretinoin monotherapy versus combined therapy with picosecond laser for the treatment of acne scars in Asian population

PURPOSE

Acne scars are common in patients with moderate to severe acne. Isotretinoin is the first-line treatment for those patients, but whether oral isotretinoin can improve acne scar is not clear. Picosecond lasers (FxPico) has been reported to improve acne scars. In the present study, we evaluated the clinical efficacy of low-dose isotretinoin with or without FxPico treatment for acne scars.

MATERIALS AND METHODS

A total of 48 patients with acne scars were enrolled and were randomly assigned to receive low dose oral isotretinoin or not. For all the patients in both treatment groups, one side of face were randomly assigned to be treated with picosecond laser. Assessments, including photos, échelle d'évaluation clinique des cicatrices d'acné (ECCA) and Global Acne Grading System (GAGS) score, the number of lesions, melanin and erythema indexes, transepidermal water loss were assessed at 0, 1, 2, and 3 month. Side effects, Dermatology Life Quality Index (DLQI) and satisfaction were recorded before and after the study.

RESULTS

A total of 44 patients completed the study (24 received oral low dose isotretinoin and 20 did not). Low dose oral isotretinoin treated group showed significant improvement on ECCA (from 112.5 [50-180] to 105 [50-160]), GAGS score (from 12.6 ± 3.3 to 10.1 ± 3.0), the count of papules (from 4.3 ± 3.7 to 1.0 ± 1.5) than the blank group, and higher improvement were noticed after isotretinoin combined with FxPico. All the side effects were temporary and tolerable, no adverse effects were observed. Higher DLQI and patients' satisfaction were achieved by oral isotretinoin alone and isotretinoin combined with FxPico.

CONCLUSIONS

This is the first paper showing the improvement of scars by early low dose-isotretinoin intervention with or without the combination of picosecond laser. Early intervention with oral low-dose isotretinoin is effective for the treatment and prevention of acne scars, the combined therapy with FxPico can achieve better outcome.

Evaluation of the efficacy and relapse rates of treatment protocols for moderate acne using isotretinoin based on the global acne grading system: Randomized, controlled, comparative study

Protocols for treating acne with isotretinoin have varied widely because some factors associated with relapse and treatment duration have not yet been fully determined. This paper evaluates the effectiveness of conventional, low, and intermittent isotretinoin dosage protocols in the treatment of moderate acne and investigates the relationships between GAGS score, treatment duration and relapse rate. The 107 patients with moderate acne were randomly divided into three groups who received isotretinoin for 24 weeks (Group A: 0.5-1 mg/kg/day; Group B: 0.25-0.4 mg/kg/day; Group C: 0.5-0.7 mg/kg/day for 1 week out of every 4 weeks). The results show that both conventional and continuous low doses achieved full clinical effectiveness with minimum relapse rates. However, fewer side effects and better patient satisfaction were reported with the low dose. Significant differences in GAGS scores after 24 weeks were found between groups B and C (p = 0.037) and between groups A and C (p < 0.001), while no significant differences were found between groups A and B (p = 0.153). It was observed that relapse rate increased with initial GAGS score. The average relapse rate was 58.0% for those with initial GAGS scores of 25-30 compared with 5.5% for those with scores of 19-24. It was also noticed that, among the patients who relapsed, the highest percentage (56.3%) were in the age group <20 years. However, GAGS (β = 0.646, t = 8.323, p < 0.001) was found to be a better predictor of relapse than age (β = 0.083, t = 1.073, p = 0.286). These results suggest that initial GAGS score is an important factor in determining the treatment protocol for moderate acne. Furthermore, this study recommends that a low-dose treatment is most suitable when GAGS <25, as it can achieve complete clearance of acne with minimal relapses and side effects.

High Neutrophil-to-Lymphocyte Ratio Facilitates Cancer Growth-Currently Marketed Drugs Tadalafil, Isotretinoin, Colchicine, and Omega-3 to Reduce It: The TICO Regimen

Simple Summary

Several elements that are composed of, or related to, neutrophils, have been shown to inhibit strong immune responses to cancer and promote cancers’ growth. This paper presents the collected data showing these elements and how their coordinated actions as an ensemble facilitate growth in the common cancers. The paper goes on to present a drug regimen, TICO, designed to reduce the cancer growth enhancing effects of the neutrophil related elements. TICO uses four already marketed, readily available generic drugs, repurposed to inhibit neutrophil centered growth facilitation of cancer.

