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Seyman Civelek Ü, Baykal Selcuk L, Arica DA, Capkin E, Yayli S. Isotretinoin‐induced inflammatory back pain and sacroiliitis in patients with moderate to severe acne vulgaris. J Cosmet Dermatol 2022; 21:4846-4851. [PMID: 35092165 DOI: 10.1111/jocd.14807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/05/2022] [Accepted: 01/17/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Isotretinoin has been reported to induce inflammatory back pain (IBP) and sacroiliitis in the patients with acne vulgaris. The aim of this study is to investigate the incidence of IBP and sacroiliitis in patients receiving isotretinoin treatment compared with oral antibiotics for acne vulgaris. MATERIALS AND METHODS A total of 201 patients with moderate-to-severe acne vulgaris who received isotretinoin (n = 100) or oral antibiotics (n = 101) were included in the study. All patients were monthly questioned for IBP symptoms during their treatment. Patients described IBP were also evaluated for sacroiliitis by c-reactive protein, sedimentation rate, HLAB27, and sacroiliac magnetic resonance imaging (MRI). Isotretinoin was discontinued in all patients diagnosed as sacroiliitis, and these patients were reevaluated after 3 months. RESULTS IBP was observed in 21 (10.4%), and sacroiliitis was detected in 11 (11%) patients on isotretinoin treatment; in oral antibiotic group, we did not observe IBP or sacroiliitis. The incidence of IBP and sacroiliitis differed significantly between the isotretinoin and oral antibiotic groups (p < 0.0001, p = 0.02). Complete regression was observed in the great majority of patients following cessation of isotretinoin. CONCLUSIONS Our study is the largest prospective controlled study that investigated the incidence of sacroiliitis in patients receiving isotretinoin and compared with patients using oral antibiotics.
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Affiliation(s)
- Ünzüle Seyman Civelek
- Karadeniz Technical University Faculty of Medicine , Dermatology and Venereology Trabzon
| | - Leyla Baykal Selcuk
- Karadeniz Technical University Faculty of Medicine , Dermatology and Venereology Trabzon
| | - Deniz Aksu Arica
- Karadeniz Technical University Faculty of Medicine , Dermatology and Venereology Trabzon
| | - Erhan Capkin
- Karadeniz Technical University Physical Therapy and Rehabilitation Trabzon 61080
| | - Savas Yayli
- Koc University School of Medicine, Dermatology Trabzon 61080
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Luzzati M, Simonini G, Filippeschi C, Giani T, Trapani S. SAPHO syndrome: the supposed trigger by isotretinoin, the efficacy of adalimumab and the specter of depressive disorder: a case report. Ital J Pediatr 2020; 46:169. [PMID: 33187546 PMCID: PMC7663872 DOI: 10.1186/s13052-020-00933-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 10/26/2020] [Indexed: 11/24/2022] Open
Abstract
Background SAPHO (synovitis, acne, pustolosis, hyperostosis and osteitis) syndrome is a rare autoinflammatory chronic disorder, presenting with non-infectious osteitis, sterile joint inflammation and skin manifestations including palmoplantar pustolosis and severe acne. It could be often misdiagnosed for its heterogeneous clinical presentation. Treatment is challenging and, due to the rarity of this syndrome, no randomized controlled clinical trials have been conducted. Empirical treatments, including non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, antibiotics and bisphosphonates and disease-modifying anti-rheumatic drugs (DMARDs) could be quite effective. Anti-tumor necrosis factor-alpha (anti-TNF-α) agents and interleukin-1 (IL-1) antagonists have shown promising results in refractory patients. Isotretinoin, commonly used for severe acne, has been rarely described as possible trigger of osteo-articular manifestations, in particular sacroiliitis. Case presentation The case of a boy, affected by acne fulminans and depression, who presented with sacroiliitis after a 10-week treatment with isotretinoin is presented. After SAPHO diagnosis, NSAIDs therapy was started but the onset of bilateral gluteal hidradenitis suppurativa required the switch to a TNF-α antagonist (Adalimumab) with the achievement of a good control of the disease. Despite specific therapy with sertraline, the patient continued to complains severe depression. Conclusions Our case reports a temporal association between the onset of osteo-articular symptoms and the introduction of isotretinoin, as previously described. However, this timeline is not sufficient to establish a causal role of this drug into the pathogenesis of sacroiliitis. At this regard, further studies are required. The occurrence of hidradenitis suppurativa during SAPHO course supported the introduction of TNF-α blockers with a favourable result, as reported in a few cases in literature. The association between SAPHO syndrome and depressive mood disorders is already reported. Our patient experienced severe depression whose trend seems to be independent from the course of the main disease. Currently, it is not clarified if depression could be considered reactive to the underling disease or if it forms an integral part of the autoinflammatory disorder.
