Retinoid hyperostosis. Skeletal toxicity associated with long-term administration of 13-cis-retinoic acid for refractory ichthyosis

Diffuse idiopathic skeletal hyperostosis in a young woman treated with isotretinoin

We present the case of a 36-year-old woman with diffuse idiopathic skeletal hyperostosis especially at cervical spine since she was 29 years old. The only relevant feature was the use of isotretinoin at regular doses in the past for severe acne.

Diffuse Idiopathic Skeletal Hyperostosis in a Young Woman Treated With Isotretinoin

We present the case of a 36-year-old woman with diffuse idiopathic skeletal hyperostosis especially at cervical spine since she was 29 years old. The only relevant feature was the use of isotretinoin at regular doses in the past for severe acne.

Premature epiphyseal growth plate arrest after isotretinoin therapy for high-risk neuroblastoma: A case series and review of the literature

BACKGROUND

Vitamin A-derived retinoids have been reported to cause skeletal abnormalities ranging from hypercalcemia to premature epiphyseal closure. Isotretinoin is a retinoid used as standard therapy for high-risk neuroblastoma and has been reported to cause premature epiphyseal growth plate arrest.

PROCEDURE

We identified patients from the Children's Hospital Los Angeles (CHLA) database with high-risk neuroblastoma diagnosed from 1991 to 2018 who experienced premature epiphyseal growth plate arrest and compared their characteristics to other patients with high-risk neuroblastoma. We then performed a literature review of this complication. Data collection included diagnosis age of neuroblastoma, presentation age, agent of exposure, dose, exposure range, and skeletal deformity.

RESULTS

Among 216 patients, high-risk neuroblastoma was diagnosed before age of five years (n = 165), between ages of 5 and 10 years (n = 41), and after 10 years of age (n = 13). Three out of 216 patients developed premature epiphyseal growth arrest after isotretinoin exposure (overall incidence = 1.38%). The incidence of bony abnormalities was significantly higher in patients diagnosed in 5- to 10-year age group than in other two groups (P = 0.014). Literature review identified eight additional patients with neuroblastoma who presented with retinoid associated skeletal abnormalities. The median range of isotretinoin exposure for these 11 patients was between 6.5 and 7.625 years (range, 2-14) with no cases of isotretinoin therapy completion before age 5 years.

CONCLUSION

Bone toxicity associated with isotretinoin exposure is a concern. Growth plate arrest is a serious adverse effect that is attributable to isotretinoin therapy. Our findings suggest the prepubescent growth plate may be most at risk, and we recommend special attention to this population.

Retinoic Acid, Leaky Gut, and Autoimmune Diseases

A leaky gut has been observed in a number of autoimmune diseases including type 1 diabetes, multiple sclerosis, inflammatory bowel disease, and systemic lupus erythematosus. Previous studies from our laboratory have shown that lupus mice also bear a leaky gut and that the intestinal barrier function can be enhanced by gut colonization of probiotics such as Lactobacillus spp. Retinoic acid (RA) can increase the relative abundance of Lactobacillus spp. in the gut. Interestingly, RA has also been shown to strengthen the barrier function of epithelial cells in vitro and in the absence of probiotic bacteria. These reports bring up an interesting question of whether RA exerts protective effects on the intestinal barrier directly or through regulating the microbiota colonization. In this review, we will discuss the roles of RA in immunomodulation, recent literature on the involvement of a leaky gut in different autoimmune diseases, and how RA shapes the outcomes of these diseases.

Isotretinoin-induced skeletal hyperostosis

We describe a case of skeletal hyperostosis in a 29 year old man presenting with non-inflammatory back pain with a past history of isotretinoin therapy for acne. The development of skeletal hyperostosis, predominantly of the spine, has been reported in association with isotretinoin use and has a radiographic picture similar to diffuse idiopathic skeletal hyperostosis. The prevalence and severity of this condition appears to correlate with duration of therapy. Isotretinoin is a well-established treatment for severe acne. It is important for the rheumatologist be aware of this phenomenon when assessing young patients with musculoskeletal symptoms and evidence of radiological abnormalities.

Diffuse idiopathic skeletal hyperostosis (Forestier-Rotes-Querol disease): what's new?

Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier-Rotes-Querol disease, is characterized by the ossification of the entheses (i.e., enthesopathy). The diagnosis of DISH requires at least two (according to Forestier) or three (according to Resnick) contiguous intervertebral bridges, without severe disk alterations (in contrast to degenerative spinal disease) or ankylosis of the sacroiliac or facet joints (in contrast to spondylarthritis). Although prevalence estimates vary with the number of bridges used to define the disease, the prevalence of DISH is consistently high and increases with age and obesity. Peripheral involvement is common but difficult to ascribe to DISH in the absence of typical spinal changes. Cervical spine ossification is the most extensively studied manifestation, as dysphagia due to esophageal compression may require surgery. As with spondylarthritis, vertebral fractures on a hyperostotic fused spine may escape recognition, placing the patient at risk for complications in the event of subsequent displacement. These fractures are particularly severe, as they often involve the cervical spine and can therefore, cause major neurological impairments. DISH is associated with an increased risk of metabolic syndrome (odds ratio, 3.88). Research into the pathophysiology of DISH has established that serum levels of the natural osteogenesis inhibitor Dickkopf-1 (DKK-1) are low in patients with DISH or spondylarthritis. Although this abnormality might contribute to the entheseal ossification, it has not been found consistently.