Abstract

This paper presents remarkably uniform data showing that higher NLR is a robust prognostic indicator of shorter overall survival across the common metastatic cancers. Myeloid derived suppressor cells, the NLRP3 inflammasome, neutrophil extracellular traps, and absolute neutrophil count tend to all be directly related to the NLR. They, individually and as an ensemble, contribute to cancer growth and metastasis. The multidrug regimen presented in this paper, TICO, was designed to decrease the NLR with potential to also reduce the other neutrophil related elements favoring malignant growth. TICO is comprised of already marketed generic drugs: the phosphodiesterase 5 inhibitor tadalafil, used to treat inadequate erections; isotretinoin, the retinoid used for acne treatment; colchicine, a standard gout (podagra) treatment; and the common fish oil supplement omega-3 polyunsaturated fatty acids. These individually impose low side effect burdens. The drugs of TICO are old, cheap, well known, and available worldwide. They all have evidence of lowering the NLR or the growth contributing elements related to the NLR when clinically used in general medicine as reviewed in this paper.

Nontargeted metabolomics to characterize the effects of isotretinoin on skin metabolism in rabbit with acne

Background: Acne vulgaris is a chronic inflammatory disease of the pilosebaceous unit. This study aimed to explore the pathogenesis of acne and the therapeutic mechanism of isotretinoin from the metabolic perspective in coal tar-induced acne in rabbits.

Methods: Ultra-high performance liquid chromatography/quadrupole time-of-flight mass spectrometry (UHPLC-qTOF-MS) based metabolomics was used to identify skin metabolites in groups C (blank control), M (model group) and T (isotretinoin group). Multivariate statistical analysis was used to process the metabolomics data.

Results: 98 differential metabolites in group C and group M were identified. The highest proportion of differential metabolites were organic acids and derivatives, lipid metabolites, organic heterocyclic compounds, and nucleoside metabolites. The most significant metabolic pathways included protein digestion and absorption, central carbon metabolism in cancer, ABC transporters, aminoacyl-tRNA biosynthesis, biosynthesis of amino acids, and sphingolipid signaling pathway. Isotretinoin treatment normalized eight of these metabolites.

Conclusions: Our study will help to further elucidate the pathogenesis of acne, the mechanism of isotretinoin at the metabolite level, and identify new therapeutic targets for treating acne.

Practical Guidelines for Managing Patients With Hidradenitis Suppurativa: An Update

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease that is characterized by the formation of comedones, papules, nodules, abscesses and sinus tracts in the axillary, inframammary, groin, and gluteal areas. Up to 3.8% of the Canadian population has HS, though due to a lack of awareness of HS, many patients are initially misdiagnosed and do not receive adequate treatment early on in the disease course. Once a diagnosis of HS is made, developing an effective management plan can be a dilemma for many providers. There is significant variability in response to any given therapy within the HS patient population and many HS patients have other medical comorbidities which must be taken into consideration. The aim of this review is to provide a practical approach for all healthcare providers to diagnose and manage HS and its associated comorbidities. A sample electronic medical record template for HS management was developed by the Canadian Hidradenitis Suppurativa Foundation Executive Board and is intended for use in clinical settings. This will help to increase collaboration between primary healthcare providers, dermatologists, and other medical specialists and ultimately improve the quality of care that HS patients receive.

