Oral isotretinoin in photoaging: objective histological evidence of efficacy and durability

Elastography findings in acne scar patients who were treated with microneedling

BACKGROUND

Acne scar (AS) is a frequent sequela in patients with acne. In addition to advanced treatment methods, microneedling (MN) is still used as an effective option in the treatment of AS. However, similar to most diseases in dermatology, there is no objective tool to determine the severity of AS and to evaluate the treatment outcome.

OBJECTIVES

In the current study, we aimed to evaluate skin elasticity in AS patients who have undergone MN therapy. Furthermore, other purposes were to determine the relationships between the history of isotretinoin use, demographic data, and changes in skin elasticity.

METHODS

In order to evaluate the skin elasticity of 20 patients with AS, shear wave elastography (SWE) was performed before and after MN treatment. The physician's clinical assessment was evaluated with quantitative AS severity scale. In order to show that SWE is a consistent method, three repeated measurements were performed on 24 healthy participants.

RESULTS

A significant increase was found between the shear-wave velocity (SWV) values that were measured baseline and after treatment in the patient group (P = 0.033). In the control group, there was no significant difference between the three repeated measurements (P > 0.05). A statistically significant decrease was also detected in the AS severity scores (P < 0.005).

CONCLUSIONS

In AS patients who underwent MN treatment, a significant increase was found in skin elasticity compared to the baseline. We argued that SWE is a method that can be useful to evaluate skin elasticity before and after similar cosmetic procedures and dermatological diseases.

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.

Oral Supplementation and Systemic Drugs for Skin Aging: A Narrative Review

Skin aging is influenced by intrinsic and extrinsic factors and involves multiple pathogenic mechanisms. The most widely used treatments are topical products and minimally invasive procedures. Evidence on the benefits of systemic therapy is limited for several reasons: Reliance on mostly small and predominantly female samples, short study durations, methodologic heterogeneity, and a lack of consensus on which outcome measures are clinically relevant. Furthermore, systemic drugs and oral supplements are not without adverse effects. Oral hydrolyzed collagen and oral hyaluronic acid are well tolerated, and numerous clinical trials show they can mitigate some signs of skin aging. Low-dose oral isotretinoin is another option, but it has a higher risk of adverse effects. Evidence is lacking on the effects of the many dietary supplements on offer, such as vitamins, flavonoids, plant extracts, and trace elements. The future of skin aging management would appear to lie in the use of senolytic and senomorphic agents targeting senescent cells in the skin.

[Translated article] Oral Supplementation and Systemic Drugs for Skin Aging: A Narrative Review

Skin aging is influenced by intrinsic and extrinsic factors and involves multiple pathogenic mechanisms. The most widely used treatments are topical products and minimally invasive procedures. Evidence on the benefits of systemic therapy is limited for several reasons: reliance on mostly small and predominantly female samples, short study durations, methodologic heterogeneity, and a lack of consensus on which outcome measures are clinically relevant. Furthermore, systemic drugs and oral supplements are not without adverse effects. Oral hydrolyzed collagen and oral hyaluronic acid are well tolerated, and numerous clinical trials show they can mitigate some signs of skin aging. Low-dose oral isotretinoin is another option, but it has a higher risk of adverse effects. Evidence is lacking on the effects of the many dietary supplements on offer, such as vitamins, flavonoids, plant extracts, and trace elements. The future of skin aging management would appear to lie in the use of senolytic and senomorphic agents targeting senescent cells in the skin.

The role of local retinoids in eliminating signs of skin aging

Skin aging is a complex process involving both internal (chronological aging) and external (biological aging) factors. Slowing down the proliferative and immune processes in the epidermis, reducing the activity of fibroblasts and vascularization of the dermis during chronological aging lead to thinning, dryness, hypersensitivity, vulnerability and superficial wrinkles. Exposure to ultraviolet rays, pollutants, climate, and thermal factors cause keratinocyte disorganization, enhanced melanogenesis, collagen dystrophy, solar elastosis, and disorder of microcirculation. The main signs of external skin aging are deep wrinkles, sagging, pigmentation, telangiectasia, skin neoplasms. Among the local anti-aging agents, retinoids occupy a leading place, as they eliminate the main signs of skin aging. Of the entire group of retinoids, retinoic acids are the most active. However, the possibility of skin irritation limits their use. Therapeutic and cosmetic products with retinol esters (retinol palmitate) have a minimal irritating effect and can be used both for the prevention of skin aging and the elimination of its signs. Oral use of isotretinoin as an anti-aging agent is undesirable due to the many side effects and contraindications.