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Affiliation(s)
- Michele Luzzati
- Post-Graduate School of Pediatrics, University of Florence, Florence, Italy.
| | - Gabriele Simonini
- Department of NEUROFARBA, University of Florence, Florence, Italy.,Rheumatology Department, Meyer Children's University Hospital, Florence, Italy
| | - Cesare Filippeschi
- Dermatology Department, Meyer Children's University Hospital, Florence, Italy
| | - Teresa Giani
- Rheumatology Department, Meyer Children's University Hospital, Florence, Italy
| | - Sandra Trapani
- Department of Health Science, University of Florence, Florence, Italy
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Karaosmanoğlu N, Mülkoğlu C. Analysis of musculoskeletal side effects of oral Isotretinoin treatment: a cross-sectional study. BMC Musculoskelet Disord 2020; 21:631. [PMID: 32977793 PMCID: PMC7519514 DOI: 10.1186/s12891-020-03656-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 09/18/2020] [Indexed: 11/12/2022] Open
Abstract
Background/ objectives Acne vulgaris is a chronic inflammatory disease affecting the pilosebaceous unit. Isotretinoin is an effective treatment option for severe acne. The aim of this study was to evaluate musculoskeletal side effects of systemic isotretinoin treatment. Methods Ninety-four patients with acne vulgaris and 100 sex- and age-matched controls were enrolled in this study. Only the patients who had musculoskeletal symptoms were evaluated in this study. All participants were firstly assessed by a dermatologist. The patients were asked whether they had any musculoskeletal symptoms after isotretinoin treatment, if so, the feature and duration of the symptoms were recorded. The dosage of the drug, treatment duration, incidence of arthralgia, myalgia, low back pain, sacroiliitis and tendinopathy and laboratory test results were noted. The severity of pain was assessed by visual analog scale (VAS). The severity of acne vulgaris was evaluated by Global Acne Grading Scale (GAGS). Sacroiliac radiography, magnetic resonance imaging (MRI) and rheumatologic blood tests were requested from the patients meeting Assessment of Spondyloarthritis International Society (ASAS) criteria. Results Of the 94 patients, 71 were female and 23 were male. 47.9% of the patients had arthralgia, 53.2% had myalgia, 70.2% (66) had low back pain, 11.7% had sacroiliitis and 4.3% had tendinopathy. 37.8% of 66 patients with low back pain had inflammatory pain and 62.2% had mechanical pain. Bone marrow edema consistent with sacroiliitis was detected by sacroiliac MRI in 11 patients with inflammatory back pain. The median total cumulative dose of isotretinoin was significantly higher in patients with low back pain than in patients without low back pain (p = 0.014). There was no significant correlation between cumulative dose of drug, treatment duration and VAS with ESR and CRP (p > 0.05). Also no correlation was found between GAGS scores and musculoskeletal symptoms (p > 0.05). Conclusion Low back pain is one of the very common complications of isotretinoin. It can be mostly mechanical or inflammatory. Isotretinoin-induced low back pain is dose-related, and inflammatory back pain without sacroiliitis is also frequent. The clinicians should be aware of the back pain may be a reflective of sacroiliitis during isotretinoin usage.
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Affiliation(s)
- Nermin Karaosmanoğlu
- Department of Dermatology, Health Sciences University Ankara Training and Research Hospital, Ankara, Turkey
| | - Cevriye Mülkoğlu
- Department of Physical Medicine and Rehabilitation, Health Sciences University Ankara Training and Research Hospital, Ankara, Turkey.
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Mülkoğlu C, Nacır B. A patient with chronic sacroiliitis undiagnosed for three years after isotretinoin use. BMC Musculoskelet Disord 2020; 21:300. [PMID: 32410688 PMCID: PMC7227041 DOI: 10.1186/s12891-020-03290-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 04/14/2020] [Indexed: 12/24/2022] Open
Abstract
Background Isotretinoin (ISO) is a synthetic vitamin A derivative which has been used for treatment-resistant acne vulgaris. Although most musculoskeletal side effects of ISO are common, including myalgia, arthralgia, and back pain, sacroiliitis is one of the uncommon side effects. ISO-induced sacroiliitis usually completely resolves within a few months by the cessation of the drug. Case presentation In this paper, we present a 26-year-old female patient with chronic sacroiliitis that was probably induced by ISO and not resolved by the discontinuation of the drug. Conclusion In this patient, sacroiliitis was overlooked for three years. Therefore, ISO usage should be considered in the differential diagnosis of sacroiliitis and low back pain.