Retinoic acid arthropathy: An unusual cause of elbow pain

Retinoic acid arthropathy typically presents in the axial skeleton as flowing ossification along the anterior longitudinal ligament and as a condition of pelvic hyperostosis. When the appendicular skeleton is involved, radiographic findings usually present late and are typically asymmetric. We present an unusual case of retinoic acid arthropathy presenting in both elbow joints. Radiologists should consider this diagnosis when faced with hyperostosis that is not explained by sports-related history.

Hypercalcemia and osteoblastic lesions induced by 13-Cis-retinoic acid mimicking relapsed neuroblastoma

A 6-year-old male diagnosed with extensive neuroblastoma was treated with chemotherapy, surgery, autotransplantation, and radiotherapy. He was then enrolled on a study to assess the monoclonal antibody Ch14.18 (anti-GD2) with 13 cis-retinoic acid. 13-cis-retinoic acid therapy caused severe bone pain and hypercalcemia. Bone scans showed multiple osteoblastic lesions suggesting recurrent disease however MIBG scans were negative. Serum markers of bone turnover were increased and the patient required pamidronate therapy to treat persistent hypercalcemia. Retinoic acid toxicity needs to be considered in the differential of painful osteoblastic lesions and/or hypercalcemia. MIBG scans can assist in differentiating from recurrent disease.

Bone mineral density and bone turnover markers in patients receiving a single course of isotretinoin for nodulocystic acne

BACKGROUND

High-dose isotretinoin has been reported to have adverse effects on bone mineral density (BMD); however, studies evaluating changes in BMD with isotretinoin therapy at different dosages and with varying treatment durations have produced conflicting results.

OBJECTIVE

To investigate the effect of a standard, single course of isotretinoin therapy on BMD and bone turnover markers in patients with nodulocystic acne.

METHODS

Thirty-six patients (15 male, 21 female) with severe, recalcitrant, nodulocystic acne and 36 healthy controls (16 male, 20 female) were enrolled in the study. Patients received isotretinoin treatment for 4-6 months until a cumulative dose of 120 mg/kg had been achieved. BMD in the lumbar spine and femur was measured at baseline and at the end of therapy by dual-energy X-ray absorptiometry. Serum calcium, phosphate, parathormone, total alkaline phosphatase, osteocalcin, free deoxypyridinoline, and urinary calcium were also measured before and at the end of treatment.

RESULTS

No significant differences were found in lumbar spine and femoral BMD between the patient and control groups at the beginning of the study (P > 0.05), and no statistically significant difference was observed between the BMD values in patients at the beginning vs. the end of treatment (P > 0.05). No statistically significant difference in bone turnover markers was found between patients and controls at the beginning of the study (P > 0.05), and no statistically significant changes in bone turnover markers were observed in patients at the beginning vs. the end of treatment (P > 0.05).

CONCLUSION

A single course of isotretinoin therapy has no clinically significant effect on bone metabolism.

Retinoid toxicity

The long-term effects of N-ethylretinamide (NER) on the haematology of the rat, and the dose-related effects of retinoids on lymphoid organs of the mouse and rat were investigated. Retinoid-induced long-bone changes were used to develop a method for quantifying skeletal effects. This technique was used to investigate the activity of five retinamides in inducing long-bone changes in the rat. The ability of non-steroidal anti-inflammatory compounds (NSAICs) to prevent retinoid-induced skeletal effects was examined, and preliminary investigations made into the mechanisms of retinoid-induced long-bone remodelling. NER-fed rats had reduced red blood cell counts and fibrinogen values. Retinoids caused dose-related proliferation of the spleen and lymph nodes in the mouse and to a lesser extent in the rat. They induced dose-related reductions in femoral diaphysis and medullary cavity diameters in both rats and mice. Aspirin prevented NER-induced changes of rat long bones, but subsequent studies indicated this effect may be closely dependent on the dose level of both the retinoid and NSAIC administered. Retinoids induce rapid long-bone remodelling in the rat which tends to revert on feeding a control diet, but remodelling processes are different in the young growing rat and the mature animal.

COL6A1, the candidate gene for ossification of the posterior longitudinal ligament, is associated with diffuse idiopathic skeletal hyperostosis in Japanese

STUDY DESIGN

Genetic screening of collagen 6A1 gene (COL6A1) in patients with diffuse idiopathic skeletal hyperostosis (DISH) recruited in Japan and the Czech Republic.

OBJECTIVE

To investigate allelic associations between DISH and nucleotide variants of COL6A1.

SUMMARY OF BACKGROUND DATA

DISH is a skeletal hyperostotic disease characterized by ligamentous ossification of the anterolateral side of the spine. Ossification of the posterior longitudinal ligament (OPLL) is a related disorder with DISH, and COL6A1 was identified as a susceptibility gene to OPLL. COL6A1 was examined for susceptibility in DISH patients from Japan and the Czech Republic.

METHODS

Seven single nucleotide polymorphisms of COL6A1 were genotyped by direct sequencing. The allele frequencies were compared between 97 Japanese DISH patients and 298 Japanese controls, and between 96 Czech DISH patients and 96 Czech controls by chi2 test.

