Efficacy and adverse events of oral isotretinoin for acne: a systematic review

Emerging lasers and light-based therapies in the management of acne: a review

Acne vulgaris, commonly known as acne, is the most prevalent skin disorder affecting mainly adolescents and young adults, though it can affect people of all ages, making it the most common complaint by patients presenting to a dermatologist. The overactivity of sebaceous glands primarily drives this skin condition due to androgen influence and the presence of Cutibacterium acnes bacteria. Although typically not directly harmful to patient health, acne can be a highly debilitating disease for patients, affecting their self-image and psychosocial well-being. Standard treatments include topical retinoids, benzoyl peroxide, topical antibiotics, and, for more severe cases, systemic antibiotics or isotretinoin, which require prolonged periods of compliance. All these pharmacologic treatments have a risk of side effects ranging from mild ones, like skin irritation and dryness, to severe ones, like depression. Thus, there is a demand for exploring other treatment modalities in treating acne, and laser and light-based therapies have garnered significant interest. This review article will comprehensively assess emerging laser and other light-based therapies that have shown efficacy in treating acne, including the recently FDA-approved 1,726 nm laser.

The effect of family history of atherosclerosıs and other risk factors on changes in serum lipid levels in acne patients treated with isotretinoin

BACKGROUND

Oral isotretinoin causes changes in serum lipid values. These changes are not seen in every patient, regardless of dose. It is unclear what causes these changes and how often serum lipid values should be followed up.

AIMS

We aimed to evaluate the relationship between the change in serum lipid values and personal and familial risk factors.

METHODS

Serum lipid values at baseline (0th), 1st, 3rd, and 6th months of isotretinoin treatment of acne patients aged 16 years and over using oral isotretinoin at a dose of 0.5-1 mg/kg/day between January 2017 and December 2019 were recorded retrospectively. The relationship between personal and familial risk factors and changes in serum lipid values were evaluated statistically.

RESULTS

In pairwise comparison, a significant difference was detected between the 0th and 1st month, 0th and 3rd month, 0th and 6th month, and 1st and 6th month in the average serum lipid (Low-density lipoprotein (LDL), high-density lipoprotein (HDL), very low-density lipoprotein (VLDL), total cholesterol, triglyceride) levels. However, no significant difference was detected between 3rd and 6th month. The change in LDL levels between the 0th and the 3rd month was significantly higher in those with a family history of atherosclerosis than those without a family history of atherosclerosis (p = 0.034). The change in VLDL levels between the 0th and 6th month was significantly higher in those with a family history of atherosclerosis than those without a family history of atherosclerosis (p = 0.022). It was observed that the changes in total cholesterol and VLDL levels between the 0th and 3rd month increased as body mass index (BMI) increased (p = 0.03, p = 0.014, respectively). Similarly, the changes in triglyceride and VLDL levels between 0th and 6th month and between 1st and 6th month increased by an increase in BMI (respectively; p = 0.006, p = 0.019; p = 0.016, p = 0.022). The increase in the levels of VLDL between the 1st and the 6th month was found to be significantly higher in smokers than in non-smokers (p = 0,032).

CONCLUSION

We recommend evaluation of serum lipids values in the 0th, 1st, and 3rd month in all acne patients using oral isotretinoin and that these values have to be checked monthly in the following months for smokers, those with a history of atherosclerosis, and those with a BMI above normal.

Common Non-Rheumatic Medical Conditions Mimicking Fibromyalgia: A Simple Framework for Differential Diagnosis

Fibromyalgia (FM) is a chronic non-inflammatory disorder mainly characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and a constellation of other symptoms. For this reason, delineating a clear distinction between pure FM and FM-like picture attributable to other common diseases can be extremely challenging. Physicians must identify the most significant confounders in individual patients and implement an appropriate diagnostic workflow, carefully choosing a minimal (but sufficient) set of tests to be used for identifying the most plausible diseases in the specific case. This article discusses prevalent non-rheumatological conditions commonly observed in the general population that can manifest with clinical features similar to primary FM. Given their frequent inclusion in the differential diagnosis of FM patients, the focus will be on elucidating the distinctive clinical characteristics of each condition. Additionally, the most cost-effective and efficient diagnostic methodologies for accurately discerning these conditions will be examined.

A comparative exploration of immunohistochemical markers in patients with papulopustular rosacea undergoing treatment with oral isotretinoin versus doxycycline

BACKGROUND

Rosacea is a chronic inflammatory disease, and doxycycline is a widely recommended treatment for it due to its anti-inflammatory action. Oral isotretinoin reduces sebaceous gland activity and modulates toll-like receptors, reducing inflammation. Our aim was to investigate the effect of these two drugs on the expression of cutaneous immunohistochemical biomarkers related to etiopathogenic factors involved in rosacea.

METHODS

We conducted a randomized, comparative, and evaluator-blinded trial, including 40 participants with moderate and severe papulopustular and ocular rosacea. Participants were treated with doxycycline (DOXY) 100 mg or isotretinoin (ISO) 0.3 mg/kg daily. Immunohistochemistry at baseline and after 4 months was used to demonstrate the expression of the biomarker on the affected skin.

RESULTS

The following changes were detected: a reduction in the vessel count after using VEGF with DOXY (P = 0.010); a decrease in VEGF intensity with ISO (P < 0.001) and DOXY (P = 0.020); a reduction of nitric oxide synthase enzyme with both drugs in the inflammatory infiltrate (ISO P < 0.001; DOXY P = 0.003); however, only with ISO was there a significant (P = 0.030) decrease at the level of the sebaceous glands, indicating a reduction of nitric oxide synthesis; a reduction of TRPV-1 expression at the level of the sebaceous glands was observed only with DOXY (P = 0.041); a decrease of cathelicidin LL37 expression, a key antimicrobial peptide in the etiopathogenesis of rosacea, was noted with both drugs, although at the level of sebaceous glands, only with DOXY (P = 0.007).

