Review of Teratogenic Effects of Leflunomide, Accutane, Thalidomide, Warfarin, Tetracycline, and Angiotensin-Converting Enzyme Inhibitors

Teratogenic agents have been shown to have drastic and detrimental effects on fetuses if exposed to the agent during uterine life. The most sensitive time for a developing fetus is during the first trimester, and teratogenic exposure during this time can lead to severe deformities in the fetus. The Food and Drug Administration has categorized teratogenic agents based on the severity of their effect on the fetus; these categories include A, B, C, D, and X. Category A is the safest, with the most dangerous, and highly contraindicated in pregnant patients being Category X. This review article will discuss the teratogenic agents leflunomide, isotretinoin, thalidomide, warfarin, tetracycline, and angiotensinogen-converting enzyme inhibitors. Leflunomide can cause cranioschisis, exencephaly, and vertebral, head, and limb malformations. Isotretinoin's main teratogenic effects include central nervous system malformations, hydrocephalus, eye abnormalities, cardiac septal defects, thymus abnormalities, spontaneous abortions, and external ear abnormalities. Thalidomide has been shown to cause limb deformities, bowel atresia, and heart defects when the embryo is exposed to the agent during development. Warfarin can lead to spontaneous abortion and intrauterine death, as well as nasal hypoplasia, hypoplasia of extremities, cardiac defects, scoliosis, and mental retardation when exposed in utero. Tetracycline's teratogenic effects include gastrointestinal distress, esophageal ulceration and strictures, teeth discoloration, hepatotoxicity, and calcifications. Angiotensinogen-converting enzyme inhibitors can cause skull hyperplasia, anuria, hypotension, renal failure, lung hypoplasia, skeletal deformation, oligohydramnios, and fetal death. Teratogenic effects can be avoided if the pregnant patient is educated on the teratogenic effects of these agents.

Use of Interleukin-12/23 Inhibitor for the Management of Acne Fulminans

Acne fulminans (AF) is a rare disorder marked by severe eruptions of inflamed nodules, hemorrhagic crusts, and ulcers accompanied by systemic symptoms and often laboratory abnormalities. Commonly affecting adolescent males with pre-existing acne, AF has been associated with isotretinoin therapy and elevated testosterone levels. With unknown pathogenesis, lesions frequently involve the trunk and face and are managed standardly with corticosteroids and isotretinoin. Uncontrolled or recurrent cases pose challenges due to prolonged high-dose corticosteroid use with increased scarring. In this study, we present a case of AF in a 17-year-old male unresponsive to corticosteroid and isotretinoin therapy, successfully treated with ustekinumab, an interleukin (IL)-12/23 inhibitor. The introduction of ustekinumab facilitated a controlled corticosteroid taper and isotretinoin dose escalation, resulting in significant clinical improvement of skin lesions and systemic symptoms. This case report underscores the potential of ustekinumab as a viable therapeutic option in the treatment of AF, particularly in cases where corticosteroid and isotretinoin combination therapy have proven ineffective.

Isotretinoin Use in Transmasculine Patients and Its Implication on Chest Masculinization Surgery: Scoping Review of the Literature

BACKGROUND

Acne often worsens in transmasculine patients who are on prolonged testosterone therapy. Isotretinoin is an oral retinoid used in the treatment of severe or refractory cases of acne, but it has the potential to cause delayed wound healing. Transmasculine patients may potentially be prescribed treatment for acne with isotretinoin while also planning to undergo chest masculinization surgery.

OBJECTIVE

This scoping review aims to determine whether isotretinoin has a negative impact on postoperative healing in transmasculine patients undergoing chest masculinization surgery.

METHODS

A scoping review was performed using the PubMed and Ovid databases. A total of 16 publications were selected for inclusion.

RESULTS

Acne tends to peak in transmasculine patients 6 months after initiation of testosterone treatment. Severe cases can be treated with isotretinoin; however, acne may recur once treatment is discontinued, given ongoing hormone therapy. There is little to no evidence in the medical literature regarding perioperative use of isotretinoin specifically among transmasculine patients undergoing chest masculinization surgery. In general, however, recent studies have found no evidence of increased hypertrophic scars or keloids in patients taking isotretinoin.

CONCLUSIONS

Further studies are required to strengthen the current evidence that suggests that isotretinoin does not need to be discontinued before or after incisional or excisional surgeries, including chest masculinization surgery in transmasculine patients.