RESULTS

The intron 32 (-29) single nucleotide polymorphisms of COL6A1 was significantly associated with the Japanese DISH patients (chi2 = 9.33; P = 0.0022), but not with the Czech DISH patients.

CONCLUSIONS

Because COL6A1 could be a susceptibility to the occurrence of DISH and OPLL in the Japanese population, we consider that COL6A1 could be responsible for the hyperostotic state, leading to ectopic bone formation in the spinal ligament.

Acitretin-induced enthesitis in a patient with psoriatic arthritis

A patient with psoriatic arthritis and cutaneous psoriasis took acitretin for 10 years to treat his skin lesions. Radiographs disclosed exuberant ossifications in several entheses. Their features were not typical for psoriatic arthritis but were consistent with acitretin-induced hyperostosis. Retinoids are known to induce hyperostosis, most notably when they are used in high dosages and over long periods. The concomitant presence of two conditions affecting the entheses may explain the exuberant nature of the ossifications in our patient.

Effect of a single course of isotretinoin therapy on bone mineral density in adolescent patients with severe, recalcitrant, nodular acne

BACKGROUND

Adverse changes in bone have been reported for patients undergoing high-dose, long-term (several years) isotretinoin therapy for disorders of cornification. The effect of short-term (4-5 months) therapy at the lower dose recommended for acne on bone development in younger, growing adolescent (12-17 years) patients has not been well studied.

OBJECTIVE

The purpose of the study was to evaluate the effect of a standard, single course of isotretinoin (Accutane) therapy on bone mineral density (BMD) of the lumbar spine and hip in adolescents ages 12 to 17 years with severe, recalcitrant, nodular acne.

METHODS

In this open-label, multicenter study, 217 adolescents (81 girls) with severe, recalcitrant, nodular acne were enrolled and treated with isotretinoin twice daily with food at the recommended total dose of approximately 1 mg/kg for 16 to 20 weeks. BMD in the lumbar spine and hip was measured at baseline and at the end of therapy by dual energy radiograph absorptiometry.

RESULTS

There was no clinically significant mean change in BMD measured at the lumbar spine (+1.4%, range: -4.9% to +12.3%) or total hip (-0.26%, range: -11.3% to +15.0%). Hyperostosis was not observed in any patient. Typical efficacy expected in the treatment of acne was observed.

CONCLUSIONS

A 16- to 20-week course of isotretinoin treatment at the recommended dose for severe acne has no clinically significant effect on lumbar spine and total hip BMD in the adolescent (12-17 years) population.

Reversible sclerotic changes of lumbar spine and femur due to long-term oral isotretinoin therapy

We present a rare case of retinoid-induced sclerotic changes of lumbar spine and femur demonstrated by dual energy x-ray absorptiometrie (DEXA). The patient had flowing ossification along thoracic spine resembling diffuse idiopathic skeletal hyperostosis (DISH), but there was no ligament calcification in the lumbar spine or pelvis. After discontinuation of the treatment, gradual decline of bone mineral density at lumbar and femoral sites was detected with serial DEXA measurements. To the best of our knowledge, although various abnormalities of bone due to retinoids have been described before, reversible sclerotic changes have not been reported.

A phase 1 study of tazarotene in adults with advanced cancer

Tazarotene is an acetylenic retinoid which is metabolised to tazarotenic acid and which binds selectively to the retinoid receptors RARbeta and RARgamma. The safety, toxicity and pharmacokinetics of oral tazarotene were determined over 12 weeks of treatment in 34 patients with advanced cancer. Commonly seen toxicities were mucocutaneous symptoms, musculoskeletal pain and headache. Dose-limiting toxicities were hypercalcaemia, hypertriglyceridaemia and musculoskeletal pain. The maximum tolerated dose of tazarotene in this schedule is 25.2 mg day(-1). Plasma concentrations of tazarotenic acid were found to peak rapidly within 1-3 h of dosing and thereafter declined quickly. The C(max) and AUC values on day 0, and weeks 2 and 4 were similar indicating no drug accumulation. The dose-normalised C(max) and AUC values at different dose levels and different study days appeared to be similar indicating linear pharmacokinetics. No objective responses were seen, although stable disease was seen in six out of eight evaluable patients receiving the three highest dose levels of tazarotene (16.8, 25.2 or 33.4 mg day(-1)). We conclude that oral tazarotene is well tolerated when administered daily for 12 weeks, has a favourable toxicity profile compared with other retinoids and merits further investigation as an anticancer therapy.

Articular cartilage degradation and de-differentiation of chondrocytes by the systemic administration of retinyl acetate-ectopic production of osteoblast stimulating factor-1 by chondrocytes in mice

OBJECTIVE

Vitamin A derivatives are widely used therapeutic agents for the treatment of dermatological and rheumatological disorders. Long-standing administration of these drugs, in turn, causes skeletal changes including ossification of ligaments, premature fusion of epiphyses and abnormalities of modeling. Recent in vitro experiments have further suggested that retinoid treatment of cultured chondrocytes may cause apoptotic cell death. The present study aims to address detailed cartilage changes associated with in vivo administration of vitamin A derivatives.

