Successful treatment of hypertrophic lupus erythematosus with isotretinoin

The Effects of Isotretinoin on The Menstrual Cycle: A Cross-Sectional Study

Menstrual irregularities during isotretinoin therapy, including amenorrhea, can cause a great deal of health-status uncertainty such as the possibility of pregnancy. This study aimed to evaluate the effects of isotretinoin treatment on the menstrual cycle. This cross-sectional study was conducted among females aged between 15−45 years taking isotretinoin for acne. Descriptive statistics were used in the form of frequencies and percentages to represent categorical variables. Pearson’s chi-squared test was performed to assess the relationship between some of the variables with menstrual irregularities. A logistic regression model was performed to assess the risk factors for developing menstrual irregularities during isotretinoin therapy. Of participants with a known regular menstrual cycle, 10.4% were found to have irregularity in their cycle after starting the drug (p < 0.001). Amenorrhea was the most commonly reported menstrual irregularity in isotretinoin-treated females. Our results showed that single females, those who took isotretinoin for 10−12 months and who were concurrently taking hormonal contraceptives all have a statistically significant higher risk of developing menstrual irregularities than others. In conclusion, we found that a statistically significant number of participants with a regular menstrual cycle pre-isotretinoin intake developed irregularity in their cycle after starting the drug. The mechanism of how isotretinoin influences female hormonal imbalances, thereby affecting menstrual irregularities is still poorly understood and needs to be clarified in further clinical studies.

An update on the management of refractory cutaneous lupus erythematosus

Management of cutaneous lupus erythematosus (CLE) involves a combination of preventive measures, topical and systemic drugs, fairly similar for the different subtypes. Although guidelines exist, to date, no specific drugs have been specifically licensed for CLE. Antimalarials remain the first-line systemic treatment, but many patients do not respond, making refractory lupus a challenge for clinicians. The choice of alternative medication should be based on effectiveness, safety and cost. Most of the available drugs for CLE have been adapted from systemic lupus erythematosus (SLE) treatment but the existing literature is limited to small studies and evidence often lacks. As knowledge of pathogenesis of both CLE and SLE is improving, promising new therapies are emerging. In this review, we discuss the available medications, focusing on the novelties under development for CLE.

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.

Primary cicatricial alopecia: Lymphocytic primary cicatricial alopecias, including chronic cutaneous lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia, and Graham-Little syndrome

Both primary and secondary forms of cicatricial alopecia have been described. The hair follicles are the specific target of inflammation in primary cicatricial alopecias. Hair follicles are destroyed randomly with surrounding structures in secondary cicatricial alopecia. This 2-part continuing medical education article will review primary cicatricial alopecias according to the working classification suggested by the North American Hair Research Society. In this classification, the different entities are classified into 3 different groups according to their prominent inflammatory infiltrate (ie, lymphocytic, neutrophilic, and mixed). Part I discusses the following lymphocytic primary cicatricial alopecias: chronic cutaneous lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia, and Graham-Little syndrome.

The safety of isotretinoin in patients with lupus nephritis: a comprehensive review