CONCLUSIONS

Oral isotretinoin and doxycycline have modified the expression of cutaneous biomarkers related to rosacea etiopathogenesis, demonstrating their role in controlling inflammatory and vascular processes.

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.

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.

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.

Retinoic Acid Action in Cumulus Cells: Implications for Oocyte Development and In Vitro Fertilization

In the field of human in vitro fertilization (IVF), selecting the best oocyte for freezing or embryo for transfer remains an important focus of clinical practice. Although several techniques are and have been used for this goal, results have generally not been favorable and/or are invasive such that damage to some embryos occurs, resulting in a reduced number of healthy births. Therefore, the search continues for non-invasive oocyte and embryo quality markers that signal the development of high-quality embryos. Multiple studies indicate the important positive effects of retinoic acid (RA) on oocyte maturation and function. We previously showed that a high follicular fluid (FF) RA concentration at the time of oocyte retrieval in IVF protocols was associated with oocytes, giving rise to the highest quality embryos, and that cumulus granulosa cells (CGCs) are the primary source of follicle RA synthesis. Data also demonstrated that connexin-43 (Cx43), the main connexin that forms gap junctions in CGCs, is regulated by RA and that RA induces a rapid increase in gap junction communication. Here, we hypothesize that CGC RA plays a causal role in oocyte competency through its action on Cx43 and, as such, may serve as a biomarker of oocyte competence. Multiple studies have demonstrated the requirement for Cx43 in CGCs for the normal progression of folliculogenesis, and that the increased expression of this connexin is linked to the improved developmental competence of the oocyte. The data have shown that RA can up-regulate gap junction intercellular communication (GJIC) in the cumulus-oocyte complex via a non-genomic mechanism that results in the dephosphorylation of Cx43 and enhanced GJIC. Recognizing the positive role played by gap junctions in CGCs in oocyte development and the regulation of Cx43 by RA, the findings have highlighted the possibility that CGC RA levels may serve as a non-invasive indicator for selecting high-quality oocytes for IVF procedures. In addition, the data suggest that the manipulation of Cx43 with retinoid compounds could provide new pharmacological approaches to improve IVF outcomes in cases of failed implantation, recurrent miscarriage, or in certain diseases that are characterized by reduced fecundity, such as endometriosis.

Managing acne vulgaris: an update

Acne vulgaris is very common and can have significant negative impact on people. While sometimes a transient problem, acne may persist for many years and often leads to permanent scars or pigment changes. Guidelines unanimously advise topical treatments as first-line, although differ in recommending either topical benzoyl peroxide or topical retinoid (mainly adapalene) alone or in combination. Guidance published by the National Institute for Health and Care Excellence advises counselling patients regarding avoidance of skin irritation when starting topical treatments and promoting adherence (treatments take 6-8 weeks to work). Oral antibiotics are currently overprescribed for acne but have a role when coprescribed with a non-antibiotic topical treatment. Hormonal treatments, such as the combined contraceptive pill, are also effective and there is growing evidence for the use of spironolactone for women with persistent acne. Recent guidance from the Medicines and Healthcare products Regulatory Agency regarding isotretinoin has implications for specialist prescribing and monitoring, and increasing public awareness of potential risks of mental health problems and sexual dysfunction. Although acne is associated with psychiatric disorder, the mental health effects of isotretinoin remain controversial.

When science and evidence is not enough: challenging the recommendations from the Commission on Human Medicines Isotretinoin Expert Working Group

The Commission on Human Medicines (CHM) Isotretinoin Expert Working Group recently released a report with several major recommendations. The authors scrutinized the evidence cited by the CHM and presented the case that their recommendations undermine evidence-based medicine and scientific thinking.

Phase 1 safety, tolerability, pharmacokinetics and pharmacodynamic results of KCL-286, a novel retinoic acid receptor-β agonist for treatment of spinal cord injury, in male healthy participants

AIMS

KCL-286 is an orally available agonist that activates the retinoic acid receptor (RAR) β2, a transcription factor which stimulates axonal outgrowth. The investigational medicinal product is being developed for treatment of spinal cord injury (SCI). This adaptive dose escalation study evaluated the tolerability, safety and pharmacokinetics and pharmacodynamic activity of KCL-286 in male healthy volunteers to establish dosing to be used in the SCI patient population.

METHODS

The design was a double blind, randomized, placebo-controlled dose escalation study in 2 parts: a single ascending dose adaptive design with a food interaction arm, and a multiple ascending dose design. RARβ2 mRNA expression was evaluated in white blood cells.

RESULTS

At the highest single and multiple ascending doses (100 mg), no trends or clinically important differences were noted in the incidence or intensity of adverse events (AEs), serious AEs or other safety assessments with none leading to withdrawal from the study. The AEs were dry skin, rash, skin exfoliation, raised liver enzymes and eye disorders. There was an increase in mean maximum observed concentration and area under the plasma concentration-time curve up to 24 h showing a trend to subproportionality with dose. RARβ2 was upregulated by the investigational medicinal product in white blood cells.

CONCLUSION

KCL-286 was well tolerated by healthy human participants following doses that exceeded potentially clinically relevant plasma exposures based on preclinical in vivo models. Target engagement shows the drug candidate activates its receptor. These findings support further development of KCL-286 as a novel oral treatment for SCI.

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.

Discovery and Characterization of a Novel Bacteriocin HA2-5 that Strongly Inhibits Propionibacterium acnes

Increased drug resistance has significantly reduced the effectiveness of antibiotics used in the treatment of Propionibacterium acnes. Therefore, there has been a trend toward the development of new antimicrobial agents to circumvent drug resistance. In this study, we isolated and purified a novel bacteriocin, HA2-5, from Bacillus haynesii HA2, which effectively killed P. acnes through membrane disruption at a minimum inhibitory concentration (MIC) of 8 μg/mL. HA2-5 with 2× MIC was able to kill 99.9% of P. acnes within 24 h. HA2-5 shows excellent stability and tolerance to temperature, pH, proteases, chemical reagents, UV radiation, and metal ions, with almost no loss of inhibitory activity after treatment. In addition, the very low hemolytic activity and cytotoxicity suggest that HA2-5 is biosafe. Notably, HA2-5 exhibits preferred antibacterial activity against gram-positive pathogens with an MIC of 16-32 μg/mL. In conclusion, this study shows that bacteriocin HA2-5 has the potential to be used as an alternative to antibiotics for acne treatment.