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Affiliation(s)
- Cevriye Mülkoğlu
- Department of Physical Medicine and Rehabilitation, Health Sciences University Ankara Training and Research Hospital, Ankara, Turkey.
| | - Barış Nacır
- Department of Physical Medicine and Rehabilitation, Health Sciences University Ankara Training and Research Hospital, Ankara, Turkey
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Mülkoğlu C, Karaosmanoğlu N. Effect of Serum 25 Hydroxy Vitamin D Level on Isotretinoin-Induced Musculoskeletal Symptoms: A Cross-Sectional Study. Sci Rep 2020; 10:2245. [PMID: 32042004 PMCID: PMC7010655 DOI: 10.1038/s41598-020-59167-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/19/2020] [Indexed: 12/20/2022] Open
Abstract
Isotretinoin (ISO) is a drug which is used for the treatment of severe and refractory acne vulgaris (AV), over the last few decades. The drug has various musculoskeletal side effects. The aim of this study was to investigate relationship between serum 25 hydroxy (OH) vitamin D levels and the ISO-induced musculoskeletal side effects in patients with AV. We included 87 patients receiving ISO and had musculoskeletal symptoms as adverse effect (AE) group. Another 90 patients receiving ISO for AV and had any musculoskeletal complaints were recruited as control (C) group. Locomotor system examination of the patients was performed by the same clinician. Serum 25 OH vitamin D levels of the all participants were measured. Patients in the AE group were divided into three subgroups by serum 25 OH vitamin D levels. Patients with serum 25 OH vitamin D level lower than 10 ng/ml was classified as Group I, the ones between 10-20 ng/ml as Group II and those higher than 20 ng/ml were classified as Group III. AE and C groups were similar in terms of age and sex (p > 0.05). There was no statistically significant difference in the mean serum vitamin D levels between two groups (p = 0.17). Also, there was no significant difference in number of arthralgia (p = 0.30), myalgia (p = 0.29), low back pain (p = 0.10) and sacroiliitis (p = 0.17) between three subgroups in AE group. In addition, we found no statistically significant correlation between the serum vitamin D levels and age, cumulative dose of ISO, arthralgia, myalgia and sacroiliitis parameters in AE group (p > 0.05). Serum 25 OH vitamin D levels between the AE and C groups were similar. We also found that no significant difference in musculoskeletal adverse events between AE subgroups. Therefore, it can be concluded that vitamin D deficiency has no effect on the musculoskeletal adverse events in patients receiving ISO.
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Affiliation(s)
- Cevriye Mülkoğlu
- Department of Physical Medicine and Rehabilitation, Health Sciences University Ankara Training and Research Hospital, Ankara, Turkey.
| | - Nermin Karaosmanoğlu
- Department of Dermatology, Health Sciences University Ankara Training and Research Hospital, Ankara, Turkey
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Elnady B, Elkhouly T, Dawoud NM, Desouky DE, Kewan HH, Dawoud DM, Ritchlin C. New onset of axial spondyloarthropathy in patients treated with isotretinoin for acne vulgaris: incidence, follow-up, and MRI findings. Clin Rheumatol 2020; 39:1829-1838. [DOI: 10.1007/s10067-020-04957-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 01/17/2020] [Accepted: 01/22/2020] [Indexed: 12/18/2022]
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Karadağ ŞG, Sönmez HE, Tanatar A, Çakan M, Aktay Ayaz N. Isotretinoin-induced sacroiliitis: Case series of four patients and a systematic review of the literature. Pediatr Dermatol 2020; 37:171-175. [PMID: 31765029 DOI: 10.1111/pde.14035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Isotretinoin is the mainstay treatment in severe acne; however, its musculoskeletal adverse effects such as lower-back pain can be disabling. Herein, we present four cases of isotretinoin-induced sacroiliitis with variable severity. We also present a review of the literature of isotretinoin-induced sacroiliitis. All our cases were male and human leukocyte antigen (HLA)-B27 negative. Sacroiliitis was detected a median of 55 (10-120) days after isotretinoin initiation. Two patients were responsive to baseline sulfasalazine and indomethacin treatment, while the other two patients required more intensive treatments: adalimumab in one and methotrexate in the other. We also identified 15 articles describing 33 patients (17 of whom were female) with isotretinoin-induced sacroiliitis. Most of them were responsive to low-to-medium doses of systemic steroids or non-steroidal anti-inflammatory drugs (NSAIDs). Our patients illustrate that severity of isotretinoin-induced sacroiliitis varies from patient to patient.