Effect of Evening Primrose Oil Supplementation on Selected Parameters of Skin Condition in a Group of Patients Treated with Isotretinoin-A Randomized Double-Blind Trial

Background: Retinoids, which include isotretinoin, reduce sebum levels, the degree of epidermal wetness (CORN) and cause an increase in transepidermal water loss (TEWL). Weight gain has also been observed in isotretinoin-treated patients. An agent that can reduce the severity of isotretinoin side effects is evening primrose oil (Oenothera paradoxa). The purpose of this study was to evaluate the effect of evening primrose oil supplementation in patients with acne vulgaris treated with isotretinoin on skin hydration status (CORN), transepidermal water loss (TEWL), skin oiliness (sebum) and changes in body weight and BMI. Methods: Patients diagnosed with acne were assigned to the isotretinoin-treated group (n = 25) or the isotretinoin and evening primrose oil-treated group (n = 25). The intervention lasted 9 months. CORN (with a corneometer), TEWL (with a tewameter) and sebum (with a sebumeter) were assessed twice, as well as body weight and BMI (Tanita MC-780). Results: The isotretinoin-treated group showed statistically significant reductions in CORN (p = 0.015), TEWL (p = 0.004) and sebum (p < 0.001) after the intervention. In the group treated with isotretinoin and evening primrose oil, TEWL and sebum levels also decreased significantly (p < 0.05), while CORN levels increased from 42.0 ± 9.70 to 50.9 ± 10.4 (p = 0.017). A significant decrease in body weight (p < 0.001) and BMI (p < 0.001) was observed in both groups after 9 months of intervention. Conclusions: During isotretinoin treatment, supplementation with evening primrose oil increased skin hydration. However, there were no differences between groups in transepidermal water loss, skin oiliness, weight loss and BMI.

Adverse Events in Isotretinoin Therapy: A Single-Arm Meta-Analysis

Isotretinoin (ISO) is an oral prescription-only retinoid, well known for its acne-treating effect. However, it affects a substantial number of human cell types, causing a broad spectrum of adverse effects. The purpose of this study is to establish the isotretinoin therapy adverse events among human clinical trials and their prevalence. Two authors (J.K., J.L.) systematically performed the literature review and assessment from December 2021-February 2022. Three databases (PubMed, ClinicalTrials, and Cochrane Library) were searched using the following terms: "isotretinoin acne vulgaris" for published studies in English from 1980-2021. Finally, 25 randomized controlled clinical trials (RCTs) and five open-label clinical trials provided 3274 acne vulgaris suffering patients. Isotretinoin therapy affects almost all of the systems in the human body, causing numerous adverse events. However, they mainly concern mild mucocutaneous conditions (severe cases are rare) and represent individual responses to a drug. In addition, all adverse events are reversible and can be avoided by specific preparations.

Effect of Evening Primrose Oil Supplementation on Biochemical Parameters and Nutrition of Patients Treated with Isotretinoin for Acne Vulgaris: A Randomized Double-Blind Trial

Background: Acne vulgaris is one of the most common skin diseases. One of the therapeutic options recommended for severe acne or acne that has not responded to previous therapies is isotretinoin. However, its use may lead to adverse changes in the serum lipid profile and increased levels of transaminases. In this study, we evaluated the effect of supplementation with evening primrose oil in acne vulgaris patients treated with isotretinoin on blood lipid parameters and transaminase activity. Methods: Study participants were randomly assigned to two treatments: conventional with isotretinoin (25 patients) and novel with isotretinoin combined with evening primrose oil (4 × 510 mg/day; 25 patients) for 9 months. Results: Compared to isotretinoin treatment, isotretinoin treatment combined with evening primrose oil had a positive effect on TCH concentrations (mean: 198 vs. 161, p < 0.001), LDL (95.9 vs. 60.2, p < 0.001), HDL (51.0 vs. 48.0, p < 0.001), TG (114 vs. 95.0, p < 0.001), ALT (24.0 vs. 22.0, p < 0.001), and AST (28.0 vs. 22.0, p < 0.001), but had no effect on the energy and ingredient content of the diets (p > 0.05) after treatment. Conclusion: Evening primrose oil was found to have beneficial effects on lipid profiles and transaminase activity during isotretinoin treatment. However, longer studies are needed to make more reliable decisions regarding the use of evening primrose oil and its safety in clinical practice. The evening primrose oil treatment group also showed a reduction in dietary energy due to a reduction in dietary protein and carbohydrates.