Oral isotretinoin for the treatment of dermatologic conditions other than acne: a systematic review and discussion of future directions

While isotretinoin has been the gold-standard of therapy for severe acne since its approval in 1982, its anti-inflammatory properties makes it a potentially applicable and versatile therapy for a wide variety of dermatologic conditions yet to be explored. This systematic review comprehensively recounts the success of oral isotretinoin in non-acne cutaneous diseases and provide insight into future directions of isotretinoin utility. A systematic literature review was performed using PubMed. Search terms included "isotretinoin" OR "accutane" AND "skin" OR "dermatology" OR "hair" OR "nails" OR "rosacea" OR "psoriasis" OR "pityriasis rubra pilaris" OR "condyloma acuminata" OR "granuloma annulare" OR "darier's disease" OR "non-melanoma skin cancer" OR "frontal fibrosing alopecia" OR "cutaneous lupus erythematosus" OR "hidradenitis suppurativa" OR "photodamaged skin" OR "skin aging" OR "wart" OR "flat warts" OR "plane warts" OR "lichen planus" OR "dissecting cellulitis" OR "folliculitis decalvans" OR "sebaceous hyperplasia" OR "cutaneous t-cell lymphoma" OR "mycosis fungoides." A total of 169 studies discuss the use of oral isotretinoin for 16 non-acne dermatologic conditions, the most common being non-melanoma skin cancers (0.2-8.2 mg/kg/day), cutaneous T-cell lymphomas (0.5-2 mg/kg/day), and rosacea (0.22-1 mg/kg/day). Inflammatory conditions such as rosacea, granuloma annulare, and hidradenitis suppurativa benefit from lower oral isotretinoin dosage of 0.3-1 mg/kg/day, whereas, hyperkeratotic diseases such as psoriasis and pityriasis rubra pilaris, consistently respond better to higher dosages of up to 2-4 mg/kg/day for lesion clearance. Recurrence of disease following discontinuation of isotretinoin have been reported for rosacea, psoriasis, granuloma annulare, Darier's disease, dissecting cellulitis, and non-melanoma skin cancers. Disease exacerbation was reported in some patients with hidradenitis suppurativa. Off-label isotretinoin is an effective treatment choice for dermatological conditions beyond acne. Further prospective, randomized human trials are needed to clarify when and how to prescribe off-label isotretinoin for maximum efficacy and safety.

Consensus on the use of oral isotretinoin in dermatology - Brazilian Society of Dermatology

BACKGROUND

Isotretinoin is a synthetic retinoid, derived from vitamin A, with multiple mechanisms of action and highly effective in the treatment of acne, despite common adverse events, manageable and dose-dependent. Dose-independent teratogenicity is the most serious. Therefore, off-label prescriptions require strict criteria.

OBJECTIVE

To communicate the experience and recommendation of Brazilian dermatologists on oral use of the drug in dermatology.

METHODS

Eight experts from five universities were appointed by the Brazilian Society of Dermatology to develop a consensus on indications for this drug. Through the adapted DELPHI methodology, relevant elements were listed and an extensive analysis of the literature was carried out. The consensus was defined with the approval of at least 70% of the experts.

RESULTS

With 100% approval from the authors, there was no doubt about the efficacy of oral isotretinoin in the treatment of acne, including as an adjunct in the correction of scars. Common and manageable common adverse events are mucocutaneous in nature. Others, such as growth retardation, abnormal healing, depression, and inflammatory bowel disease have been thoroughly investigated, and there is no evidence of a causal association; they are rare, individual, and should not contraindicate the use of the drug. Regarding unapproved indications, it may represent an option in cases of refractory rosacea, severe seborrheic dermatitis, stabilization of field cancerization with advanced photoaging and, although incipient, frontal fibrosing alopecia. For keratinization disorders, acitretin performs better. In the opinion of the authors, indications for purely esthetic purposes or oil control are not recommended, particularly for women of childbearing age.