Ichthyosis: presentation and management

PURPOSE OF REVIEW

This review focuses on the presentation and management of ichthyoses and highlights recent advances in treatment that hold promise for better targeted therapy.

RECENT FINDINGS

The ichthyoses are a group of rare genetic diseases with a wide phenotypic spectrum, characterized most often by generalized hyperkeratosis and scaling with variable erythema. The highly visible scaling and frequent itch contribute to decreased quality of life. Management for ichthyosis focuses on symptomatic relief and scale reduction with emollients, keratolytics, and retinoids. Recent advances in immune profiling and genotype-phenotype mapping have increased understanding of ichthyosis and shifted focus to pathogenesis-based targeted therapies with emerging biologics, small molecular inhibitors, and gene therapy.

SUMMARY

This article discusses clinical assessment and genotyping to make the diagnosis of specific forms of ichthyosis, provides guidance for management, and reviews new treatment options with systemic agents.

Prevalence of adverse events varies with the different oral isotretinoin brands in acne treatment: a retrospective observational study

Oral isotretinoin remains the most effective treatment for acne. The aim of this retrospective single-center cohort study was to estimate the prevalence of adverse events with the different oral isotretinoin brands used in acne treatment. The population consisted of all patients who consulted for acne between January 2015 and January 2020. The inclusion criterion was the initiation of treatment with oral isotretinoin. The exclusion criteria were the use of two or more brands during the same course of treatment and previous treatment with oral isotretinoin. Statistical analysis was carried out using Chi-square and Mann-Whitney tests. We analyzed 468 patients of whom 68.6% were female. The median age was 21 years. The median weight was 65 kg. The treatment was Roaccutane®, Curacné®, Acnotren®, Isosupra®, Contracné®, or Acnogen® in 44.2%, 28%, 14.5%, 10.5%, 1.7% and 0.4% of cases, respectively. Xerosis was the most frequently reported side effect regardless of the brand. The highest frequencies of hypercholesterolemia (25.6%) and eczema (13%) were noted with Roaccutane®; hypertriglyceridemia (16.8%), epistaxis (9.9%) and fatigue (3.1%) with Curacné®; excessive sweating (4.1%) and headache (4.1%) with Isosupra®; and abnormal liver function tests (11%) with Acnotren®. We found a significant correlation mainly between abnormal ASAT and Acnotren® (p = 0.009), hypercholesterolemia and Roaccutane® [OR = 1.652 (95% CI 1.056-2.585)], hypertriglyceridemia and higher body weight (p = 0.004). Factors related to the drug brand and to characteristics of acne patients could explain the variability in the prevalence of some adverse events.

Physiological and Psychological Effects of Isotretinoin in the Treatment of Patients with Acne: A Narrative Review

Isotretinoin (ISO) is a powerful vitamin A derivative that offers the potential for treatment of permanent remission of acne; however, its potential side effects on both physiological and psychological aspects limit its application. This article reviews the side effects of ISO from physiological and psychological aspects in detail, to better screen the suitable population of ISO and improve the efficiency of clinical treatment. Our findings indicate that ISO may cause teratogenicity, skin reactions, ocular reactions, changes in blood indicators, and occasional acne fulminans. To optimize clinical treatment, more attention should be paid to identifying the specific conditions under which these reactions occur, how severe they are, and how they subside to alleviate patient concerns. Regarding the controversial issue of psychological side effects caused by ISO, researchers should shift their focus to the psychological problems that acne itself may cause.

Isotretinoin treatment upregulates the expression of p53 in the skin and sebaceous glands of patients with acne vulgaris

The transcriptomic regulation induced by isotretinoin (13-cis retinoic acid) is still a matter of debate as short-term exposures of immortalized sebocytes with isotretinoin produced conflicting results. Based on translational evidence, it has been hypothesized that oral isotretinoin treatment upregulates the expression of the transcription factor p53. Twenty-five patients suffering from acne vulgaris were treated with isotretinoin (0.6 mg/kg body weight) for 6 weeks. Biopsies from back skin were taken before and after isotretinoin treatment for the determination of p53 expression by immunohistochemical staining, quantification of p53 protein concentration by enzyme-linked immunosorbent assay and TP53 gene expression by quantitative reverse transcription real time PCR. Fifteen socio-demographically cross-matched healthy volunteers served as controls. Isotretinoin treatment significantly increased the nuclear expression of p53 in sebaceous glands of treated patients compared to pre-treatment levels and p53 levels of untreated controls. Furthermore, the p53 protein and gene expression significantly increased in the skin after treatment. The magnitude of p53 expression showed an inverse correlation to acne severity score and body mass index. Under clinical conditions, isotretinoin induced the expression of p53, which controls multiple transcription factors involved in the pathogenesis of acne vulgaris including FoxO1, androgen receptor and critical genes involved in the induction of autophagy and apoptosis. Increased p53-FoxO1 signalling enhanced by systemic isotretinoin treatment explains the underlying transcriptomic changes causing sebum suppression but also the adverse effects associated with systemic isotretinoin therapy.