METHODS

Retinyl acetate was administrated to experimental mice, C3H-Heston, for more than 12 months. Modified morphometry on the articular cartilage and fluorescent labeling of the subchondral bone were carried out to address the changes in the articular cartilage and subchondral bone. In order to address the detailed chondrocytes phenotypes, electron microscopy was carried out. Since findings of these studies suggested that biological properties of the cartilage matrix might be altered, the present study also immunolocalized functional matrix molecules, type I collagen and osteoblast-stimulating factor-1 (OSF-1).

RESULTS

Histomorphometry demonstrated that retinoid administration lead to progressive atrophy of the articular cartilage with concomitant proliferation of subchondral bone. Furthermore, detailed light and electron microscopy suggested that the subchondral bone proliferates into the degenerating cartilage. The affected articular cartilage also resembled that of osteoarthritis in terms of ectopic type I collagen production. Furthermore, the affected articular cartilage produced a developmentally regulated matrix molecule, osteoblast-stimulating factor-1 (OSF-1) that is normally expressed in both the fetal cartilage and the epiphyseal growth plate cartilage but not in the articular cartilage.

CONCLUSION

The present results indicate that the systemic retinoid administration may alter the biological properties of the articular cartilage.

Phase I Clinical Trial of Alitretinoin and Tamoxifen in Breast Cancer Patients: Toxicity, Pharmacokinetic, and Biomarker Evaluations

PURPOSE: To determine the overall and dose-limiting toxicities (DLTs) of alitretinoin (9-cis-retinoic acid) in combination with tamoxifen and the pharmacokinetics of alitretinoin alone and when combined with tamoxifen in patients with metastatic breast cancer. The effect of tamoxifen and alitretinoin on MIB-1, a marker of proliferation, in unaffected breast tissue was explored.

PATIENTS AND METHODS: Eligible patients had metastatic breast cancer. Previous tamoxifen therapy was allowed. Planned dose levels for alitretinoin ranged from 50 to 140 mg/m2/d with 20 mg/d tamoxifen in all patients after 4 weeks of alitretinoin as a single agent. Plasma concentrations of alitretinoin and retinol were measured at baseline and after 1, 2, and 3 months. Breast core biopsies were obtained at baseline and after 2 months of therapy.

RESULTS: Twelve patients with metastatic breast cancer received a total of 86 cycles of therapy. At 90 mg/m2/d, three of five patients experienced a DLT: grade 3 headache, grade 3 hypercalcemia, and grade 3 noncardiogenic pulmonary edema. At 70 mg/m2/d, one of six patients experienced a DLT (headache), and this level was considered the maximal tolerated dose in this study. Three toxicities occurred that had not been reported previously with alitretinoin: an asymptomatic delay in dark adaptation, a marked decrease in high-density lipoprotein cholesterol, and the occurrence of enthesopathy. Two of the nine assessable patients had a durable clinical response: one partial response and stable disease for 18 months and one complete response in continuous remission for 48+ months. Both responding patients were estrogen receptor–positive and had had previous tamoxifen therapy. There was a high degree of interpatient variability of plasma alitretinoin concentrations, although a significant decline in alitretinoin plasma levels over time was observed. MIB-1 scores declined in four of the eight paired breast specimens obtained.

CONCLUSION: The combination of tamoxifen and alitretinoin is well tolerated and has antitumor activity in metastatic breast cancer. The recommended phase II dose is 70 mg/m2/d with 20 mg/d tamoxifen.

Greater trochanter enthesopathy: an example of "short course retinoid enthesopathy": a case report

Irreversible skeletal changes have been described in patients with dermatologic disorders treated with isotretinoin (Accutane), a synthetic vitamin A derivative. Although retinoids were developed to avoid toxicity associated with vitamin A, skeletal lesions and rheumatologic consequences are possible hazards of isotretinoin treatment. Enthesopathy is one of the potential musculoskeletal sequelae and is characterized by pathologic, sometimes painful changes at the insertion sites (entheses) of tendons, ligaments, and articular capsules into bone. We report a patient who was referred secondary to an extended history of bilateral hip region pain. She was subsequently found to have a greater trochanteric enthesopathy. A detailed patient history revealed past use of Accutane for cystic acne. The subsequent treatment course, including medications, corticosteroid injections, physical therapy, and activity modifications, is described and the pertinent literature is reviewed. We believe that patients who are prescribed isotretinoin should be warned about this potential pathologic condition at the initiation of treatment and that physicians who are treating patients with a history of Accutane use should be suspicious of underlying enthesopathies as the etiology behind pain of musculoskeletal origin.

Extraspinal enthesopathy caused by isotretinoin therapy

OBJECTIVE

To discuss a case of diffuse peripheral enthesopathy in a patient previously treated with long-term isotretinoin (Accutane) for severe acne.

CLINICAL FEATURES

A 47-year old man with 1 month history of moderate neck and right upper extremity pain, with hypoesthesia of the right second and third fingers. Palpable bony prominences around multiple superficial joints were noted on physical examination, raising the initial question of osteochondromatosis. Multiple active acne pustules were noted. A limited skeletal survey demonstrated diffuse peripheral enthesophyte formation and hyperostoses, resembling those of diffuse idiopathic skeletal hyperostosis, but without accompanying spinal changes. A history of long-term Accutane therapy was then elicited.

INTERVENTION AND OUTCOME

The enthesopathy was believed to represent an asymptomatic, longstanding, iatrogenically induced abnormality. No specific therapy or follow-up was indicated. The patient had discontinued use of Accutane years ago. Cervical symptoms improved with four sessions of cervical traction and nonsteroidal anti-inflammatory medications, but upper extremity symptoms were refractory.