Emergency contraception in the iPLEDGE program: A cross-sectional survey of pediatric dermatology provider understanding and practice

For patients with acne treated with the teratogen isotretinoin, emergency contraception (EC) is the only recourse when abstinence fails or effective contraception is not properly used. The purpose of this study was to evaluate the current understanding and provision of EC among pediatric dermatology providers. The survey found that 37% (21/57) of providers indicated they were at least somewhat confident in their understanding of EC. 7% (4/57) of providers agreed/strongly agreed that they provided EC counseling to all patients of reproductive potential at their initial visit and 3.5% (2/57) agreed/strongly agreed that they provide EC counseling at follow-up visits. Our survey results suggest the need for improved EC education for pediatric dermatology providers and subsequent counseling for patients of reproductive potential on isotretinoin therapy.

A Common Drug With a Dangerous Side Effect: Acute Rhabdomyolysis Caused by the Synergistic Effect of Isotretinoin and Exercise in an Adolescent

Isotretinoin or 13-cis-retinoic acid, a derivative of vitamin A, is a highly effective therapy for severe and resistant acne. Its usage is restricted worldwide because of its teratogenic potential. The most common side effects are dermatologic, cheilitis, increased skin fragility, and susceptibility to sunburns. Rare side effects include myalgias and arthralgias. It also causes transient laboratory abnormalities such as elevated creatine kinase (CK). Very few cases of isotretinoin-induced severe muscle injury leading to rhabdomyolysis have been reported in the literature. We report a 15-year-old adolescent who developed rhabdomyolysis after a bout of vigorous exercising while on long-term isotretinoin therapy.

Social Media as a Surveillance Tool for Monitoring of Isotretinoin Adverse Effects

Social media is an underutilized method for the surveillance of the patient perspective regarding their pharmacologic therapies. The purpose of this study was to investigate the nature of content posted on the social media platform Instagram with respect to the systemic acne medication isotretinoin. The search term "#accutane" was queried into Instagram to generate all public posts using this hashtag between February 1 and May 31, 2018. Four independent investigators then scrutinized posts for eligibility. Our inclusion criteria were posts written in English, accessible by URL, primarily focused on isotretinoin, and posted by users of the medication. Data regarding multiple variables (tone of post, reason for positive or negative elements, posting of a face or other body part, mention of side effects, etc.) from each individual post was then entered into a Microsoft Excel template. Of 7,661 posts, 3,082 were eligible. Among posts that contained negative tone (n=1312), this element was more commonly due to the presence of side effects (65%) than lack of improvement in skin appearance (33%). Overall, 1,263 posters (41%) mentioned adverse effects of oral isotretinoin, most commonly dry facial skin (17%), dry/cracked lips (16%), or arthralgias/myalgias (8%). Neuropsychiatric side effects were also documented, with users reporting fatigue (4%), mood changes (3%), and headache (2%). In conclusion, reported side effects of oral isotretinoin on Instagram closely tracked its known side effects in frequency. Social media may be a valuable tool to surveil the general pattern and burden of adverse effects for patients undergoing treatment of dermatologic conditions.

Determining the effect of low-dose isotretinoin on proliferative vitreoretinopathy: the DELIVER trial

PURPOSE

To examine the effect of low-dose, oral isotretinoin in lowering the risk of proliferative vitreoretinopathy (PVR) following rhegmatogenous retinal detachment (RRD) repair.

METHODS

Prospective, open label, dual-cohort study with pathology-matched historical controls. The prospective experimental arms included two cohorts, composed of 51 eyes with recurrent PVR-related RRD and 58 eyes with primary RRD associated with high-risk features for developing PVR. Eyes in the experimental arms received 20 mg of isotretinoin by mouth once daily for 12 weeks starting the day after surgical repair. The primary outcome measure was single surgery anatomical success rate at 3 months following the study surgery.

RESULTS

The single surgery anatomic success rate was 78.4% versus 70.0% (p=0.358) in eyes with recurrent PVR-related retinal detachment exposed to isotretinoin versus historical controls, respectively. In eyes with RRD at high risk for developing PVR, the single surgery success rate was 84.5% versus 61.1% (p=0.005) for eyes exposed to isotretinoin versus historical controls, respectively. For eyes enrolled in the experimental arms, the most common isotretinoin-related side effects were dry skin/mucus membranes in 106 patients (97.2%), abnormal sleep/dreams in 4 patients (3.7%) and fatigue in 3 patients (2.8%).

CONCLUSION

The management and prevention of PVR is challenging and complex. At the dose and duration given in this study, oral istotretinoin may reduce the risk of PVR-associated recurrent retinal detachment in eyes with primary RRD at high risk of developing PVR.