Advantages of Tailored Isotretinoin Treatment in Moderate to Severe Acne: Real-Life Data

This retrospective single-center study analyzes the efficacy and safety of isotretinoin for the treatment of moderate to severe acne in real-life clinical practice, particularly with regard to acne severity, isotretinoin cumulative dosage, and patients’ gender. The results suggest the opportunity of an early isotretinoin systemic treatment in patients affected by moderate acne and emphasize the importance of an appropriate dose adjustment in order to minimize adverse events.

Dermatology: how to manage acne vulgaris

Background

Acne vulgaris is the most common skin disease that can lead to disfigurement and psychological distress. This article aims to provide a narrative updated review on the management of acne vulgaris.

Methods

A PubMed search was performed with Clinical Queries using the key term “acne”. The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies and reviews. The search was restricted to articles published in English.

Results

Treatments of acne include proper skin care, topical medications, oral medications and procedural therapies. Topical agents are the first-line treatment for mild-to-moderate acne and can be used as combination therapy for more severe acne. Systemic therapies are usually prescribed for the initial treatment of moderate-to-severe acne as well as for acne that is refractory to topical therapies.

Conclusion

Topical retinoids are the drugs of choice for the treatment and maintenance therapy of patients with mild-to-moderate acne vulgaris. Depending on the severity of the acne, topical retinoids may be used alone or in combination with benzoyl peroxide and topical or oral antibiotics. Oral antibiotics are an important therapy for inflammatory acne unresponsive to topical therapy. Neither topical nor oral antibiotics should be used as monotherapy. Oral contraceptives and/or spironolactone are useful for many women with acne. Oral isotretinoin is the drug of choice for severe, extensive, nodular acne vulgaris but is also often used in moderate cases where scarring is evident, acne-related psychosocial distress is significant or other treatment modalities have failed.

Effect of Blue Light on Acne Vulgaris: A Systematic Review

Acne is a dermatosis that affects almost 90% of the adolescent population worldwide and its treatment is performed with retinoids, antimicrobials, acids, and topical or systemic antibiotics. Side effects such as skin irritation in addition to microbial resistance to antibiotics are the main side effects found. Phototherapy with blue light is being used as an alternative treatment. Our objective was to analyze the use of blue light to treat inflammatory acne. We conducted a systematic literature review, following the recommendation PRISMA (Preferred Reporting Items for Systematic Reviews and MetaAnalyses), including in the sample randomized clinical trial studies that compared blue light with another intervention as control. The research was carried out in the PUBMED and WEB of SCIENCE databases and the methodological quality of the studies evaluated were made by the Cochrane Collaboration Bias Risk Scale. After the exclusion of duplicates, the titles and abstracts of 81 articles were evaluated, and 50 articles were selected for full reading, including in the review at the end 8 articles. Studies have shown significant improvements in the overall picture of acne. It is concluded that despite the great potential in its use in the treatment of acne, there is a need for more detailed trials on the effect of blue light on the treatment of inflammatory acne.

Acupuncture: A therapeutic approach against acne

Acne is a common but chronic skin disease that influence large population especially juvenile. Acne can continue, begin, or grow into severe form in adult age, affecting face, back, and chest. It may be a serious issue if not cared or treated timely. Even if acne got treated it leaves a persistent scar, which is difficult to alleviate. These acne lesions are long-lasting and result in significant impact on mental and physical health of an individual. There are four mechanisms that are involved in acne lesion formation. However, the accurate series of events of the interaction among the factors in acne pathogenesis is still unsettled. Pubescent acne is due to increase hormone levels, when in fact adult acne is due to fluctuation in hormone levels. There are various approaches for the treatment of acne, including oral medications, creams or gels, acupuncture. Traditional Chinese Medicine stated acne as a infection that is associated with the pathogenic influence of damp heat and heat on specific meridians. As an ancient and integral part of Chinese medicine acupuncture therapy is employed in the treatment of many diseases including acne. It functions by ameliorating the deep-rooted mechanisms playing crucial role in acne development. In this review, we have explained the acne causes, pathogenesis, and its available treatment options. Additionally, we also discussed the acupuncture therapy methods, devices, different techniques. and its mechanism of action in treating acne. Furthermore, clinical trials studies motivated us to highlight the scope of acupuncture in the growing system of medicine.