TFOS Lifestyle: Impact of elective medications and procedures on the ocular surface

The word "elective" refers to medications and procedures undertaken by choice or with a lower grade of prioritization. Patients usually use elective medications or undergo elective procedures to treat pathologic conditions or for cosmetic enhancement, impacting their lifestyle positively and, thus, improving their quality of life. However, those interventions can affect the homeostasis of the tear film and ocular surface. Consequently, they generate signs and symptoms that could impair the patient's quality of life. This report describes the impact of elective topical and systemic medications and procedures on the ocular surface and the underlying mechanisms. Moreover, elective procedures performed for ocular diseases, cosmetic enhancement, and non-ophthalmic interventions, such as radiotherapy and bariatric surgery, are discussed. The report also evaluates significant anatomical and biological consequences of non-urgent interventions to the ocular surface, such as neuropathic and neurotrophic keratopathies. Besides that, it provides an overview of the prophylaxis and management of pathological conditions resulting from the studied interventions and suggests areas for future research. The report also contains a systematic review investigating the quality of life among people who have undergone small incision lenticule extraction (SMILE). Overall, SMILE refractive surgery seems to cause more vision disturbances than LASIK in the first month post-surgery, but less dry eye symptoms in long-term follow up.

The updates and implications of cutaneous microbiota in acne

Acne is a chronic inflammatory skin disorder that profoundly impacts the quality of life of patients worldwide. While it is predominantly observed in adolescents, it can affect individuals across all age groups. Acne pathogenesis is believed to be a result of various endogenous and exogenous factors, but the precise mechanisms remain elusive. Recent studies suggest that dysbiosis of the skin microbiota significantly contributes to acne development. Specifically, Cutibacterium acnes, the dominant resident bacterial species implicated in acne, plays a critical role in disease progression. Various treatments, including topical benzoyl peroxide, systemic antibiotics, and photodynamic therapy, have demonstrated beneficial effects on the skin microbiota composition in acne patients. Of particular interest is the therapeutic potential of probiotics in acne, given its direct influence on the skin microbiota. This review summarizes the alterations in skin microbiota associated with acne, provides insight into its pathogenic role in acne, and emphasizes the potential of therapeutic interventions aimed at restoring microbial homeostasis for acne management.

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.

Reduction of New Heterotopic Ossification (HO) in the Open-Label, Phase 3 MOVE Trial of Palovarotene for Fibrodysplasia Ossificans Progressiva (FOP)

Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare, severely disabling genetic disorder of progressive heterotopic ossification (HO). The single-arm, open-label, phase 3 MOVE trial (NCT03312634) assessed efficacy and safety of palovarotene, a selective retinoic acid receptor gamma agonist, in patients with FOP. Findings were compared with FOP natural history study (NHS; NCT02322255) participants untreated beyond standard of care. Patients aged ≥4 years received palovarotene once daily (chronic: 5 mg; flare-up: 20 mg for 4 weeks, then 10 mg for ≥8 weeks; weight-adjusted if skeletally immature). The primary endpoint was annualized change in new HO volume versus NHS participants (by low-dose whole-body computed tomography [WBCT]), analyzed using a Bayesian compound Poisson model (BcPM) with square-root transformation. Twelve-month interim analyses met futility criteria; dosing was paused. An independent Data Monitoring Committee recommended trial continuation. Post hoc 18-month interim analyses utilized BcPM with square-root transformation and HO data collapsed to equalize MOVE and NHS visit schedules, BcPM without transformation, and weighted linear mixed-effects (wLME) models, alongside prespecified analysis. Safety was assessed throughout. Eighteen-month interim analyses included 97 MOVE and 101 NHS individuals with post-baseline WBCT. BcPM analyses without transformation showed 99.4% probability of any reduction in new HO with palovarotene versus NHS participants (with transformation: 65.4%). Mean annualized new HO volume was 60% lower in MOVE versus the NHS. wLME results were similar (54% reduction fitted; nominal p = 0.039). All palovarotene-treated patients reported ≥1 adverse event (AE); 97.0% reported ≥1 retinoid-associated AE; 29.3% reported ≥1 serious AE, including premature physeal closure (PPC)/epiphyseal disorder in 21/57 (36.8%) patients aged <14 years. Post hoc computational analyses using WBCT showed decreased vertebral bone mineral density, content, and strength, and increased vertebral fracture risk in palovarotene-treated patients. Thus, post hoc analyses showed evidence for efficacy of palovarotene in reducing new HO in FOP, but high risk of PPC in skeletally immature patients. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

ALA-PDT augments intense inflammation in the treatment of acne vulgaris by COX2/TREM1 mediated M1 macrophage polarization

Severe acne vulgaris is a common chronic inflammatory skin disease worldwide. 5-Aminolaevulinic acid photodynamic therapy (ALA-PDT) is effective and safe for severe acne. However, the mechanism is not fully understood. Intense acute inflammatory response at 24 h after ALA-PDT is reported positively correlated to the effectiveness. Inflammation regulation influence the progression or outcome of diseases. ALA-PDT may exert its therapeutic effect by augmenting intense inflammation and break the chronic inflammation. This study was set out to explore the mechanism of ALA-PDT augmenting intense acute inflammation in the treatment of acne. As a result, transcriptome microarrays analysis of severe acne patients showed that ALA-PDT significantly up-regulated expression of various inflammation-related genes, especially TREM1 and PTGS2, which were further confirmed by a C.acnes induced acne-like mouse ear model. The subsequent experiments demonstrated that ALA-PDT could trigger pro-inflammatory M1 polarization of macrophages in vitro and in vivo. Additionally, the crosstalk between keratinocytes and macrophages studied by a transwell co-culture system indicated that PGE2 secreted by ALA-PDT treated HaCaT cells could promote THP-1 macrophages M1 polarization by COX2/PGE2/TLR4/TREM1 axis to augment inflammation. Our study provides a novel insight that ALA-PDT could amplify inflammation by COX2/TREM1 mediated macrophages M1 polarization for the treatment of acne. It is hoped that this research will decipher the mechanism of ALA-PDT for the treatment of acne and provide a theoretical basis for optimizing the clinical ALA-PDT management.