Oral isotretinoin (13-cis-retinoinc acid) is a derivative of vitamin A and belongs to the first generation of retinoids, which act as synthetic isomers of retinoic acid (RA). It is a very effective agent in a treatment of acne vulgaris; however, multiple side effects related to therapy with retinoids preclude the use of isotretinoin in less severe acne vulgaris. A significant limitation for the administration of isotretinoin appears in case of concomitant kidney disease with a special attention regarding the safety of the agent in patients with lupus nephritis (LN). The aim of this review is an assessment of the safety of isotretinoin for the treatment of acne vulgaris in patients with LN. We searched both MEDLINE and SCOPUS databases, as well as several dermatological textbooks, to present all limitations and benefits of therapy with isotretinoin or its isomer (ATRA) for patients with kidney diseases. Several mouse models of SLE revealed a significant modulatory influence of retinoids on autoimmune injury of the glomerular unit. Retinoids were demonstrated to affect mononuclear cell infiltrations of renal tissue allowing for a reduction in the overall glomerular damage. Presumptively, they can affect a synthesis of autoantibodies significantly limiting their deposition in the glomerular unit. Moreover, retinoids were also shown to affect the synthesis of different cytokines specific both for lymphocytes Th1 (IL-2, IL-12, INFγ) ant Th2 (IL-4, IL-10). The influence of retinoids on the course of LN seems to be more multidimensional than only restricted to immune aspects and these synthetic RA isomers manifest also antiproteinuric activity in comparable extent to steroidal agents. The agents were demonstrated to counteract a loss of podocytes after the injury of the glomerular unit. They can promote a differentiation of renal progenitor cells (RPCs) within the Bowman capsule into mature podocytes leading to regeneration of podocyte number. Additionally, retinoids can probably protect podocytes from injury limiting their apoptosis, as well as reducing foot process effacement. Although, an endogenous production of RA isomers increases after the injury of the glomerular unit aiming to the restoration of podocyte number, it can be significantly impaired by a loss of albumins into urine. RA isomers are progressively sequestered by albumin within the Bowman's space and therefore, they are quickly eliminated with urine. It was demonstrated that the administration of exogenous RA isomers (retinoids) can bypass the activity of albumins enhancing the regeneration of podocytes. Finally, retinoids can regulate the production of vasoactive substances influencing on different vascular functions in the kidney. They can beneficially change a balance of angiotensin metabolites through by down-regulation of angiotensin-converting enzyme type 1 and the enhancement of an expression of angiotensin-converting enzyme type 2. Another studies revealed that retinoids could also alter the activity of renal endothelin pathway; however, the significance of this effect requires further elucidation. Taken all these presented effects of retinoids in the kidney into consideration, we can conclude that isotretinoin can be the safe treatment option of acne vulgaris in patients with LN.

Hypertrophic Lupus Erythematosus Treated Successfully with Acitretin as Monotherapy

Hypertrophic lupus erythematosus (HLE) is a distinct and rare subset of chronic cutaneous lupus erythematosus characterized by verrucous lesions which are chronic in course and resistant to treatment (1). We describe the successful use of acitretin in a patient with HLE who had multiple hyperkeratotic verrucous plaques over the dorsa of his hands, feet, and legs and who failed to respond to local steroids and antimalarials.

Cutaneous Hypertrophic Lupus Erythematosus: A Challenging Histopathologic Diagnosis in the Absence of Clinical Information

Hypertrophic lupus erythematosus (HLE) is rare variant of chronic cutaneous lupus characterized histologically by irregular epidermal hyperplasia associated with features of classic chronic cutaneous lupus, including interface changes. Lesions frequently demonstrate reactive squamous atypia of the basal layer and may show histopathologic overlap with other more common cutaneous atypical squamoproliferative lesions. Typical histologic features of cutaneous lupus, such as follicular plugging, angiocentric lymphocytic inflammation, and dermal mucin, are very helpful clues to the diagnosis of hypertrophic lupus erythematosus. Recently, immunohistochemistry for CD123 used to detect increased plasmacytoid dendrocytes in hypertrophic lupus erythematosus has proven to be diagnostically useful. A high index of suspicion for hypertrophic lupus erythematosus is essential to avoid overdiagnosis of squamous neoplasia, particularly in limited cutaneous biopsies in the absence of adequate clinical information.

Extensive hypertrophic lupus erythematosus: atypical presentation

Lupus erythematosus (LE) is a disease with a wide spectrum of cutaneous and systemic manifestations. Clinical features of patients with LE show a great variation, and for this reason it is difficult to develop a unifying concept of this disease. Our objective is to present a case of hypertrophic LE with atypical morphology and extensive involvement, who responded favorably to isotretinoin. Diagnosis of hypertrophic lupus erythematosus (HLE) was confirmed by characteristic histopathological findings. Combination therapy with isotretinoin and hydroxychloroquine resulted in flattening and repression of previously refractory skin lesions. Sometimes, HLE lesions may present a diagnostic and therapeutic dilemma. In long standing lesions, squamous cell carcinoma may arise. Therefore, HLE requires adequate therapy with clinical and histopathological follow up.