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Affiliation(s)
- Şerife Gül Karadağ
- Department of Pediatric Rheumatology, Kanuni Sultan Süleyman Research and Training Hospital, University of Health Science, Istanbul, Turkey
| | - Hafize Emine Sönmez
- Department of Pediatric Rheumatology, Kanuni Sultan Süleyman Research and Training Hospital, University of Health Science, Istanbul, Turkey
| | - Ayşe Tanatar
- Department of Pediatric Rheumatology, Kanuni Sultan Süleyman Research and Training Hospital, University of Health Science, Istanbul, Turkey
| | - Mustafa Çakan
- Department of Pediatric Rheumatology, Kanuni Sultan Süleyman Research and Training Hospital, University of Health Science, Istanbul, Turkey
- Department of Pediatric Rheumatology, Şanlıurfa Research and Training Hospital, Şanlıurfa, Turkey
| | - Nuray Aktay Ayaz
- Department of Pediatric Rheumatology, Kanuni Sultan Süleyman Research and Training Hospital, University of Health Science, Istanbul, Turkey
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Coskun BN, Yagiz B, Pehlivan Y, Dalkilic E. Isotretinoin-induced sacroiliitis in patients with hidradenitis suppurativa: a case-based review. Rheumatol Int 2019; 39:2159-2165. [DOI: 10.1007/s00296-019-04434-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 08/22/2019] [Indexed: 12/13/2022]
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Sacroiliitis during isotretinoin treatment: Causal association or coincidence? North Clin Istanb 2019; 6:75-80. [PMID: 31180372 PMCID: PMC6526982 DOI: 10.14744/nci.2018.93798] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 02/07/2018] [Indexed: 11/20/2022] Open
Abstract
Isotretinoin, a retinoid derivate used in acne treatment, has a variety of side effects involving the musculoskeletal system; however, sacroiliitis is rarely observed. Our aim was to present nine cases of sacroiliitis in patients being treated with isotretinoin. Sacroiliitis was identified and monitored using magnetic resonance imaging (MRI). Clinical symptoms were resolved with nonsteroidal anti-inflammatory drug therapy after isotretinoin treatment was ceased. Different from the other cases, follow-up MRI was done. Follow-up MRI revealed improvement in some patients. Although the association between isotretinoin therapy and sacroiliitis has been covered in literature, this association is not yet completely understood. We aimed to discuss the relationship between two.
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Baykal Selçuk L, Aksu Arıca D, Baykal Şahin H, Yaylı S, Bahadır S. The prevalence of sacroiliitis in patients with acne vulgaris using isotretinoin. Cutan Ocul Toxicol 2016; 36:176-179. [PMID: 27764978 DOI: 10.1080/15569527.2016.1237521] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND/OBJECTIVE Acne vulgaris is a chronic inflammatory disease affecting the pilosebaceous unit in the skin. Isotretinoin is a synthetic vitamin A derivative regarded as the most effective agent in the treatment of acne. There have recently been increasing reports of adverse effects of isotretinoin on the skeletal system. Our aim in this study was to evaluate the rheumatic side-effects triggered by this drug, and particularly the prevalence of sacroiliitis. MATERIALS AND METHODS A total of 73 patients receiving isotretinoin due to moderate or severe acne vulgaris were included. All patients were questioned about inflammatory low back pain and musculoskeletal pains during the treatment process. Inflammatory low back pain was evaluated using Assessment of Spondyloarthritis International Society (ASAS) criteria. Patients meeting ASAS criteria were evaluated with radiography and when necessary with sacroiliac magnetic resonance. RESULTS The dose range for isotretinoin was between 0.4 and 0.8 mg/kg/day (mean 0.53 mg/kg/day). Treatment lasted for 6-8 months (mean 6.8 months). Lethargy was determined in 37 (50.7%) patients, myalgia in 31 (42.5%) and low back pain in 36 (49.3%). Mechanical low back pain symptoms were present in 20 of the patients describing low back pain and inflammatory low back pain in 16. Acute sacroiliitis was determined in six patients (8.2%) following a sacroiliac magnetic resonance imaging (MRI). Five (83.3%) of the patients with sacroiliitis were female and one (16.7%) was male. No statistically significant difference was determined between male and female patients in terms of prevalence of sacroiliitis (p = 0.392). CONCLUSION The incidence of sacroiliitis in patients using isotretinoin is quite high. Patients using isotretinoin must be questioned about sacroiliitis findings and must be subjected to advanced assessment when necessary. Further studies regarding the development of sacroiliitis under isotretinoin therapy are now needed.