Isotretinoin-Induced Distal Ileitis Mimicking Crohn's Disease

Terminal ileitis is a common condition defined as inflammation of the terminal portion of the ileum, which is typically associated with inflammatory bowel disease (IBD), classically Crohn's disease (CD). However, it can have other etiologies, including drug-induced ones. Isotretinoin is an effective and commonly used treatment for acne vulgaris, presenting multiple adverse effects. There have been discussions over its association with enteric inflammation, particularly over IBD emergence risk. We report a case of a previously healthy 17-year-old female who presented transitory clinical, laboratory, imaging, and endoscopic evidence of distal ileitis, temporally related to extended isotretinoin treatment and mimicking CD. Repeated clinical, laboratory, imaging, and endoscopic reassessment after isotretinoin discontinuation confirmed an almost complete resolution of the condition, avoiding IBD misdiagnosis and specific medication initiation. Our case highlights the differential diagnosis of ileitis as being of critical importance to avoid further unnecessary diagnostic investigations and inadequate treatment. Serial re-evaluation may be of key importance to reach a final diagnosis. Although recent literature suggests that isotretinoin is not associated with an increased IBD risk, our case highlights the possibility of it inducing small bowel injury and inflammation, similar to what has been reported with other drugs.

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

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

Anabolic-androgenic steroids: How do they work and what are the risks?

Anabolic-androgenic steroids (AAS) are a class of hormones that are widely abused for their muscle-building and strength-increasing properties in high, nontherapeutic, dosages. This review provides an up-to-date and comprehensive overview on how these hormones work and what side effects they might elicit. We discuss how AAS are absorbed into the circulation after intramuscular injection or oral ingestion and how they are subsequently transported to the tissues, where they will move into the extravascular compartment and diffuse into their target cells. Inside these cells, AAS can biotransform into different metabolites or bind to their cognate receptor: the androgen receptor. AAS and their metabolites can cause side effects such as acne vulgaris, hypertension, hepatotoxicity, dyslipidemia, testosterone deficiency, erectile dysfunction, gynecomastia, and cardiomyopathy. Where applicable, we mention treatment options and self-medication practices of AAS users to counteract these side effects. Clinicians may use this review as a guide for understanding how AAS use can impact health and to assist in patient education and, in some cases, the management of 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.

Action of Mangifera indica Leaf Extract on Acne-Prone Skin through Sebum Harmonization and Targeting C. acnes

(1) Background: Preclinical studies report that the ethanolic fraction from Mangifera indica leaves is a potential anti-acne agent. Nevertheless, the biological activity of Mangifera indica leaves has scarcely been investigated, and additional data are needed, especially in a clinical setting, for establishing the actual effectiveness of Mangifera indica extract as an active component of anti-acne therapy. (2) Methods: The evaluation of the biological activity of Mangifera indica extract was carried out through different experimental phases, which comprised in silico, in vitro, ex vivo and clinical evaluations. (3) Results: In silico and in vitro studies allowed us to identify the phytomarkers carrying the activity of seboregulation and acne management. Results showed that Mangifera indica extract reduced lipid production by 40% in sebocytes, and an improvement of the sebum quality was reported after the treatment in analyses performed on sebaceous glands from skin explants. The evaluation of the sebum quantity and quality using triglyceride/free fatty acid analysis conducted on Caucasian volunteers evidenced a strong improvement and a reduction of porphyrins expression. The C. acnes lipase activity from a severe acne phylotype was evaluated in the presence of Mangifera indica, and a reduction by 29% was reported. In addition, the analysis of the skin microbiota documented that Mangifera indica protected the microbiota equilibrium while the placebo induced dysbiosis. (4) Conclusions: Our results showed that Mangifera indica is microbiota friendly and efficient against lipase activity of C. acnes and supports a role for Mangifera indica in the therapeutic strategy for prevention and treatment of acne.

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.

Skin microbiome reconstruction and lipid metabolism profile alteration reveal the treatment mechanism of Cryptotanshinone in the acne rat

BACKGROUND

Acne has become one of the most prevalent skin disorders, affecting mostly young people's physical and mental health globally. Cryptotanshinone (CPT) is a potential drug for acne, but its mechanism of acne treatment has not been thoroughly studied on the microbiota. Till date, only a few studies are directed to the impact of acne therapy on skin microbiota and lipid metabolites.

PURPOSE

The action mechanism of CPT treatment of acne was investigated by the strategy of microbiome integration with lipidomics.

METHODS

The 16Sr DNA sequencing was used to detect skin microbiota composition, and absolute quantitative lipidomics was utilized to identify lipid metabolites profiles levels. Four key proteins of the glycolysis pathway were detected with the immunochemistry method. Antibacterial analysis was used to evaluate CPT treatment of acne.

RESULTS

CPT significantly inhibited Staphylococcus epidermidis and Staphylococcus aureus. Combination of the skin microbiome and lipidomics analysis, 29 types of differentially expressed flora (DEFs) and 782 differentially expressed lipid metabolites (DELMs) were significantly altered, especially Staphylococcus, Corynebacterium, Ralstonia, Enhydrobacter, Burkholderia, and Streptococcus. Cer was mainly regulated by Staphylococcus and Corynebacterium, whereas TG and DG were mainly regulated by Ralstonia, Enhydrobacter, Burkholderia, and Streptococcus. The glycolysis pathway was significantly regulated by Staphylococcus on CPT treatment of acne. The energy metabolism, lipid metabolism, immune system, glycan biosynthesis, and metabolism could be reversed by CPT.

CONCLUSION

CPT might help acne rats rebuild their skin microbiota and alter lipid metabolism signatures. Furthermore, since skin microbes and skin lipid metabolites have a close correlation and are both regulated by CPT, the findings potentially provide a research foundation for the discovery of biomarkers of skin microbiome imbalance and targeted treatment of acne development mechanisms.