CONCLUSION

Accutane-induced enthesopathy should be considered in individuals with correlating radiologic and clinical features and history of retinoic acid therapy for acne. This should be a diagnosis by exclusion, after eliminating other potential causes of peripheral enthesopathy, particularly diffuse idiopathic skeletal hyperostosis, seronegative spondylarthropathy, and fluorosis.

Effect of fenretinide on bone mineral density and metabolism in women with early breast cancer

Prolonged administration of natural or synthetic retinoids has been associated with significant skeletal abnormalities, including osteoporosis. We studied the effects of the synthetic retinoid fenretinide (N-4-hydroxyphenylretinamide, or 4-HPR) administered for a mean of 40 months on bone mineral density and metabolism in 66 consecutive women with early breast cancer belonging to a secondary prevention trial. The mean (+/-SD) bone mineral density at the distal and ultradistal forearm were, respectively, 0.61+/-0.08 and 0.30+/-0.05 g/cm2 in 33 treated women and 0.62+/-0.07 and 0.29+/-0.07 g/cm2 in 33 control women (p = ns for both). Also, no significant difference was observed in markers of bone formation such as bone alkaline phosphatase and osteocalcin, nor in urinary bone resorption markers such as calcium, hydroxyproline, and type I bone collagen cross-linked N-telopeptide (NTx). However, a border-line higher excretion of urinary calcium and NTx was found in the 4-HPR group after adjustment for menopausal status. We conclude that prolonged administration of 4-HPR is not associated with significant alterations of bone mineral density of the forearm. However, a trend towards an increase in bone resorption markers suggests the need for further assessment at different skeletal sites.

Posttransplantation skin cancer: scope of the problem, management, and role for systemic retinoid chemoprevention

Long-term immunosuppression necessary for transplantation places susceptible individuals with chronic actinic damage at increased risk for the development of aggressive skin cancers. Candidates for transplantation should be evaluated for the risk factors associated with skin cancer. Those who are at risk should be educated in the measures for and the importance of diligent UVR protection, frequent self-examination of the skin, and regular dermatologic evaluation to minimize the morbidity and morality from NMSC. Identified skin cancers (especially SCC) should be treated aggressively. Individuals who are actively developing many cancers may be candidates for retinoid chemoprevention.

Retinoic acid responsiveness of cells and tissues in developing fetal limbs evaluated in a RAREhsplacZ transgenic mouse model

Limb morphogenesis is a complex phenomenon in which retinoids play an important role. Abnormal maternal retinoid levels from high oral doses cause fetal malformations, including abnormalities of the musculoskeletal system. Our purpose was to identify the retinoid-responsive cells in bone and cartilage during limb development by using a transgenic line of mice containing a reporter gene insert consisting of a retinoic acid response element linked to an Escherichia coli beta-galactosidase gene. Transgenic fetuses from day 11.5 after conception to birth (day 20) were analyzed histologically. Retinoid-responsive cells and tissues were first seen in the limb bud at 12.5 days in the webs between the forming digits. The webs stained maximally at 14.5 days, after which staining intensity subsided. Staining in the muscles was detectable at 13.5 days, at a stage coinciding with myoblast fusion. Specific regions of perichondrium and periosteum also stained at this stage. Occasional staining was observed in individual chondroblasts in all chondrogenic regions, including hypertrophic chondroblasts and certain articular surfaces of developing joints. Staining of these tissues decreased in intensity in subsequent stages. Osteoclasts started to express beta-galactosidase at 15.5 days and continued to stain into maturity. Our results indicate that specific subsets of cells respond to retinoids at specific stages in the course of normal limb development. In hypertrophic chondrocytes and cells in the webs and joints that display such a response, retinoid-induced effects may be linked to cell death that occurs in these regions. Staining in muscle, perichondrium, and periosteum may reflect retinoid-induced effects associated with cell differentiation and growth. These results suggest that retinoids play a role in a variety of tissues, including bone and cartilage, at specific stages during morphogenesis.

Comparative study of systemic interferon alfa-2a with oral isotretinoin and oral isotretinoin alone in the treatment of recurrent condylomata accuminata

OBJECTIVES

We attempted to test the hypothesis that the combination of systemic interferon alfa-2a and oral isotretinoin is more effective than isotretinoin alone in the treatment of recurrent condylomata accuminata.

STUDY DESIGN

Fifty seven women with recurrent condylomata accuminata were randomly assigned in two groups. Group A (n = 24) received isotretinoin alone (Roaccutan, Roche) 1 mg/kgr orally daily for 3 months or until a remission was achieved; Group B (n = 33) received Interferon alfa-2a (Roferon-A, Roche) 3 million units subcutaneously three times for 8 weeks plus isotretinoin 1 mg/Kg orally for 3 months or until a remission was achieved.

RESULTS

There was no statistically significance in remission rates between the two groups (18/24 vs 28/33, p > 0.1). However the duration of treatment was statistically significantly shorter in Group B (1.9 vs 2.5 months, p < 0.01). Side effects were minimal.

