Isotretinoin use and subsequent depression and suicide: presenting the evidence

13-cis-Retinoic acid alters intracellular serotonin, increases 5-HT1A receptor, and serotonin reuptake transporter levels in vitro

In addition to their established role in nervous system development, vitamin A and related retinoids are emerging as regulators of adult brain function. Accutane (13-cis-retinoic acid, isotretinoin) treatment has been reported to increase depression in humans. Recently, we showed that chronic administration of 13-cis-retinoic acid (13-cis-RA) to adolescent male mice increased depression-related behaviors. Here, we have examined whether 13-cis-RA regulates components involved in serotonergic neurotransmission in vitro. We used the RN46A-B14 cell line, derived from rat embryonic raphe nuclei. This cell line synthesizes serotonin (5-hydroxytryptamine, 5-HT) and expresses the 5-HT(1A) receptor and the serotonin reuptake transporter (SERT). Cells were treated with 0, 2.5, or 10 microM 13-cis-RA for 48 or 96 hrs, and the levels of 5-HT; its metabolite, 5-hydroxyindoleacetic acid (5HIAA); 5-HT(1A) receptor; and SERT were determined. Treatment with 13-cis-RA for 96 hrs increased the intracellular levels of 5-HT and tended to increase intra-cellular 5HIAA levels. Furthermore, 48 hrs of treatment with 2.5 and 10 microM 13-cis-RA significantly increased 5-HT(1A) protein to 168.5 +/- 20.0% and 148.7 +/- 2.2% of control respectively. SERT protein levels were significantly increased to 142.5 +/- 11.1% and 119.2 +/- 3.6% of control by 48 hrs of treatment with 2.5 and 10 microM of 13-cis-RA respectively. Increases in both 5-HT(1A) receptor and SERT proteins may lead to decreased serotonin availability at synapses. Such an effect of 13-cis-RA could contribute to the increased depression-related behaviors we have shown in mice.

Blue and red light combination LED phototherapy for acne vulgaris in patients with skin phototype IV

BACKGROUND AND OBJECTIVES

Blue light is effective for acne treatment, inducing photodynamic destruction of Propionibacterium acnes (P. acnes). This study was designed to investigate the efficacy of combined blue and red light-emitting diode (LED) phototherapy for acne vulgaris.

MATERIALS AND METHODS

Twenty-four patients with mild to moderately severe facial acne were treated with quasimonochromatic LED devices, alternating blue (415 nm) and red (633 nm) light. The treatment was performed twice a week for 4 weeks. Objective assays of the skin condition were carried out before and after treatment at each treatment session. Clinical assessments were conducted before treatment, after the 2nd, 4th, and 6th treatment sessions and at 2, 4, and 8 weeks after the final treatment by grading and lesion counting.

RESULTS

The final mean percentage improvements in non-inflammatory and inflammatory lesions were 34.28% and 77.93%, respectively. Instrumental measurements indicated that the melanin levels significantly decreased after treatment. Brightened skin tone and improved skin texture were spontaneously reported by 14 patients.

CONCLUSION

Blue and red light combination LED phototherapy is an effective, safe and non-painful treatment for mild to moderately severe acne vulgaris, particularly for papulopustular acne lesions.

Discovery of novel hippocampal neurogenic agents by using an in vivo stable isotope labeling technique

