Isotretinoin-induced Spondyloarthropathy-related Symptoms: A Prospective Study

Isotretinoin‐induced inflammatory back pain and sacroiliitis in patients with moderate to severe acne vulgaris

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.

Evaluation of musculoskeletal adverse effects in patients on systemic isotretinoin treatment: A cross-sectional study

Objectives

This study aims to investigate the frequency of musculoskeletal adverse effects in acne vulgaris patients receiving systemic isotretinoin treatment.

Patients and methods

Between January 2016 and December 2017, a total of 200 severe acne patients (22 males, 178 females; mean age: 21.8±0.4 years; range, 15 to 53 years) who were on isotretinoin treatment were retrospectively analyzed. Data including age, sex, body mass index (BMI), duration of disease, diagnosis, and comorbidities were recorded. Back pain severity was evaluated with the Visual Analog Scale (VAS).

Results

The treatment period was mean 8.5±0.1 (range, 6 to 12) months. The dose of isotretinoin was mean 0.6±0.1 (range, 0.5 and 1) mg/kg. Musculoskeletal side effects were seen in 99 (49.5%) patients. Back pain was reported during the treatment period in 78 (78.7%) patients. The diagnosis was mechanical back pain in 31 (39.7%) and inflammatory back pain in 47 (60.3%) patients. The moderate-severe back pain group received higher cumulative isotretinoin doses than the mild back pain group (p=0.003). The BMI values did not show a significant difference between the patients with and without back pain (p=0.55). There was no significant correlation between the BMI and VAS scores (p=0.06). The VAS scores were found to be correlated with age (p=0.04). Sacroiliitis was diagnosed in four (4%) patients. One (1%) patient was diagnosed with enthesitis. Creatine kinase elevation was reported in 18 (18.1%) patients, while three (3%) patients described myalgia of mild severity.

Conclusion

Low back pain is one of the most common musculoskeletal side effects of isotretinoin treatment that usually resolves with dose reduction. The cumulative dose of isotretinoin does not seem to play a role in the development of back pain, but can determine pain severity. Pain severity is directly correlated with the increasing age. Evaluation of the patients for musculoskeletal side effects during isotretinoin use is important in clinical practice, as it is a common occurrence.

SAPHO syndrome: the supposed trigger by isotretinoin, the efficacy of adalimumab and the specter of depressive disorder: a case report

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.

Etiopathogenesis of sacroiliitis: implications for assessment and management

The sacroiliac joints connect the base of the sacrum to the ilium. When inflamed, they are suspected to cause low back pain. Inflammation of the sacroiliac joints is called sacroiliitis. The severity of the pain varies and depends on the degree of inflammation. Sacroiliitis is a hallmark of seronegative spondyloarthropathies. The presence or absence of chronic sacroiliitis is an important clue in the diagnosis of low back pain. This article aims to provide a concise overview of the anatomy, physiology, and molecular biology of sacroiliitis to aid clinicians in the assessment and management of sacroiliitis. For this narrative review, we evaluated articles in English published before August 2019 in PubMed. Then, we selected articles related to the painful manifestations of the sacroiliac joint. From the retrieved articles, we found that chronic sacroiliitis may be caused by various forms of spondyloarthritis, such as ankylosing spondyloarthritis. Sacroiliitis can also be associated with inflammatory bowel disease, Crohn’s disease, gout, tuberculosis, brucellosis, and osteoarthritis, indicating common underlying etiological factors. The pathophysiology of sacroiliitis is complex and may involve internal, environmental, immunological, and genetic factors. Finally, genetic factors may also play a central role in progression of the disease. Knowing the genetic pre-disposition for sacroiliitis can be useful for diagnosis and for formulating treatment regimens, and may lead to a substantial reduction in disease severity and duration and to improved patient performance.

Analysis of musculoskeletal side effects of oral Isotretinoin treatment: a cross-sectional study

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.

Two pediatric cases of isotretinoin-induced sacroiliitis successfully treated with adalimumab

Isotretinoin is widely used in severe acne. Isotretinoin has many side effects. Sacroiliitis is one of these side effects and has been rarely reported in the children. Herein, we present two children with isotretinoin-induced sacroiliitis resistant to anti-rheumatic drugs and successfully treated with adalimumab.

A patient with chronic sacroiliitis undiagnosed for three years after isotretinoin use

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.

Isotretinoin-induced sacroiliitis: Case series of four patients and a systematic review of the literature

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.

Isotretinoin induced achilles tendinopathy: Histopathological and biomechanical evaluation on rats

OBJECTIVE

The aim of the present study was to evaluate histopathological and biomechanical effects of isotretinoin on Achilles tendon.

MATERIALS & METHODS

Sixteen rats were divided into two groups including the control group (n = 8) and isotretinoin group (n = 8). The control group received 1.42 ml/kg soy oil per day whereas the isotretinoin group received 15 mg/kg/day (gavage dose 1.42 ml/kg) isotretinoin dissolved in soy oil through gavage method for 6 weeks. Achilles tendons were excised at the end of week 6. The tendon samples were evaluated by hematoxylin-eosin under a light microscope. Quantitative evaluation was performed via Movin and Bonar scoring. A computer-monitored tensile testing machine was utilised for biomechanical testing. Biomechanical characteristics of the tendon samples (elastic modulus, yield force, ultimate tensile force) were measured.

RESULTS

Histopathological evaluation revealed a significantly higher Movin and Bonar scores in histopathological evaluation. Movin score in isotretinoin group was 4.1 ± 2.5 and it was 2.3 ± 1.0 in control group (p = 0.032). Bonar score in isotretinoin group was 2.9 ± 1.4 and it was 1.6 ± 0.7 in control group (p = 0.022). In line with histopathological evaluation, biomechanical measurements in isotretinoin group (elastic modulus, yield force, ultimate tensile force) were significantly lower than the control group. Elastic modulus in isotretinoin group was 227 ± 27.7 N/mm² and in control group it was 281.7 ± 38.7 N/mm² (p = 0.006). In isotretinoin group; yield force was 33.7 ± 4.3 Pa and in control group it was 40.8 ± 5.9 Pa (p = 0.021). Ultimate tensile force in isotretinoin group was 35.7 ± 4.2 Pa and in control group it was 44 ± 7 Pa (p = 0.009).

CONCLUSION

The present study detected histopathological and biomechanical negative effect of isotretinoin on Achilles tendon. Therefore, isotretinoin should be questioned in medical history of patients with tendinopathy.

Perinuclear antineutrophil cytoplasmic antibody-positive vasculitis, oligoarthritis, tendinitis, and myositis associated with isotretinoin in a 15-year-old boy: Case report and review of literature

We present a patient in whom a combination of perinuclear antineutrophil cytoplasmic antibody-positive vasculitis, oligoarthritis, tendinitis, and myositis was considered to be associated with isotretinoin use. Discontinuation of the drug resulted in complete clinical and biochemical remission (normalization of perinuclear antineutrophil cytoplasmic antibody titer). Although we were unable to prove causality, no other underlying cause for the patient's course was found. We report this occurrence to bring it to the attention of physicians prescribing isotretinoin.

The prevalence of sacroiliitis in patients with acne vulgaris using isotretinoin

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.