Cutaneous lupus erythematosus: issues in diagnosis and treatment

Cutaneous lupus erythematosus (LE) may present in a variety of clinical forms. Three recognized subtypes of cutaneous LE are acute cutaneous LE (ACLE), subacute cutaneous LE (SCLE), and chronic cutaneous LE (CCLE). ACLE may be localized (most often as a malar or 'butterfly' rash) or generalized. Multisystem involvement as a component of systemic LE (SLE) is common, with prominent musculoskeletal symptoms. SCLE is highly photosensitive, with predominant distribution on the upper back, shoulders, neck, and anterior chest. SCLE is frequently associated with positive anti-Ro antibodies and may be induced by a variety of medications. Classic discoid LE is the most common form of CCLE, with indurated scaly plaques on the scalp, face, and ears, with characteristic scarring and pigmentary change. Less common forms of CCLE include hyperkeratotic LE, lupus tumidus, lupus profundus, and chilblain lupus. Common cutaneous disease associated with, but not specific for, LE includes vasculitis, livedo reticularis, alopecia, digital manifestations such as periungual telangiectasia and Raynaud phenomenon, photosensitivity, and bullous lesions. The clinical presentation of each of these forms, their diagnosis, and the inter-relationships between cutaneous LE and SLE are discussed. Common systemic findings in SLE are reviewed, as are diagnostic strategies, including histopathology, immunopathology, serology, and other laboratory findings. Treatments for cutaneous LE initially include preventive (e.g. photoprotective) strategies and topical therapies (corticosteroids and topical calcineurin inhibitors). For skin disease not controlled with these interventions, oral antimalarial agents (most commonly hydroxychloroquine) are often beneficial. Additional systemic therapies may be subdivided into conventional treatments (including corticosteroids, methotrexate, thalidomide, retinoids, dapsone, and azathioprine) and newer immunomodulatory therapies (including efalizumab, anti-tumor necrosis factor agents, intravenous immunoglobulin, and rituximab). We review evidence for the use of these medications in the treatment of cutaneous LE.

Management of primary cicatricial alopecias: options for treatment

Primary cicatricial alopecias (PCAs) are a poorly understood group of disorders that result in permanent hair loss. Clinically, they are characterized not only by permanent loss of hair shafts but also of visible follicular ostia along with other visible changes in skin surface morphology, while their histopathological hallmark usually (although not always) is the replacement of follicular structures with scar-like fibrous tissue. As hair follicle neogenesis in adult human scalp skin is not yet a readily available treatment option for patients with cicatricial alopecias, the aim of treatment, currently, remains to reduce symptoms and to slow or stop PCA progression, namely the scarring process. Early treatment is the key to minimizing the extent of permanent alopecia. However, inconsistent terminology, poorly defined clinical end-points and a lack of good quality clinical trials have long made management of these conditions very challenging. As one important step towards improving the management of this under-investigated and under-serviced group of dermatoses, the current review presents evidence-based guidance for treatment, with identification of the strength of evidence, and a brief overview of clinical features of each condition. Wherever only insufficient evidence-based advice on PCA management can be given at present, this is indicated so as to highlight important gaps in our clinical knowledge that call for concerted efforts to close these in the near future.