Neurogenesis occurs in discrete regions of adult mammalian brain, including the subgranular zone of the hippocampus. Hippocampal neurogenesis is enhanced by different classes of antidepressants, but screening for neurogenic actions of novel antidepressants has been inefficient because of limitations of 5-bromo-2'-deoxyuridine labeling techniques. We describe an efficient in vivo method for measuring hippocampal neurogenesis involving incorporation of the stable isotope, (2)H, into genomic DNA during labeling with (2)H(2)O (heavy water). Male rodents received 8 to 10% (2)H(2)O in drinking water; DNA was isolated from hippocampal progenitor cells or neurons. Label incorporation into progenitor cells of Swiss-Webster mice revealed subpopulation kinetics: 16% divided with t(1/2) of 2.7 weeks; the remainder did not divide over 1 year. Progenitor cell proliferation rates in mice were strain-dependent. Chronic antidepressant treatment for 3 weeks, with (2)H(2)O administered during the final week, increased progenitor cell proliferation across all the strains tested. Fluoxetine treatment increased (2)H incorporation into DNA of gradient-enriched neurons or flow-sorted neuronal nuclei 4 weeks after (2)H(2)O labeling, representing the survival and differentiation of newly divided cells into neurons. By screening 11 approved drugs for effects on progenitor cell proliferation, we detected previously unrecognized, dose-dependent enhancement of hippocampal progenitor cell proliferation by two statins and the anticonvulsant topiramate. We also confirmed stimulatory activity of other anticonvulsants and showed inhibition of progenitor cell proliferation by isotretinoin and prednisolone. In conclusion, stable isotope labeling is an efficient, high-throughput in vivo method for measuring hippocampal progenitor cell proliferation that can be used to screen for novel neurogenic drugs.

Isotretinoin and the controversy of psychiatric adverse effects

Isotretinoin is a synthetic oral retinoid that has great efficacy against severe, recalcitrant, nodulocystic acne. Since its introduction to the market, it has been associated with a variety of adverse psychiatric effects, including depression, psychosis, mood swings, violent behavior, suicide, and suicide attempts. A MEDLINE review was performed to compile all case reports, case series, adverse drug event reportings, and prospective and retrospective studies relating psychiatric adverse events to isotretinoin. In addition, literature linking a biological mechanism for psychiatric adverse events to retinoid signaling pathways was also reviewed. Although a variety of anecdotal and epidemiologic studies are available, the overall lack of concrete scientific data limits any conclusion that can be drawn about a causal relationship between istotretinoin and psychiatric adverse events. Several lines of evidence link retinoid signaling to theorized psychiatric pathogenesis, but are limited in their applicability to adult neurophysiology.

Chronic administration of 13-cis-retinoic acid increases depression-related behavior in mice

Retinoid signaling plays a well-established role in neuronal differentiation, neurite outgrowth, and the patterning of the anteroposterior axis of the developing neural tube. However, there is increasing evidence that nutritional vitamin A status and retinoid signaling play an important role in the function of the adult brain. 13-Cis-retinoic acid (13-cis-RA) (isotretinoin or Accutane), a synthetic retinoid that is an effective oral treatment for severe nodular acne, has been linked with depression and suicide in patients. The purpose of this study was to test the hypothesis that chronic administration of 13-cis-RA would lead to depression-related behaviors in mice. Young, adult male mice received 13-cis-RA (1 mg/kg) by daily intraperitoneal injection for 6 weeks. This treatment paradigm produced plasma levels of 13-cis-RA that are comparable to those reported in human patients taking Accutane. In both the forced swim test and the tail suspension test, we found that 13-cis-RA-treated mice spent significantly more time immobile compared to vehicle-treated controls. In the open field test, there was no change in anxiety-related behavior in 13-cis-RA-treated mice. Furthermore, chronic administration of 13-cis-RA did not impair locomotion in either the open field or the rotarod test. Taken together, these results suggest that administration of 13-cis-RA increases depression-related behaviors in mice.

Increased use of mental health services related to isotretinoin treatment: a 5-year analysis

BACKGROUND

The association between exposure to Isotretinoin, the development of depression and suicide attempts is controversial.

OBJECTIVE

To retrospectively assess pattern of utilization of mental health services in the Israeli Defense Forces (IDF) during a 5-year period for all subjects exposed to Isotretinoin in comparison to a control group consisting of army conscripts suffering from psoriasis. All subjects were young adults (18 to 21 years old) in compulsory military service.

METHOD

Exposure to Isotretinoin mandates reporting and marking as a coded medical profile in the IDFs' computerized medical record of each conscript and soldier. Medical data, tracked by military medical profiles, were summarized from medical records of all subjects treated by Isotretinion during the years 1999-2003 and for the control group for the same period. Use of mental health services was the a-priori defined primary outcome measure.