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Affiliation(s)
- Leyla Baykal Selçuk
- a Dermatology Department, School of Medicine, Karadeniz Technical University , Trabzon , Turkey and
| | - Deniz Aksu Arıca
- a Dermatology Department, School of Medicine, Karadeniz Technical University , Trabzon , Turkey and
| | - Hanife Baykal Şahin
- b Physical Therapy and Rehabilitation Department, Maçka Ömer Burhanoğlu Physical Therapy and Rehabilitation Hospital , Trabzon , Turkey
| | - Savas Yaylı
- a Dermatology Department, School of Medicine, Karadeniz Technical University , Trabzon , Turkey and
| | - Sevgi Bahadır
- a Dermatology Department, School of Medicine, Karadeniz Technical University , Trabzon , Turkey and
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Alkan S, Kayiran N, Zengin O, Kalem A, Kimyon G, Kilinc EO, Pehlivan Y, Kirtak N, Onat AM, Kisacik B. Isotretinoin-induced Spondyloarthropathy-related Symptoms: A Prospective Study. J Rheumatol 2015; 42:2106-9. [DOI: 10.3899/jrheum.150013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2015] [Indexed: 12/16/2022]
Abstract
Objective.Acne vulgaris is a chronic inflammatory disease involving the pilosebaceous unit of the skin. Isotretinoin is a systemic retinoid that is often used as an effective treatment option for severe and treatment-resistant acne. Isotretinoin may also cause rheumatologic symptoms. The aim of this prospective observational study was to present followup results regarding the rheumatologic symptoms of patients who received systemic therapy for the treatment of acne (isotretinoin and tetracycline).Methods.For inclusion in the study, all consecutive patients with acne who were aged > 18 years were evaluated by the same dermatologist. The first 42 consecutive patients were included in the isotretinoin group, and after matching for age and sex, 32 consecutive patients were included in the tetracycline group. Isotretinoin treatment was planned as an average dose of 30 mg daily and a total dose of 120–150 mg/kg for 4–6 months. The patients were administered a dose of 1 g/day of tetracycline as 2 equal doses for 3 months.Results.Forty-two patients diagnosed with acne vulgaris were treated with isotretinoin 20.6 ± 4.4 (male/female: 17/22), and 32 patients were treated with tetracycline 20.6 ± 2.7 (male/female: 8/24). There was no significant difference between the 2 groups with respect to age and sex. Unilateral Achilles enthesopathy developed in 3 patients, whereas both Achilles enthesopathy and unilateral sacroiliitis developed in 1 patient. Inflammatory back pain developed in 6 patients in the isotretinoin group.Conclusion.To our knowledge, this was the first prospective observational study that assessed the rheumatologic symptoms of isotretinoin treatment. The spondyloarthropathy findings were identified in 23.1% of the patients who used isotretinoin.
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Yilmaz Tasdelen O, Yurdakul FG, Duran S, Bodur H. Isotretinoin-induced arthritis mimicking both rheumatoid arthritis and axial spondyloarthritis. Int J Rheum Dis 2014; 18:466-9. [DOI: 10.1111/1756-185x.12464] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Ozlem Yilmaz Tasdelen
- Department of Physical Medicine and Rehabilitation; Ankara Numune Training and Research Hospital; Ankara Turkey
| | - Fatma Gul Yurdakul
- Department of Physical Medicine and Rehabilitation; Ankara Numune Training and Research Hospital; Ankara Turkey
| | - Semra Duran
- Department of Radiology; Ankara Numune Training and Research Hospital; Ankara Turkey
| | - Hatice Bodur
- Department of Physical Medicine and Rehabilitation; Ankara Numune Training and Research Hospital; Ankara Turkey
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