Combined use of energy-based interventions with low-dose isotretinoin for the treatment of inflammatory acne: An retrospective cohort analysis

BACKGROUND

The combined use of oral isotretinoin with energy-based interventions including fractional microneedle radiofrequency, pulsed dye laser, and ablative fractional laser is an effective way to treat moderate-to-severe inflammatory acne lesions. However, studies regarding its efficacy and safety are limited.

AIMS

This study aimed to assess the efficacy and safety of a treatment using low-dose isotretinoin with energy-based interventions for inflammatory acne.

PATIENTS AND METHODS

This retrospective cohort study included 126 patients who were diagnosed with inflammatory acne and were treated with systemic isotretinoin for at least 3 months. Patients were divided into EBD (energy-based intervention) (n=82) and non-EBD groups (n=44). Clinical outcomes of both groups were assessed using medical records and digital photographs.

RESULTS

After treatment, the modified Global Acne Grading Score of the EBD and non-EBD groups decreased by 35.1±17.2 and 25.6±10.1, respectively. The improvement in acne severity was significantly greater in the EBD group than in the non-EBD group. Cumulated isotretinoin dose and frequency of drug-related side effects were significantly higher in the non-EBD group than in the EBD group.

CONCLUSION

Combined treatment with low-dose isotretinoin and energy-based intervention is well tolerated and associated with positive responses in patients with inflammatory acne.

Comprehensive Treatment of Severe Follicular Occlusion Triad: A Case Report

Follicular occlusion triad (FOT) is a chronic inflammatory skin disease that comprises hidradenitis suppurativa, acne conglobata, and perifolliculitis capitis abscedens et suffodiens and can seriously affect a patient’s quality of life. Currently, there is no consensus on the treatment plan for FOT. There are also only a few reports on the treatment of severe FOT. In July 2020, a male patient who was diagnosed with severe FOT was treated in our hospital and received comprehensive surgical treatment for 2 months. This treatment strategy was effective and the patient had no recurrence during a follow-up period of >1 year. By retrospectively analyzing the clinical data of the patient, recording the patient’s condition during postoperative recovery, and reviewing relevant literatures, the clinical manifestations, diagnosis, choice of treatment methods, and prognosis of FOT were evaluated.

Epidemiologic features and risk of scarring in pediatric patients with kerion celsi

BACKGROUND

Kerion celsi represents the inflammatory extreme of tinea capitis, as a delayed hypersensitivity reaction to the causative dermatophyte. Data regarding prevalence, trends in pathogens, and risk factors for scarring are limited.

OBJECTIVE

The main objective of the study is to assess clinical and epidemiologic features of children with kerion celsi and risk factors for scarring.

METHODS

We reviewed medical records of pediatric patients with kerion celsi treated between January 2006 and July 2020.

RESULTS

Among 80 patients, the prevalence of permanent alopecia was 27.5%. Patients with remaining alopecia presented to our clinic at a mean 1.3 months earlier than those with complete response to treatment (2.2 ± 2.1 and 3.4 ± 4.8, respectively; p < .05). Patients of Ethiopian ethnicity were more represented than in the general population; however, scarring was observed in only 11% (p = 0.08). Outcomes did not differ by pathogen, antifungal treatment prescribed, duration of treatment, or the use of prednisone or antibiotics.

CONCLUSIONS

Scarring alopecia is a common complication of kerion celsi. Host innate immune response, pathogen virulence, and treatment timeline should be considered as possible variables affecting risk of scarring in the future studies.

Factors associated with increased suicidality risk following referral for isotretinoin commencement

OBJECTIVE

To establish whether there is a significant change in suicidality risk following psychiatric assessment for commencement of isotretinoin and identify factors that underpin any potential risk change.

METHOD

Retrospective cohort study. Suicidality risk was defined as a combination of the following: (i) actual/intended self-harm and/or attempted/completed suicide, and (ii) increased service utilisation associated with suicidal ideation/behaviour. All patients referred to Psychiatry for assessment prior to commencement of isotretinoin between 2014 and 2019 were examined. Inclusion criteria: >16 years of age, assessed for commencement of isotretinoin, complete clinical records. Data were collected by reviewing the Electronic Patient Records. Fifty-seven patients were eligible. We employed descriptive statistics, parametric/non-parametric/normality tests and logistic regression analysis, using socio-demographic and clinical characteristics as independent parameters, and suicidality risk as the dependent parameter.

RESULTS

Actual/intended self-harm/attempted suicide decreased significantly following assessment without significant change in service utilisation. Female gender, absence of protective factors and assessment by Consultation-Liaison Psychiatry were linked to increased suicidality risk, after controlling for age, ethnicity, recommendation for isotretinoin, and substance misuse.

CONCLUSIONS

Psychiatric assessment is helpful before commencing isotretinoin. Female gender, and absence of ongoing psychopharmacological and/or psychological intervention and/or regular psychiatric follow-up predict increased suicidality risk among patients assessed for prescription of isotretinoin.

Cross-sectional assessment of the ellipsoid zone and the retinal pigment epithelium-Bruch membrane complex after systemic isotretinotin use

PURPOSE

To evaluate the cross-sectional areas of the retinal pigment epithelium-Bruch membrane complex (RPE-B) and ellipsoid zon (EZ) and the thickness of the macula, retinal nerve fibre layer (RNFL), and ganglion cell-inner plexiform layer (GC-IPL) in patients using short-term systemic isotretinoin.

METHOD

A total of 43 right eyes of 43 patients treated with systemic isotretinoin for acne vulgaris were included in this prospective study. Macula, GC-IPL, RNFL thicknesses and central cross-sectional EZ and RPE-B areas were evaluated with optical coherence tomography (Zeiss, Cirrus HD OCT 5000) prior to treatment and in first, second and third months after the onset of isotretinoin treatment. For the measurement of EZ and RPE-B area, foveal EDI-OCT scans were binarized by using the public domain software ImageJ 1.51 s.