RESULTS

During the study period 1419 subjects were exposed to Isotretinoin and 1102 suffered from psoriasis. Utilization of mental health services was highest for the index group wherein 17.2% (245/1419) of subjects were evaluated or treated compared to 12.5% in the control group (psoriasis). The inter-group differences were statistically significant; Chi-square=15.9 (df=2), p=0.0003.

CONCLUSIONS

We suggest that psychiatric evaluation be regularly undertaken prior to initiation of Isotretinion treatment in young adults at risk, as well as providing follow-up visits during and at completion of treatment.

Acne: more than skin deep

Acne is one of the most prevalent skin conditions affecting teenagers. It is a disease of the pilosebaceous unit. Blockage of sebaceous glands and colonisation with Proionobacterium acnes leads to acne. Grading the severity of acne helps to determine the appropriate treatment. Treatment of acne should be started as early as possible to minimise the risk of scarring and adverse psychological effects. It should be tailored to the individual patient, the type of acne, its severity, the patient's ability to use the treatment, and the psychological state. Topical agents are the mainstay for treatment of mild acne. Moderate acne is treated with oral antibiotics. Resistance to antibiotics may be reduced by subsequent use of non-antibiotic topical medications. Severe acne is treated with isotretinoin, and this can lead to permanent remission. With better education and care given by medical profession, acne treatment could be significantly improved.

Topical methyl aminolaevulinate photodynamic therapy for treatment of facial acne vulgaris: results of a randomized, controlled study

BACKGROUND

There is a need for alternative treatments for moderate to severe acne vulgaris. Preliminary experience suggests that topical methyl aminolaevulinate photodynamic therapy (MAL-PDT) may have potential.

OBJECTIVES

To investigate the efficacy and tolerability of MAL-PDT for treatment of moderate inflammatory facial acne.

PATIENTS/METHODS

Thirty patients aged 15-28 years with moderate to severe acne were included in a blinded, prospective, randomized, placebo-controlled multicentre study. Each side of each patient's face was randomly assigned to treatment with MAL (160 mg g1) or placebo cream, applied for 3 h prior to illumination. A second treatment was given 2 weeks later. On each occasion, patients assessed the intensity of pain using a 10-cm visual analogue scale. Inflammatory and noninflammatory acne lesions were counted at baseline and 4 and 10 weeks after the last PDT treatment. The investigator assessed the global severity of acne at baseline (seven patients had severe acne on at least one side of the face) and each study visit using a six-point rating scale. Data were analysed on an intention-to-treat basis, including all 30 patients.

RESULTS

There was a statistically significant greater reduction in the total inflammatory lesion count with MAL-PDT compared with placebo PDT at week 12; median reduction 54% [95% confidence interval (CI) 35-64%] vs. 20% (95% CI 8-50%), P = 0.0006. MAL-PDT was associated with more pain than placebo PDT, although intensity varied across centres and was reduced with repeated treatment. Local adverse events were consistent with this treatment modality.

CONCLUSIONS

MAL-PDT is effective in the treatment of moderate to severe inflammatory facial acne. Further studies are warranted to optimize this promising procedure.

Nonpsychiatric medical treatment of body dysmorphic disorder

Many individuals with body dysmorphic disorder seek nonpsychiatric medical and surgical treatment to improve perceived defects in their physical appearance. However, the types of treatments sought and received, as well as the treatment outcome, have received little investigation. This study describes the frequency, types, and outcomes of treatments sought and received by 200 individuals with body dysmorphic disorder. Treatment was sought by 71.0% and received by 64.0%. Dermatological treatment was most frequently sought and received (most often, topical acne agents), followed by surgery (most often, rhinoplasty). Twelve percent of the subjects received isotretinoin. Such treatment rarely improved body dysmorphic disorder. Thus, nonpsychiatric medical treatments do not appear effective in its treatment.