Non-acne dermatologic indications for systemic isotretinoin

Systemic isotretinoin has been used to treat severe acne vulgaris for 20 years. However, isotretinoin also represents a potentially useful choice of drugs in many dermatologic diseases other than acne vulgaris. Diseases such as psoriasis, pityriasis rubra pilaris, condylomata acuminata, skin cancers, rosacea, hidradenitis suppurativa, granuloma annulare, lupus erythematosus and lichen planus have been shown to respond to the immunomodulatory, anti-inflammatory and antitumor activities of the drug. Isotretinoin also helps prevent skin cancers such as basal cell carcinoma or squamous cell carcinoma. A combination of systemic isotretinoin and interferon-alpha-2a may provide a more potent effect than isotretinoin alone in the prevention and treatment of skin cancers.Systemic isotretinoin may be considered as an alternative drug in some dermatologic diseases unresponsive to conventional treatment modalities. However, randomized clinical trials aimed at determining the role of systemic isotretinoin therapy in dermatologic diseases other than acne vulgaris are required.

Cutaneous lupus erythematosus: diagnosis and management

Cutaneous lupus erythematosus (CLE) includes a variety of lupus erythematosus (LE)-specific skin lesions that are subdivided into three categories - chronic CLE (CCLE), subacute CLE (SCLE) and acute CLE (ACLE) - based on clinical morphology, average duration of skin lesions and routine histopathologic examination. This paper describes our personal experience in the management of CLE over the last 30 years, with details on preferential therapeutic options related to clinical, histologic and immunopathologic aspects of each clinical subset of the disease. Effective sunscreening and sun protection are considered the first rule in the management of CLE because of the high degree of photosensitivity of the disease. Antimalarial agents are crucial in the treatment of CLE and are the first-line systemic agents, particularly in discoid LE (DLE) and SCLE. Dapsone is the drug of choice for bullous systemic LE (BSLE) as well as for LE in small dermal vessels (e.g. leukocytoclastic vasculitis). Retinoids, known as second-line drugs for systemic therapy, are sometimes used to treat chronic forms of CLE and are particularly successful in treating hypertrophic LE. Systemic immunosuppressive agents are required to manage the underlying systemic LE disease activity in patients with ACLE. These drugs, especially azathioprine, methotrexate, cyclophosphamide and cyclosporine, together with corticosteroids, constitute third-line systemic therapy of CLE. In our experience, oral prednisone or parenteral 'pulsed' methylprednisolone are useful in exacerbations of disease activity. Thalidomide provides one of the most useful therapeutic alternatives for chronic refractory DLE, although its distribution is limited to a few countries because of the risk of teratogenicity and polyneuropathy. However, medical treatment with local corticosteroids remains the mainstay of CLE treatment, especially for DLE. Patient education regarding the disease is also important in the management of CLE, because it helps relieve undue anxiety and to recruit the patient as an active participant in the treatment regimen.

Hypertrophic lupus erythematosus: a clinicopathological study of 14 cases

BACKGROUND

Hypertrophic lupus erythematosus (HLE) is a distinct and rare subset of lupus erythematosus (LE). It is characterized by verrucous lesions, chronic in its course, and resistant to treatment. The purpose of this study was to identify clinical and histological characteristics of HLE.

METHODS

We review our experience with 14 cases of HLE identified in a group of 220 patients with different forms of LE, at the UNICAMP Hospital, between 1976 and 2002.

RESULTS

All patients presented verrucous plaques concomitantly with discoid lesions. The most common sites of involvement were the face and the arms. Histology of HLE lesions revealed pseudoepitheliomatous hyperplasia engulfing elastotic material. Elastic fibers were seen in migration throughout the epidermis. Classic features of LE were noted in all cases. Three of the patients developed hyperkeratotic papules with central keratinous plug on their arms at the previous LE sites. These lesions resemble clinically and histopathologically keratoacanthomas. In one patient, HLE lesion progressed to squamous cell carcinoma (SCC), 26 years after the onset of the disease.

CONCLUSIONS

Transepithelial elimination of the elastotic material may be a feature of HLE. Some HLE lesions may present as keratoacanthoma, but classical features of LE aid the correct diagnosis. SCC may arise on a long-standing HLE lesion; therefore HLE requires clinical and histopathological follow up.