Hypervitaminosis A as a complication of treatment for neuroblastoma

A case of hypervitaminosis A (HVA) as a complication of therapy for stage-IV neuroblastoma is presented. The patient was randomized to a trial of 13-cis -retinoic acid (a vitamin A-related compound) after completing routine chemotherapy. This acid was given as a means of maturing potential minimal residual disease. A routine follow-up bone scan revealed areas of increased activity, initially along the midshaft of the right ulna and subsequently bilaterally, which were ultimately found to be due to HVA. Hypervitaminosis A has not been previously reported in this setting, and awareness of the condition is important in centers where this treatment is contemplated.

Comparative study of systemic interferon alfa-2a plus isotretinoin versus isotretinoin in the treatment of recurrent condyloma acuminatum in men

OBJECTIVES

Purpose of the present study was to evaluate the effectiveness of isotretinoin versus interferon alfa-2a plus isotretinoin in the treatment of recurrent condyloma acuminatum in 86 men.

METHODS

Men were randomly assigned to group A (n = 42) who received isotretinoin 1 mg/kg orally daily until remission was achieved, but not more than 3 months, or to group B (n = 44) who received interferon alfa-2a 3 x 10(5) IU subcutaneously three times weekly until remission was achieved, but not more than 8 weeks, plus isotretinoin in the same dosage as in group A.

RESULTS

The reduced duration of treatment to achieve remission was statistically significant in group B (2.18 versus 2.5 months; P < 0.01) and the recurrence rate was less in group B (4 of 44 versus 16 of 42; P < 0.01).

CONCLUSIONS

The results of this study are encouraging and demonstrated that the combination of isotretinoin plus interferon alfa-2a achieves higher remission rates and a shorter duration of treatment than isotretinoin alone.

Rheumatologic complications of vitamin A and retinoids

Retinoids are synthetic derivatives of vitamin A. They are administered primarily for dermatological conditions, such as psoriasis, acne, and disorders of keratinization. Toxicity has proven a significant problem with long-term administration of the retinoids. Bone abnormalities mimicking seronegative spondyloarthropathy or diffuse idiopathic skeletal hyperostosis have been described in many cases, as well as other rheumatologic manifestations such as arthritis, myopathy, and vasculitis. These retinoid-related adverse effects are reviewed.

Extensive extraspinal hyperostoses after long-term oral retinoid treatment in a patient with pityriasis rubra pilaris

We describe a patient with severe pityriasis rubra pilaris in whom extensive extraspinal hyperostoses developed after 13 years of oral retinoid treatment. The most prominent abnormality was a bridging exostosis between the left acetabulum and collum. X-ray examinations of the spine during retinoid therapy showed no abnormalities. During oral retinoid treatment, it is important to ask the patient on a regular basis about any skeletal pains or mobility restriction. Normal spinal x-ray results are no guarantee that a patient is free of hyperostoses. Discontinuation of acitretin therapy resulted in a severe exacerbation of the patient's pityriasis rubra pilaris after 2 weeks. The clinical response to administration of azathioprine was clearly inferior to that of acitretin. However, low-dose oral methotrexate therapy appeared to be a good alternative in this patient, with a clinical result comparable to acitretin and no side effects after 6 months of therapy.

POEMS syndrome with myocardial infarction: observations concerning pathogenesis and review of the literature

A 27-year-old white man with no significant risk factors for coronary artery disease presented with a 9-month history of progressive impotence, gynecomastia, lower extremity paresthesias, and extensive myocardial infarction and subsequently developed ulcerative proctitis. A diagnosis of POEMS syndrome was made based on the clinical presentation; additional physical findings of papilledema, clubbing, and hyperpigmentation; and laboratory findings of an immunoglobulin G M component of the lambda subtype, elevated cerebrospinal fluid protein, and typical sclerotic bone lesions. Abnormal in vitro binding of the patient's serum immunoglobulin to testicular tissue was also seen. Cardiac catheterization showed evidence of diffuse coronary artery narrowing and left ventricular wall motion abnormalities. Diffuse coronary involvement and ulcerative proctitis have not been previously described in POEMS syndrome. It is hypothesized that an abnormal immunoglobin (or fragment) is responsible for both findings. Furthermore, the detection of antitesticular autoantibodies suggests the possibility of an interaction between the antibody and Leydig cells, leading to an alteration in the synthesis and release of sex steroids and thereby explaining the gonadal failure seen in this syndrome. Long-term glucocorticoid therapy for the past 5 years has resulted in marked subjective and objective improvement.

Long-term safety of retinoid therapy

The concern about long-term toxicity of oral synthetic retinoids has developed because many patients, especially those with genodermatoses, require lifelong therapy. Several organ systems are at risk, especially the hepatic, skeletal, and cardiovascular systems. Although acute hepatotoxicity is a rare side effect of etretinate and acitretin therapy, prospective studies have not demonstrated chronic liver toxicity. The frequency of bone changes induced by retinoids is difficult to estimate, because this adverse effect is usually asymptomatic and requires x-ray or scintigraphic examination for detection. Atherosclerosis develops in many patients who receive long-term retinoid therapy, but the extent to which the process is aggravated by drug-induced hyperlipidemia is not known. Many patients have now been treated with either etretinate or isotretinoin continuously for as many as 15 years and have not developed any signs of severe chronic toxicity. However, continued intense surveillance is recommended for patients expected to require lifelong therapy.

