Flare of cystic acne from oral isotretinoin

Carboxytherapy in management of acne flare in patients with moderate to severe acne vulgaris under treatment with oral isotretinoin: a case series

Oral isotretinoin is successfully used for the treatment of moderate and severe acne vulgaris and prevention of acne scars and its psychosocial sequels. Acne flare as an adverse event of this agent, which is characterized by an initial exacerbation of acne, develops worsening lesions and increases the risk of scar development. For the first time, the efficacy of carboxytherapy was assessed in the management of acne flare in patients with moderate to severe acne vulgaris under isotretinoin therapy. This study is a case series of 10 subjects with moderate to severe facial acne. Along with initiation of isotretinoin, carboxytherapy was randomly performed on one side of the face. The response to treatment was studied through evaluation of the number of inflammatory and non-inflammatory acne lesions, modified total lesion count (mTLC), modified acne severity index (mASI), subjective satisfaction, and scar correction. The minimum age of the subjects was 24.4 years. The male to female ratio was 2:8. The effect of carboxytherapy on decrease of papule counts and mASI (as important index of acne flare) and increase of subjective satisfaction was statistically significant. In comparison with the control group, the effect of carboxytherapy on white and black comedone, pustule, and cyst counts, and mTLC was better in the interventional group, their differences were not statistically significant. In addition to overcoming acne flare, carboxytherapy could decrease scar severity. No significant side effects were reported. Carboxytherapy can be considered as an effective and safe adjuvant therapy with oral isotretinoin to overcome acne flare and decrease risk of acne scarring.

Biguanides Induce Acute de novo Lipogenesis in Human Primary Sebocytes

Introduction

Acne arises during puberty, in part, due to elevated hormones and growth factors which stimulate de novo lipogenesis (DNL) in primary sebocytes to significantly increase sebum production. Oral isotretinoin is an effective acne therapy, reducing sebum production through inducing apoptosis in sebocytes. However, isotretinoin is teratogenic and has additional unwanted side effects, including an initial acne flare-up, which limits its utility. The biguanide, metformin has been found to alleviate severe acne in women with polycystic ovary syndrome (PCOS) through normalization of their insulin and androgen hormone levels. Metformin’s broader effectiveness to improve acne in non-PCOS populations lacks significant clinical support. In an effort to determine whether biguanides directly affect sebogenesis, we investigated their ability to alter DNL in cell-based assays in vitro.

Methods

De novo lipogenesis was measured in human primary sebocytes using [14C]-acetate labeling. Lipid species analysis was performed by extracting newly synthesized lipids and subjecting them to thin layer chromatography. Gene expression changes in sebocytes were identified through qPCR analysis of isolated RNA. Metabolic parameters including oxygen consumption rate, lactate production and activation of adenosine monophosphate-dependent protein kinase (AMPK) were assessed in human primary sebocytes.

Results

Using human primary sebocytes, we found that biguanides, isotretinoin and azithromycin induced an acute dose and time-dependent increase in [14C]-acetate labeling of neutral lipids, while AICAR, an AMPK activator, inhibited this DNL response. Biguanides did not activate AMPK in sebocytes, however, they significantly reduced oxygen consumption rate and increased lactate production. Treatment with biguanides, but not isotretinoin, significantly upregulated ACSS2 gene expression in primary sebocytes and showed synergism with lipogenic activators to induce DNL genes.

Discussion

These changes are consistent with an acute increase in sebocyte lipogenesis and support the potential of biguanides to cause an initial flare-up in patients suffering from severe acne.

Modeling acne in vitro

To help elucidate the factors responsible for the infundibular changes seen in acne, the human sebaceous pilosebaceous infundibulum was isolated by microdissection and maintained for 7 d in keratinocyte serum-free medium supplemented with 50 micrograms/ml bovine pituitary extract, 100 units/ml penicillin and streptomycin, 2.5 micrograms/ml amphotericin B and CaCl2(10H2O) to give a final Ca2+ concentration of 2 mM. Infundibular structure was maintained over 7 d in this medium; the pattern of cell division mimicked that in vivo. The rate of cell division was significantly higher than previously described for infundibula maintained in supplemented William's E medium, and moreover did not fall over 7 d. The addition of 1 ng/ml interleukin-1 alpha (IL-1 alpha) caused hypercornification of the infundibulum similar to that seen in comedones; this could be blocked by 1000 ng/ml interleukin-1 receptor antagonist (IL-1ra). In about 20% of subjects there was spontaneous hypercornification of the infundibulum that could be blocked by 1000 ng/ml IL-1ra, suggesting that the infundibulum is capable of synthesising IL-1 alpha. The addition of 5 ng/ml epidermal growth factor or 5 ng/ml transforming growth factor-alpha to the medium caused a disorganisation of the keratinocytes of the infundibulum that resulted in rupturing similar to that seen in the more severe, purulent grades of acne. The addition of 1 microM 13-cis retinoic acid caused a significant reduction in the rate of DNA synthesis and apparent parakeratosis. We are now, therefore, able to model histologically the major infundibular changes in acne.

Acne fulminans: report of clinical findings and treatment of twenty-four patients

BACKGROUND

Acne fulminans is an ulcerative form of acne with an acute onset and systemic symptoms. It most commonly affects adolescent boys.

OBJECTIVE

Clinical and laboratory findings and treatment results of patients with acne fulminans were reviewed to obtain a better understanding of the clinical course and outcome of the disease.

METHODS

Data of patients with severe acne were collected from the Dermatology Departments of Finnish hospitals during the years 1970 to 1991.