New therapeutic target for CNS injury? The role of retinoic acid signaling after nerve lesions

Experiments with sciatic nerve lesions and spinal cord contusion injury demonstrate that the retinoic acid (RA) signaling cascade is activated by these traumatic events. In both cases the RA-synthesizing enzyme is RALDH-2. In the PNS, lesions cause RA-induced gene transcription, intracellular translocation of retinoid receptors, and increased transcription of CRBP-I, CRABP-II, and retinoid receptors. The activation of RARbeta appears to be responsible for neurotrophic and neuritogenic effects of RA on dorsal root ganglia and embryonic spinal cord. While the physiological role of RA in the injured nervous system is still under investigation three domains of functions are suggested: (1) neuroprotection and support of axonal growth, (2) modulation of the inflammatory reaction by microglia/macrophages, and (3) regulation of glial differentiation. Few studies have been performed to support nerve regeneration with RA signals in vivo, but a large number of experiments with neuronal and glial cell cultures and spinal cord explants point to beneficial effects of RA, so that future therapeutic approaches will likely focus on the activation of RA signaling.

The Acne Quality of Life Index (Acne-QOLI): development and validation of a brief instrument

BACKGROUND

Acne affects many people and can be detrimental to affected patients' quality of life. Assessing the impact of acne on quality of life requires well-validated and reliable measures of acne-specific quality of life that are brief and easy to administer and interpret.

OBJECTIVES

This paper reports on the development and validation of the Acne Quality of Life Index (Acne-QOLI) for use in clinical care, research, and product development.

METHODS

Focus groups consisting of people from demographically different populations were conducted to identify the most relevant domains of functioning affected by acne; on the basis of these findings, candidate items were developed. An initial item pool of 58 items was included in a survey of 480 persons with mild to severe acne ranging in age from 12 to 62 years. Factor analysis and qualitative analysis were used to reduce the item pool to 21 items. The construct validity, concurrent validity, internal consistency, and test-retest reliability of the items were evaluated.

RESULTS

The 21-item Acne-QOLI showed excellent face validity, content validity, concurrent validity, and construct validity. High internal consistency and test-retest reliability were also found.

CONCLUSIONS

Quality of life is now recognized as an important outcome in medical care. The Acne-QOLI is a brief and easily administered and interpreted measure of acne-related quality of life that can be used in clinical care, research, and product development.

A case of Darier's disease successfully treated with topical tacrolimus

Tacrolimus is a macrolide that inhibits T-cell activation. The most extensive experience with topical tacrolimus has been in treating atopic dermatitis but it has been used in various skin diseases, including Hailey-Hailey disease, with encouraging results. We report a case of extensive Darier's disease successfully treated with topical tacrolimus, after suspension of oral isotretrinoin due to major depression.

Systemische Aknetherapie

The development of scarring in inflammatory acne may induce permanent disfigurement and considerable psychosocial impact on the lives of affected individuals. The early use of systemic acne therapy can help to prevent these unfortunate consequences. Antiinflammatory antibiotics such as tetracyclines are required in moderate to severe papulopustular acne. The recommended treatment duration is 3 months; combination with topical retinoids and benzoyl peroxide increases the speed and efficacy of lesion reduction and helps to prevent bacterial resistance. Oral isotretinoin is the treatment of choice in severe acne resistant to adequate conventional therapy. Hormonal treatment represents an alternative regimen for women with acne and is the first choice in late-onset acne and in those with clinical signs of hyperandrogenism.

Acne, depression, and suicide

Acne is a common disorder that may have a considerable psychologic impact including anxiety and depression. Depression and suicide occur frequently in adolescents and young adults. Although case reports suggest an association between isotretinoin and depression and suicide, more rigorous observational studies and epidemiologic studies, using different designs, have not shown any effect of isotretinoin use in increasing the occurrence of depression and suicide. It is prudent for the practitioner to continue to use isotretinoin to treat severe acne, while at the same time informing patients and their relatives that depressive symptoms should be actively assessed at each visit and, if necessary, referral to a psychiatrist and a discontinuation of isotretinoin should be considered.