Bone changes and their significance in children with ichthyosis on long-term etretinate therapy

Anxiety about the use of etretinate in children has been provoked by several reports describing skeletal abnormalities during long-term therapy. However, we have observed no evidence of skeletal toxicity in 42 children treated over an 11-year period. Radiological screening before and during treatment has failed to reveal abnormalities that would influence our decision to commence or to continue etretinate administration. We recommend that children who are to be treated with etretinate should have a baseline selective skeletal survey, with follow-up radiology restricted to those with pretreatment radiological abnormalities and those who develop musculo-skeletal symptoms. In addition we advise that dosage should not exceed 1 mg/kg/day. If these guidelines are followed, we believe that long-term therapy with etretinate can be given to children, with an acceptable margin of safety.

Monitoring for adverse effects from systemic drugs used in dermatology

Systemic drugs with an associated element of risk are essential in managing many important dermatoses. This review identifies eight major drugs or drug groups used in dermatology that require systematic monitoring for adverse effects. The complete monitoring process is emphasized, including significant patient involvement in reporting key signs or symptoms that allow early diagnosis of many of these adverse effects. The concepts of "risk-risk" assessment and "critical toxicities" are defined, emphasizing their important role in maximizing drug benefits and safety. Drug-related risk factors, disease-specific risk factors, and patient characteristics or habits that increase the risks from systemic drugs are identified. Basic principles of monitoring for adverse effects, specific clinical features of the most important adverse effects, along with detailed monitoring guidelines for methotrexate, retinoids, dapsone, corticosteroids, and cyclosporine are presented.

Acitretin. A review of its pharmacology and therapeutic use

Acitretin (etretin), a second generation monoaromatic retinoid for use in the treatment of severe psoriasis and other dermatoses, is the major active metabolite of etretinate and possesses a similar therapeutic index; i.e. a similar ratio of clinical efficacy to adverse effects. When used alone at a maintenance dosage of 30 to 50mg daily, acitretin is effective in the treatment of psoriasis, causing a reduction in the severity of scaling, erythema and induration. Efficacy appears to be further enhanced by combination with psoralen-ultraviolet A photochemotherapy (PUVA) or ultraviolet B irradiation (UVB). These combinations reduce the time to lesion clearance and reduce the total radiation dose, improving overall safety. Comparative studies have confirmed the equivalence of acitretin and etrtinate with regard to efficacy and toxicity. Adverse reactions are dose-related and generally typical of hypervitaminosis A. Alopecia and mucocutaneous symptoms such as cheilitis and drying of the mucous membranes are particularly prevalent. Hypertriglyceridaemia and elevation of cholesterol levels also occur. Examination of the pharmacokinetic profile of acitretin reveals its main advantage over etretinate. Acitretin is less lipophilic than etretinate, and its lack of sequestration into 'deep' fatty storage sites is reflected in a comparatively short terminal elimination half-life of 50 to 60 hours, compared with 120 days for etretinate. Due to its teratogenic potential, acitretin is strictly contraindicated in women of childbearing potential unless effective contraceptive measures are employed. Etretinate has been identified in plasma samples of some patients treated with acitretin. Thus, acetretin has an established place in the treatment of keratinising disorders, although its use in women of child-bearing potential must be accompanied by effective contraceptive measures, with a further 2-year contraceptive period after therapy completion.

Intracellular actions of vitamin A

Because the effects of vitamin A vary with tissue type and often with the form of vitamin A itself, a complete understanding of the mechanism(s) of action still has not been attained. The action of vitamin A may be at the level of genomic expression, at the membrane level, or both. Intercellular and intracellular transport of vitamin A are facilitated by specific binding proteins but probably not in the cellular uptake of vitamin A. Subcellularly, vitamin A may exert a direct effect on transit through the Golgi apparatus, as observed from both biochemical and morphological studies. In my laboratory, recent work using cell-free systems has shown that retinol stimulates transition vesicle formation from endoplasmic reticulum in a GTP-requiring step.

Increased concentrations of endogenous 13-cis- and all-trans-retinoic acids in diffuse idiopathic skeletal hyperostosis, as demonstrated by HPLC

Endogenous 13-cis- and all-trans-retinoic acids have been quantitated in human serum using a solvent extraction procedure followed by isocratic reversed phase high performance liquid chromatography and UV detection. In healthy adults, after an overnight fasting period, the concentrations of 13-cis- and all-trans-retinoic acids yielded 5.3 +/- 2.43 nmol/l and 11.8 +/- 3.3 nmol/l, respectively (mean +/- SD). The method has been successfully applied to the analysis of both isomers in serum from patients with idiopathic skeletal hyperostosis in whom, the 13-cis- as well as all-trans-retinoic acid levels were raised as compared to the control group.

Gout and vitamin A intoxication: is there a connection?

Several lines of indirect evidence implicate vitamin A intoxication, associated mainly with impaired renal function, in the etiopathogenesis of gouty arthritis. The enzyme xanthine oxidase is involved not only in the conversion of xanthine to uric acid but also in that of retinol to its more toxic metabolite, retinoic acid. Retinoic acid should therefore be present in high concentration in hyperuricemic states.