RESULTS

Twenty-four patients with acne fulminans are described. All patients had ulcerative acne with acute onset. In 22 patients acne was associated with high fever for at least 1 week. All patients had musculoskeletal pain. Increased uptake in bone scan or radiographic findings compatible with an infectious origin were detected in 17 patients. Eight patients were treated with antibiotics alone, but the response was poor; three patients had a relapse of musculoskeletal symptoms. Ten patients were given systemic steroids in addition to antibiotics. In this group the response was rapid, but acne and musculoskeletal symptoms tended to relapse when the steroid dosage was reduced. Four patients were treated with a combination of antibiotics, systemic steroids, and isotretinoin; all responded well, but one of these patients also had a relapse.

CONCLUSION

Musculoskeletal symptoms are common in patients with acne fulminans. Systemic steroid treatment rapidly controls the skin lesions and systemic symptoms. The duration of steroid treatment should be 2 to 4 months to avoid relapses. Therapy with isotretinoin, antibiotics, or both was often combined with steroids, but the role of these agents is still uncertain.

Acne fulminans and 13-cis-retinoic acid

We report a case of acne fulminans occurring during treatment with 13-cis-retinoic acid for cystic acne. Continuing the treatment with 13-cis-retinoic acid without systemic steroid eventually cleared the systemic manifestations and skin lesions. We review the literature and discuss its pathogenesis.

A double-blind evaluation of topical isotretinoin 0.05%, benzoyl peroxide gel 5% and placebo in patients with acne

A double-blind, randomized study comparing isotretinoin gel (Isotrex), its vehicle base, and benzoyl peroxide was performed on 77 patients with mild to moderate acne vulgaris. The effect of treatment was assessed by acne grade and lesion count. The vehicle base had no effect, but both active groups produced significant improvements. Benzoyl peroxide and isotretinoin significantly reduced non-inflamed lesions at 4 (P < 0.05), 8 (P < 0.01), 12 (P < 0.01) weeks. Benzoyl peroxide had a more rapid effect on inflamed lesions, their being significant reductions at 4, 8 and 12 weeks (P < 0.01), whereas with isotretinoin there was a significant improvement at 12 weeks (P < 0.01). In addition, compared to placebo, both active treatments significantly reduced inflamed and non-inflamed lesions. Acne grade had improved significantly in the benzoyl peroxide group by 4 weeks (P < 0.01) and in the isotretinoin group by 8 weeks (P < 0.05). No significant change in haematological or biochemical parameters occurred. An irritant dermatitis occurred equally with both treatments but was well tolerated by the patients. This data confirms the clinical benefit of benzoyl peroxide in acne. The initial effect of isotretinoin on non-inflamed lesions in this study suggests that the prime mode of action is on comedone formation or separation whereas benzoyl peroxide has an effect on both comedones and inflammation.

The effect of treatment with 13-cis-retinoic acid on the metabolic burst of peripheral blood neutrophils from patients with acne

The N-formylmethionyl-leucyl-phenylalanine (f-MLP)-induced metabolic burst activity of peripheral blood neutrophils isolated from acne patients undergoing treatment with 13-cis-retinoic acid at a dose of 1.0 mg/kg/day was investigated using a luminol-enhanced chemiluminescence assay. The mean and median chemiluminescence response were significantly greater (P less than 0.05) in patients receiving 13-cis-retinoic acid than in untreated acne patients or age-matched controls. Pre-incubation of neutrophils with 13-cis-retinoic acid (10 nmol/l) did not affect the chemiluminescence response to formyl peptide. A sequential study over 20 weeks in seven patients demonstrated that chemiluminescence peaked after 2-8 weeks of treatment. In three patients this was accompanied by a worsening of their acne. These studies suggest that, in the initial phase, treatment with 13-cis-retinoic acid may exacerbate, through pro-inflammatory priming of neutrophils, certain neutrophil-mediated inflammatory processes in acne.

Acne, retinoids, and dermabrasion

A group of nine patients with severe nodulocystic acne vulgaris were treated with oral 13-cis-retinoic acid and their acne cleared. During or after retinoid therapy, all patients underwent full-face dermabrasion. Postoperative healing was normal, and no significant complications were seen.

Isotretinoin therapy for acne: results of a multicenter dose-response study

One hundred fifty patients with treatment-resistant nodulocystic acne were entered into a double-blind clinical study. Three different dosing levels (0.1, 0.5, 1.0 mg/kg/day) were used in equal-sized groups. In addition to the clinical response, the clinical side effects, the laboratory abnormalities, and the duration of the induced remissions were evaluated with each dose of the drug. There was a highly significant clinical response to treatment with all three dosages of isotretinoin. There was no significant difference in the clinical response between dosages. However, 42% of the patients who received 0.1 mg/kg/day of isotretinoin required retreatment with the drug. This finding, coupled with only minor differences in the clinical side effects and the laboratory abnormalities, indicates that higher dose levels of isotretinoin are indicated for treatment of nodulocystic acne.

Isotretinoin treatment of acne and related disorders: an update

In the one year since isotretinoin has been available in the United States for the treatment of severe, recalcitrant, nodulocystic acne, there has been extensive clinical verification of the reports of its dramatic efficacy in the treatment of this troublesome disease. Proper selection of patients, as well as treatment with adequate doses of drug for 3 to 5 months, will most often result in significant clinical improvement or total clearing. Although dosages of less than 1 mg/kg/day may produce a nearly equivalent degree of improvement with somewhat fewer or less severe side effects, the recommended daily dose remains 1 mg/kg/day because lower dosages are associated with more frequent relapses. In severe cases, the daily dosage may be increased to 2 mg/kg/day. Teratogenicity, elevation of serum triglycerides, liver function abnormalities, pancreatitis, and pseudotumor cerebri may all be associated with isotretinoin therapy and require close monitoring of the patient.