RESULTS

Mean duration of isotretinoin treatment was 77 ± 15 days and mean dose was 2228 ± 574 milligrams. There was a statistically significant increment in central cross-sectional EZ and RPE-B areas in each follow-up examination, when analysed by repeated measurement analysis (p:0.002 and p:0.006, respectively). There was no correlation between total isotretinoin dose and the difference between final and basal EZ and RPE-B areas (p > 0.05, for both). When repeated measurements in follow-up examinations were compared, GC-IPL thicknesses except the superotemporal region (p:0.040) and RNFL thicknesses did not show a significant difference (p > 0.05). There was not any significant relation between total isotretinoin dose and 3rd month and basal measurement differences in macula, GC-IPL and RNFL thicknesses in any area (p > 0.05, for all).

CONCLUSION

There has been an increase in the area of RPE-B and EZ with short-term use of isotretinoin therapy. Future studies examining the relationship between functional tests and the RPE-B and EZ areas may provide more in-depth information on the effects of isotretinoin in the eye.

Risk of psychiatric disorders in patients taking isotretinoin: A nationwide, population-based, cohort study in Taiwan

BACKGROUND

After isotretinoin's approval to treat patients with recalcitrant acne, there have been continued debates around its psychiatric safety profile. This study aimed to assess the risk of psychiatric disorders in patients with acne who are taking isotretinoin.

METHODS

We used de-identified information from Taiwan's National Health Insurance Research Database from 2000 to 2015 to examine the risk for psychiatric disorders among patients with acne who were taking isotretinoin. We performed subgroup analyses based on the dosage and duration of isotretinoin administration.

RESULTS

This study included 29,943 participants during a 16-year follow-up period. We found no significantly increased risk for psychiatric disorders among patients taking isotretinoin compared with patients who did not receive isotretinoin treatment (adjusted hazard ratio [aHR]: 1.009, 95% confidence interval [CI]: 0.422-1.696). Subgroup analyses showed no significantly increased risk for psychiatric disorders in patients taking different doses of isotretinoin (≤ 20 mg per day, aHR: 0.892, 95% CI: 0.371-1.501; > 20 mg per day, aHR: 1.068, 95% CI: 0.446-1.798). There was also no significant increase in risk for patients undergoing isotretinoin treatment over different periods (≤ 6 months, aHR: 0.924, 95% CI: 0.392-1.612; > 6 months, aHR: 1.196, 95% CI: 0.488-2.004).

LIMITATIONS

We did not analyze the risk of suicidal ideation, and it could be underestimated in medical claims databases.

CONCLUSIONS

We found no increased risk of psychiatric disorders among Taiwanese patients with acne who were taking isotretinoin. Higher dosage or longer duration of isotretinoin treatment did not increase the risk for developing a psychiatric disorder.

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.

Conformational polymorphs of isotretinoin and their impact on physicochemical and biological properties

Isotretinoin is the first-line drug for treatment of severe acne. Only one polymorph was reported even though it has been launched for nearly 40 years, and its clinic application was however limited by its stability and solubility challenges. In our study, two new polymorphs of isotretinoin were discovered and fully characterized. The transformation relationships between these solid forms were fully discussed, and a visible color change during single-crystal-to-single-crystal phase transition with the conformational change was investigated. Form II is determined to be thermodynamic stable form at room temperature, but metastable form at body temperature. The results show that form II is an ideal solid state possessing both superior thermal stability (60℃, open air) and higher absorption once delivered into body. The thermal stability can be associated with the crystal structure such as torsion angle. The relative bioavailability of form II is higher than form I as expected, and the bioavailability of form II formulation is about 2 times as that of the marketed form I capsule. Therefore, form II formulation could provide an alternative for better performing isotretinoin.

Dermatologists' Knowledge and Attitude Toward Isotretinoin Ocular Side Effects in Egypt

Aim

The FDA approved isotretinoin for moderate and severe nodulo-cystic acne, in which it proved effective. However, this misled the dermatologists into using isotretinoin for mild cases as well. This misuse increased the risk of developing adverse effects, especially on the ocular system. These adverse effects vary from mild reversible eye dryness to severe irreversible loss of night vision. Also, it causes contact lens intolerance and corneal ulcer on top. Both ophthalmologists and dermatologists have different perceptions of the drug.

Purpose

To evaluate dermatologists' knowledge and attitude toward ocular adverse effects of isotretinoin in Egypt.

Methods

This cross-sectional study was conducted via an online questionnaire. The questionnaire had three parts: 1) demographic data, 2) knowledge about isotretinoin dry eye disorders, contact lens intolerance, and refractive surgery precautions and 3) dermatologists' management of a case on isotretinoin therapy. We contacted 111 participants from Facebook dermatologists' groups between March and April 2021.

Results

We surveyed 111 dermatologists. One hundred and five (94.6%) reported their knowledge about ocular side effects. One hundred of them (90.1%) informed their patients about the drug's adverse effects. Eighty-three (74.8%) reported their knowledge about contact lens intolerance. Forty-one dermatologists (36.9%) screened their patients for recent refractive surgery before isotretinoin therapy. Nearly, all dermatologists routinely prescribed lubricant eye drops for the patients, and 63 (56.8%) dermatologists sometimes referred their patients to an ophthalmologist. We found an association between knowledge about contact lens intolerance and years of experience (p=0.012). As well, we found that the academic degree of dermatologists is directly proportional with warning patients about ocular side effects (p=0.003) and refractive surgery (p=0.039).

Conclusion

Egyptian dermatologists were knowledgeable about the effects of isotretinoin on eyes with inappropriate clinical practice.