Rheumatological symptoms due to retinoids

Isotretinoin and etretinate are synthetic derivatives of vitamin A widely used in the treatment of dermatological diseases, mainly those affecting keratinization. They have numerous side-effects, among which the rheumatic symptoms are not the most common or the most severe. The main skeletal adverse reaction of retinoids is hyperostosis. It mainly occurs with protracted treatments and high dosages, and its incidence may exceed 80% after a few years of administration. Hyperostosis is axial, located in the cervical and thoracic spine, and may be responsible for limitation of movement; in the appendicular bone, enthesopathies occur at the foot, pelvis, hip, and less commonly the shoulder and elbow. They are usually mild and asymptomatic. The radiological appearance is very similar to diffuse idiopathic skeletal hyperostosis. Isotretinoin tends to be responsible for axial involvement, etretinate for peripheral locations. The other skeletal side-effects are uncommon and include periosteal proliferation, calcification of the interosseous membrane of the forearm and diffuse radiological bone hyperlucency. In children, premature epiphyseal closure is very rare. About 20% of patients complain of musculoskeletal pain and arthralgias. A few cases of true arthritis have been reported. Retinoids may be responsible for muscular damage and an abnormality of muscular tone resembling the stiff-man syndrome. Some cases of necrotizing vasculitis and three cases of Wegener's granulomatosis have been observed in patients treated with retinoids. Except for these latter arguable cases, rheumatoid syndromes due to retinoids are rather benign, and should not be an obstacle to the future development of their therapeutic utilization.

Musculoskeletal syndromes associated with acne

The acne conglobata (AC)-, acne fulminans (AF)-, and isotretinoin-associated musculoskeletal syndromes are three distinct clinical entities. The AC-associated musculoskeletal syndrome occurs primarily in black men over the age of 22, who develop sacroilitis with or without a peripheral arthropathy. In contrast, the AF-associated musculoskeletal syndrome is found almost exclusively in white male teenagers. Fever, weight loss, and arthralgias are prominent components of this syndrome. A unique feature of the AF-associated musculoskeletal syndrome is osteolytic lesions that occur most frequently in the clavicle, sternum, long bones, and ilium. The isotretinoin-associated musculoskeletal syndrome occurs with equal frequency in male and female acne patients. Mild, transient myalgias and arthralgias are very common and do not require discontinuation of isotretinoin therapy. Asymptomatic, small, hyperostotic lesions of the spine occur in approximately 10% of acne patients with the isotretinoin-associated musculoskeletal syndrome.

Retinol, supplemental vitamin A and bone status

Studies of hypervitaminosis A in animals and anecdotal reports of accidental vitamin A poisoning in humans suggest impairment of bone remodeling and increased numbers of fractures. Because of the widespread use of high-dose vitamin A supplements which may produce subclinical hypervitaminosis associated with decreased bone mass and increased risk of fracture, we studied the relationship between current vitamin A supplement use, serum retinol levels, radial bone mass and fracture history in a geographically-defined population of 246 postmenopausal women, 55-80 years of age. More than 36% of this population used a vitamin A supplement with 8% of these consuming an amount in excess of 2000 retinol equivalents (RE)/day. Serum retinol was measured using high-pressure liquid chromatography and radial bone mass was measured using single photon absorptiometry. After controlling for age, current estrogen replacement, and current thiazide antihypertensive use, we observed no statistically significant relationship between vitamin A supplement use or serum retinol with radial bone mass or fractures.

Comparative assessment of the toxicology of vitamin A and retinoids in man

As the title implies, any assessment of the toxic effects of vitamin A derivatives must distinguish between vitamin A in the truest sense, i.e. retinol, and retinoic acid and its synthetic derivatives. Just as no single description is universally applicable to the mode of action of vitamin A derivatives, so too do their toxic effects defy generalization. The recommendation made in 1982 by IUPAC [Eur. J. Biochem., 129 (1989) 1] to designate all derivatives with the typical structure of the vitamin as being retinoids may be chemically logical and correct but, when it comes to describing the effects and side-effects of vitamin A derivatives, it leads to misunderstandings. Retinol, which is frequently used as synonym for vitamin A, can eliminate all symptoms of vitamin A deficiency if it is taken in sufficient quantity with the diet. The term retinol will therefore be used here as a synonym for vitamin A whereas retinoic acid and its derivatives--including the synthetic ones--will be referred to as retinoids because they do not cover the whole spectrum of effects exerted by retinol and because they also vary markedly in their side-effects. In contrast to the nomenclature proposed by IUPAC, this system provides a clear and logical distinction for describing biological processes. Other authors have favoured it in recent times [Chytil, F., J. Am. Acad. Dermatol., 15 (1986) 741; Olson, J.A., Semin. Oncol., x (3) (1983) 290; Olson, J.A., Am. J. Clin. Nutr., 45 (1987) 704; Zbinden, G., Acta Dermatovener., 74 (1975) 36]. By vitamin A, therefore, is meant all derivatives that can possibly originate from retinol in the organism. This also covers the small quantities of retinoic acid formed from retinol. On the other hand, by retinoids is meant the natural retinoic acid derivatives and their synthetic forms in their special modes of action. Since retinoic acid cannot be reduced to retinol in the organism, this nomenclature provides a clear demarcation within the biological system. Vitamin A is essential to the growth and development of higher life forms and functions in many different ways within the organism. Although vitamin A was one of the first vitamins to be described, even today there is still some uncertainty as to its mode of action, with the exception of that of retinal (vitamin A aldehyde) in vision.(ABSTRACT TRUNCATED AT 400 WORDS)