Local therapy for cutaneous and systemic lupus erythematosus: practical and theoretical considerations

Local therapeutic measures should be maximized in the management of lupus erythematosus (LE), particularly for patients with forms of LE-specific skin disease such as SCLE and CCLE. Local therapy consists of sun protection and locally-applied pharmacologic agents, e.g. topical/intralesional corticosteroids. Patients should be advised to avoid direct sun exposure, wear lightweight tightly woven clothing and broad-brimmed hats, and use broad-spectrum, water-resistant sunscreens. There are several modalities that enhance permeability of local therapeutics through the stratum corneum that could be applied to topical therapy of cutaneous LE, e.g. polar solvent, liposomal encapsulation, ethosomal system, iontophoresis, electroporation and sonophoresis. As novel and more effective modalities to deliver pharmacologic agents across the stratum corneum become available, therapeutics that have been experimental and untested thus far may become part of the local armamentarium in the near future. In addition, physical/contact therapy as well as dermatosurgical methods can be invaluable in enhancing self-image and quality of life of patients with disfiguring cutaneous LE lesions.

Cutaneous lupus erythematosus

Lupus erythematosus (LE) has many different clinical manifestations including a variety of cutaneous findings. Some of the cutaneous manifestations are not specific for LE, such as photosensitivity reactions, oral ulcers, alopecia, urticaria, vasculitis, vesiculo-bullous lesions, acral changes, cutaneous mucinoses, and cutaneous calcinosis. Other findings are specific for LE in that they are found only in patients who have lupus erythematosus. These LE-specific disorders include acute cutaneous LE, subacute cutaneous LE, and several forms of chronic cutaneous LE, including discoid LE. Skin biopsies are often helpful in differentiating LE-specific skin lesions from other disorders that can mimic them. Photoprotective measures and a number of drugs are useful in treating cutaneous LE.

Uncommon cutaneous manifestations of lupus erythematosus

Cutaneous manifestations of lupus erythematosus (LE) are, usually, characteristic enough to permit an easy diagnosis. However, some patients may present less typical lesions, associated or not to the classic ones. Therefore, irrespectively of the variety of LE (acute, subacute and chronic), in absence of the typical butterfly rash, erythematosquamous papules or plaques, or any of the characteristic cutaneous alterations, it is important (even though not always easy) to recognize the uncommon and/or atypical changes of the skin.

Discoid lupus erythematosus

Discoid lupus erythematosus is a manifestation of chronic cutaneous lupus erythematosus with a small risk of systemic involvement. In this review article, the role of predisposing factors such as haplotype, hormones, antibodies and sunlight are discussed. The clinical features, including variants and associations, and management options are presented.

Treatment of cutaneous lupus erythematosus

The mainstays of treatment of cutaneous lupus erythematosus (LE) are topical and intralesional steroids, sunscreen, and the antimalarials. However, the practitioner is often faced with the challenge of cutaneous disease unresponsive to these conventional measures. We present our approach to the management of cutaneous LE and review the literature regarding therapy of refractory disease.

Isotretinoin for refractory lupus erythematosus

We describe six patients with cutaneous manifestations of lupus erythematosus who were treated with isotretinoin, 1 mg/kg/day. In each case the cutaneous lesions had proved resistant to systemic corticosteroids and antimalarial therapy. Treatment with isotretinoin resulted in rapid clinical improvement in all cases. Recurrences were similarly rapid when the drug was discontinued. Side effects were minimal and easily controlled by adjustments in dose or by the use of lubricants.

Surgical excision of trauma-induced verrucous lupus erythematosus

Verrucous papulonodules are an uncommon manifestation of chronic discoid lupus erythematosus. The differential diagnosis and pathogenesis of this rare entity are discussed. This is the first report of successful surgical excision of trauma-induced lesions of verrucous lupus erythematosus.