Investigation of relapse rate and factors affecting relapse after oral isotretinoin treatment in patients with acne vulgaris

Oral isotretinoin is the most effective treatment option used in acne treatment. However, varying rates of relapse have been reported after oral isotretinoin therapy. The aim of this study was to evaluate factors that affect relapse after oral isotretinoin treatment in patients with acne. In this cross-sectional study, 212 patients with acne using 0.3-1 mg/kg/day oral isotretinoin for at least 4 months were analyzed retrospectively regarding relapse frequency and factors that affected relapse. In the study, the female-to-male ratio was 3.15, with a mean age of 23.5 ± 6.2 years. The relapse rate was found as 37.3%. The median time to relapse was 10 months. The relapse rate was higher in younger patients (age ≤ 20 years), macrocomedone-type acne, and those with residual lesions at the end of the treatment (p < 0.05 and p < 0.01, respectively). To prevent relapse in patients with acne using oral isotretinoin, it is of great importance to continue the treatment until complete clinical improvement, and extend the treatment for at least one more month regardless of the cumulative dose. Relapse may also occur with younger age and macrocomedone-type acne.

The human vermilion surface contains a rich amount of cholesterol sulfate than the skin

BACKGROUND

The vermilion of the human lip presents characteristic features and undergoes aging faster than the skin. Therefore, knowledge of the vermilion surface-specific functional molecules is important to understand lip aging and formulate lip care products. Previously, we analyzed the free fatty acids distributions and showed that docosahexaenoic acid highly accumulated in the vermilion's epithelium than in the skin.

OBJECTIVE

We aimed to explore the functional molecules other than the free fatty acids on the vermilion's surface.

METHODS

Human lip tissues from children and tape-stripped samples from smooth and rough lips of adults were measured by desorption electrospray ionization-mass spectrometry imaging (DESI-MSI).

RESULTS

DESI-MSI of children's lip sections revealed a major distribution of five phospholipid species in the viable layer, but not in the superficial area, of both the vermilion and the skin than that in the underlying tissue. Interestingly, a remarkably higher distribution of cholesterol sulfate was observed in the vermilion's superficial area compared to that in the skin in all subjects under this study. Furthermore, theDESI-MSI of tape-stripped lip sample showed an overall higher accumulation of cholesterol sulfate in the stratum corneum of the rough lip than that in the smooth lips showed an overall higher accumulation of cholesterol sulfate in the stratum corneum of the rough lips than that in the smooth lips.

CONCLUSION

Our study concluded that cholesterol sulfate has a characteristic distribution to the vermilion's surface and showed an association with the roughness of the lip.

Is there an association between long-term antibiotics for acne and subsequent infection sequelae and antimicrobial resistance? A systematic review

BACKGROUND

Antimicrobial resistance (AMR) is a global health priority. Acne vulgaris is a common skin condition for which antibiotic use ranges from a few months to years of daily exposure.

AIM

To systemically search for and synthesise evidence on the risk of treatment-resistant infections, and other evidence of AMR, following long-term oral antibiotic use for acne.

DESIGN & SETTING

In this systematic review, a literature search was carried out using the databases Embase, MEDLINE, Cochrane, and Web of Science. They were searched using MeSH, Emtree, or other relevant terms, and followed a pre-registered protocol.

METHOD

Search strategies were developed with a librarian and undertaken in July 2019. All searches date from database inception. The primary outcome was antibiotic treatment failure or infection caused by a resistant organism. Secondary outcomes included detection of resistant organisms without an infection, rate of infection, or changes to flora.

RESULTS

A total of 6996 records were identified. Seventy-three full-text articles were shortlisted for full review, of which five were included. Two investigated rates of infection, and three resistance or changes to microbial flora. Three studies had 35 or fewer participants (range 20-118 496). Three studies had a serious or high risk of bias, one moderate, and one a low risk of bias. Weak evidence was found for an association between antibiotic use for acne and subsequent increased rates of upper respiratory tract infections and pharyngitis.

CONCLUSION

There is a lack of high quality evidence on the relationship between oral antibiotics for acne treatment and subsequent AMR sequelae. This needs to be urgently addressed with rigorously conducted studies.

Efficacy of a New Non-drug Acne Therapy: Aloe Vera Gel Combined With Ultrasound and Soft Mask for the Treatment of Mild to Severe Facial Acne

Background: Acne is a chronic disorder that affects almost 80% of adolescents and young adults, causing psychological and emotional distress. However, the current treatments for acne are either ineffective or have many side effects. This study was designed to confirm and objectively quantify the effect of a new non-drug combined therapy on acne. Methods: This study innovatively utilized ultrasound, which enhanced the absorption of aloe vera gel, and soft mask to make a purely physical method without any drugs. In both the treatment group and control group, the number of papules/pustules and the area of hyperpigmented lesions were counted, and a smart mirror intelligent face system was used before and after the combined therapy. Alterations in the skin functional index were recorded and analyzed statistically. Results: In the treatment group, the combined therapy significantly reduced the number of papules and the area of hyperpigmented lesions and improved skin roughness and local blood circulation. In the control group, there was no obvious improvement over 2 months. Conclusion: This study suggests that the new non-drug combined therapy significantly improved acne, which provided experimental evidence and treatment guidance for patients with mild to severe acne, especially patients with moderate acne. This new therapy may possibly be an appropriate method for patients who seek topical treatments with mild side effects and low antibiotic resistance rates.

Treatment challenges in adult female acne and future directions

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

Concurrent Serotonin Syndrome and Prolong QT Interval Induced by Paroxetine Overdose With Isotretinoin

The use of serotonergic drugs has increased in the last decade especially selective serotonin reuptake inhibitors (SSRIs) with increased indications. Serotonin syndrome (SS) and QT prolongation are serious adverse reactions of SSRI use, they usually occur with concomitant use of two or more serotonergic medication. Herein, we are presenting an interesting unique case of SS and prolongation of QT interval after a suicidal attempt in a patient on isotretinoin with paroxetine overdosing. The prolongation of QT interval observed in this case could be related to isotretinoin synergistic effect. The risk of suicide and side effects of SSRI with isotretinoin, especially in patient with psychiatric illness would be a huge concern. This case hopes to raise the awareness of the risks when prescribing SSRI and isotretinoin in this group of patients.