Depression and Suicidal Behavior in Acne Patients Treated With Isotretinoin: A Systematic Review

Isotretinoin (13-cis retinoic acid) is an effective treatment for severe cystic or recalcitrant acne vulgaris; however, concerns have been raised regarding its potential association with depression and suicidal behavior. We sought to explore the proposed relationship between isotretinoin use and the risk of depression and attempted and completed suicide in patients with acne vulgaris by performing a systematic literature search for studies reporting primary data on depression and suicidal behavior in patients treated with isotretinoin for acne vulgaris. Nine studies met the qualifying criteria for our analysis. Rates of depression among isotretinoin users ranged from 1% to 11% across studies, with similar rates in oral antibiotic control groups. Overall, studies comparing depression before and after treatment did not show a statistically significant increase in depression diagnoses or depressive symptoms. Some, in fact, demonstrated a trend toward fewer or less severe depressive symptoms after isotretinoin therapy. This decrease was particularly evident in patients with pretreatment scores in the moderate or clinical depression range. No correlation between isotretinoin use and suicidal behavior was reported, although only one retrospective study presented data on this topic. Although the current literature does not support a causative association between isotretinoin use and depression, there are important limitations to many of the studies. The available data on suicidal behavior during isotretinoin treatment are insufficient to establish a meaningful causative association.

Role of retinoid signalling in the adult brain

Vitamin A (all-trans-retinol) is the parent compound of a family of natural and synthetic compounds, the retinoids. Retinoids regulate gene transcription in numerous cells and tissues by binding to nuclear retinoid receptor proteins, which act as transcription factors. Much of the research conducted on retinoid signalling in the nervous system has focussed on developmental effects in the embryonic or early postnatal brain. Here, we review the increasing body of evidence indicating that retinoid signalling plays an important role in the function of the mature brain. Components of the metabolic pathway for retinoids have been identified in adult brain tissues, suggesting that all-trans-retinoic acid (ATRA) can be synthesized in discrete regions of the brain. The distribution of retinoid receptor proteins in the adult nervous system is different from that seen during development; and suggests that retinoid signalling is likely to have a physiological role in adult cortex, amygdala, hypothalamus, hippocampus, striatum and associated brain regions. A number of neuronal specific genes contain recognition sequences for the retinoid receptor proteins and can be directly regulated by retinoids. Disruption of retinoid signalling pathways in rodent models indicates their involvement in regulating synaptic plasticity and associated learning and memory behaviours. Retinoid signalling pathways have also been implicated in the pathophysiology of Alzheimer's disease, schizophrenia and depression. Overall, the data underscore the likely importance of adequate nutritional Vitamin A status for adult brain function and highlight retinoid signalling pathways as potential novel therapeutic targets for neurological diseases.

Retinoic acid signaling in the nervous system of adult vertebrates

The majority of the functions of vitamin A are carried out by its metabolite, retinoic acid (RA), a potent transcriptional activator acting through members of the nuclear receptor family of transcription factors. In the CNS, RA was first recognized to be essential for the control of patterning and differentiation in the developing embryo. It has recently come to light, however, that many of the same functions that RA directs in the embryo are involved in the regulation of plasticity and regeneration in the adult brain. The same intricate metabolic control system of synthetic and catabolic enzymes, combined with cytoplasmic binding proteins, is used in both embryo and adult to create regions of high and low RA to modulate gene transcription. This review summarizes some of the discoveries in the new field of retinoid neurobiology including its functions in neural plasticity and LTP in the hippocampus; its possible role in motor disorders such as Parkinson's disease, motoneuron disease, and Huntington's disease; its role in regeneration after sciatic nerve and spinal cord injury; and its possible involvement in psychiatric diseases such as depression.

Disfunción eréctil durante el tratamiento con isotretinoína

Isotretinoin is a very effective drug for the treatment of severe recalcitrant acne. However, it's use is associated with many side effects, sometimes is associated with the emergence of psychiatric symptoms. During of a prospective study to evaluate the efficacy and safety of isotretinoin in acne, six male patients, refer difficulties in maintaining adequate penile erection in association with clinical symptoms of depression. To our knowledge this is the first time that this side effect is reported, so the results suggest that further studies of it's use in similar patients are warranted.