CONCLUSIONS

Approved and non-approved indications, efficacy and adverse effects of oral isotretinoin in dermatology were presented and critically evaluated.

Oral isotretinoin and photoaging: A review

INTRODUCTION

Over the past 20 years, evidence has emerged indicating oral isotretinoin could be considered a potential treatment for photoaged skin. In this review, we provide a succinct overview of the available evidence and provide commentary on the current and future directions for utilizing oral isotretinoin as a potential treatment for photoaging.

METHODS

We prepared a review protocol and searched the PubMed and Cochrane databases for relevant literature published between January 1982 and April 2020. Using a defined keyword search, a total of 23 papers were initially identified by the main author. Two authors independently reviewed each of the 23 articles, and 6 articles were deemed relevant to this study.

RESULTS

Of the six studies included in this review, three were randomized clinical trials, one was a nonrandomized clinical trial and two were prospective cohort studies. All studies were conducted between 2000 and 2015. Across all 6 studies, 251 patients were recruited, with a mean of 42 patients per study. Four studies were in favor of isotretinoin to improve photoaged skin, 1 study showed no benefit, and 1 study showed no benefit when compared to topical tretinoin treatment. Of the studies available, many were hampered by methodological challenges.

CONCLUSION

Oral isotretinoin may be useful for treating photoaging but there is currently insufficient evidence to support its use. In comparison with other established anti-photoaging treatments, it is not clear whether the potential benefits of oral isotretinoin outweigh the potential risks.

Fractional Laser Resurfacing Treats Photoaging by Promoting Neocollegenesis and Cutaneous Edema

BACKGROUND: Laser resurfacing is a common treatment for photoaging. This treatment creates skin incisions that initiate the wound healing cascade, including reorganization of the collagen matrix, in a dermal remodeling process that can last up to 12 months. OBJECTIVE: We compared the effects of nonablative and ablative Erbium fractional laser resurfacing on dermal content and arrangement of Collagen Types I and III, and on fibroblast activation. METHODS: Ten female patients (50-63 years) with Fitzpatrick Skin Types I-IV and clinical signs of photoaging underwent two types of Erbium fractional laser resurfacing (nonablative, 1540nm; ablative, 2940nm) on opposite sides of the face. Skin biopsies were obtained pretreatment and three months post-treatment. Morphometric analysis was performed using Picrosirius staining for overall collagen, and immunohistochemistry for Collagen Types I and III. Finally, hematoxylin and eosin staining was used to identify fibroblast activation. RESULTS: Both laser treatments induced reorganization of Collagen Types I and III and demonstrated signs of fibroblast activation. However, morphometric analysis of Picrosirius staining revealed that, after both treatments, there was a lower density of collagen fibers, which is characteristic of edema. CONCLUSION: At three months after laser resurfacing, skin lifting in photoaged skin likely resulted from new collagen deposition but also from edema.

Erosive Pustular Dermatosis: A Manifestation of Immunosenescence A Report of 8 Cases

Erosive pustular dermatosis (EPD) is a rare condition of the scalp and legs that is marked by crusted erosions or superficial ulcerations that may result in scarring alopecia and chronic wounds. The condition predominantly affects elderly female as compared to male patients. Its pathogenesis remains poorly understood. The majority of the cases in the literature are from the United Kingdom and continental Europe. In this series, we present 8 North American patients with EPD of the scalp, one of whom also had involvement of the legs and another with the involvement of the face. All our patients were advanced in age and had a predisposition to chronic actinic damage, which are common characteristics of EPD previously reported in the literature. We hypothesize that immunosenescence leads to an aberrant immune response to wound healing and, along with other factors such as a loss of the normal epidermal barrier, ultraviolet damage, and hormonal factors, may contribute to the development of this condition.

Facial Papules in Frontal Fibrosing Alopecia: Beyond Vellus Hair Follicle Involvement

Background

Frontal fibrosing alopecia (FFA) is considered a variant of lichen planopilaris affecting mainly the frontotemporal hairline. Since the first report in 1994, several other clinical features have been associated with the disease, such as facial papules (FP). Even though FP have been linked to facial vellus hair follicle involvement, how this finding alone could lead to the formation of clinically evident FP in FFA patients had not yet been addressed.

Objective

To describe histopathological findings of FP in the context of FFA and to highlight features that may be linked to their clinical formation.

Methods

Cutaneous FP biopsies of FFA patients performed between January 2016 and May 2017 were retrieved from our pathology database and reexamined by 2 pathologists.

Results

Histological sections of thirteen 3.0-mm punch biopsy specimens (2 horizontally and 11 vertically oriented) were collected from 7 patients. Eleven specimens demonstrated prominent sebaceous glands and 10 dilated sebaceous ducts. Pinkus acid orcein staining revealed reduction and fragmentation of the elastic fibers in 12 samples and, in 7 of these, this finding was observed in both the papillary and reticular dermis, particularly around sebaceous lobules. Vellus hair follicle involvement was only seen in 2 samples.

Conclusions

Prominent sebaceous lobules with dilated ducts associated with an abnormal elastic framework seem to be the main explanation for the formation of FP in the context of FFA.

Topical Retinoids: Therapeutic Mechanisms in the Treatment of Photodamaged Skin

Retinoids are a group of substances comprising vitamin A and its natural and synthetic derivatives. Retinoids were first used in dermatology in 1943 by Straumfjord for acne vulgaris. Since that time, retinoids have been utilized in the management and treatment of various skin conditions, including photoaging. Photodamage of the skin occurs as a consequence of cumulative exposure to solar ultraviolet radiation (UVR) and is characterized by deep wrinkles, easy bruising, inelasticity, mottled pigmentation, roughness, and telangiectasias. The mechanism of UVR-induced photodamage is multifactorial. Retinoids have demonstrated efficacy in the treatment of photoaged skin. Indeed, understanding the pathophysiology of photoaging and the molecular mechanism of retinoids can not only provide insight into the effects retinoids can exert in treating photoaging but also provide the rationale for their use in the treatment of other dermatologic diseases.

Photoaging and the clinical utility of fractional laser

The description of atomic structure by Niels Bohr set the basis for the emergence of quantum physics. Based on these fundamentals, Einstein published in 1917 a paper on the amplification of energy by Stimulated Emission of Radiation as part of his quantum theories. In 1955, Townes and Gordon turned Einstein’s theories into practice, creating a coherent and amplified microwave device using ammonia gas in an optical medium. But it was at the beginning of the 1980s, that Anderson and Parrish published an article about the selective photothermolysis model which revolutionized clinical practice. The use of laser in photoaging began with CO₂ (10,600 nm). In 1989, it was first used for resurfacing of a face with prominent photoaging. Ablative lasers have therefore had great popularity in the 1980s and 1990s, but prolonged postoperative time and significant risk of side effects have lowered the acceptance by patients. In 2004, the description of the fractionated radiation for the treatment of photoaging, by Mainstein, represented a great event. The stimulation of collagen occurred through fractional laser beams, which would reach the selected area while saving islands of sound skin. These islands accelerated the process of cicatrization of the treated tissue and shortened the postprocedure time. Furthermore, the fractionated radiation presented a smaller range of side effects, increasing the safety of the procedure. As mentioned earlier, as fractional lasers incise on the skin, they leave islands of healthy skin that accelerate recovery, while generating necrosis columns. Such necrosis columns remove damaged extracellular matrix material, allowing resettlement of fibroblasts. Such resettled fibroblasts, under the influence of a new tensile strength, restart to produce structures for extracellular matrix, such as collagen, elastin, and proteoglycans, in a more physiological way. Fractional lasers are considered by many dermatologists as the best choice in laser therapy for the treatment of photoaging.