Isotretinoin and neuropsychiatric side effects: Continued vigilance is needed

Background

Isotretinoin (13-cis-retinoic acid, marketed under the names Accutane, Roaccutane, and others) is an effective treatment for acne that has been on the market for over 30 years, although reports of neuropsychiatric side effects continue to be reported. Isotretinoin is an isomer of the active form of Vitamin A, 13-trans-retinoic acid, which has known psychiatric side effects when given in excessive doses, and is part of the family of compounds called retinoids, which have multiple functions in the central nervous system.

Methods

The literature was reviewed in pubmed and psychinfo for research related to isotretinoin and neuropsychiatric side effects including depression, suicidal thoughts, suicide, mania, anxiety, impulsivity, emotional lability, violence, aggression, and psychosis.

Results

Multiple case series have shown that successful treatment of acne with isotretinoin results in improvements in measures of quality of life and self esteem However, studies show individual cases of clinically significant depression and other neuropsychiatric events that, although not common, are persistent in the literature. Since the original cases of depression were reported to the United States Food and Drug Administration, numerous cases have been reported to regulatory agencies in the United Kingdom, France, Ireland, Denmark, Australia, Canada, and other countries, making isotretinoin one of the top five medications in the world associated with depression and other neuropsychiatric side effects. Clinicians are advised to warn patients of the risks of neuropsychiatric side effects with isotretinoin which may arise from the medication itself, and not just as a side effect of acne or youth.

A Prospective Study Examining Trigger Factors and Hormonal Abnormalities in Adult Female Acne

Background:

Numerous triggers have been implicated in adult female acne including endogenous (hormonal dysfunction and genetic predisposition) and exogenous causes (drugs, cosmetics, sunscreens, stress, and smoking).

Aims:

To evaluate the role of various trigger factors in adult female acne and to analyze the androgenic hormone pattern including anti-Mullerian hormone (AMH) in these patients.

Materials and Methods:

Patients having acne of age ≥25 years were analyzed using a pre devised proforma to elicit trigger factors while the severity was graded using the Global Acne Grading System (GAGS). A detailed hormonal assessment was undertaken that assessed total testosterone (TT), sex hormone-binding globulin (SHBG), free androgen index (FAI), AMH, 17-hydroxyprogesterone (17-OHP), dehydroepiandrosterone sulfate (DHEAS), follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyroid-stimulating hormone (TSH), and prolactin.

Results:

Out of the 165 cases seen and sub-analyzed for triggers, premenstrual flare, diet, cosmetics, and stress were the most commonly implicated causes. Among cosmetics, fairness creams and foundations were implicated. The hormonal analysis revealed deranged values of all hormones with the most common being 17-OHP and AMH. Almost 42.8% patients with DHEAS derangement and 58.75% females with raised 17-OHP suffered from moderate to severe stress.

Limitations:

A prospective cohort correlation study of the implicated triggers is needed to confirm the association with adult female acne.

Conclusions:

Adult female acne may be triggered by diet, stress, and cosmetics and there is a distinct hormonal milieu that accounts for hyperandrogenemia. We noted high levels of adrenal androgens which have been known to be associated with stress and sleep deprivation. Our study shows the value of counseling adult female acne patients about various acne triggers.

Is there an association between isotretinoin therapy and adverse mood changes? A prospective study in a cohort of acne patients

Background: Treatment with isotretinoin has been associated with adverse mood changes. However, even though a number of studies support this association, others refute it, and a concrete causal link has yet to be proven. Acne itself is associated with depressive symptoms, thus making studies on the topic difficult to design and interpret. Objectives and methods: Using validated tools, we performed a prospective study in order to assess the effects of treatment with isotretinoin on the mood of patients with acne vulgaris. Results: Fifty-six patients were included with a mean age of 21 years. At baseline, questionnaire scores for all measured parameters were indicative of lower mood than published norms. During and after treatment, values of either stable or improving mood were displayed across all questionnaires. Three patients developed significantly deteriorating moods, two of whom also experienced severe physical adverse effects. Conclusion: The relationship between isotretinoin and depression is the most debated aspect of isotretinoin therapy. Our results link isotretinoin to an overall improvement in psychological wellbeing, even in patients suffering with stable mental illness. However, we also found that a small minority of patients are susceptible to severe mood deterioration, particularly in conjunction with severe physical side effects.

Isotretinoin was not associated with depression or anxiety: A twelve-week study

AIM: To investigate the frequency and severity of depression and/or anxiety in isotretinoin (ITT)-treated subjects and in a non-ITT control group.

METHODS: Sixty consecutively-admitted non-psychiatric outpatients with acne were assigned to either ITT at a fixed dose of 30 mg/d (n = 36) or “other treatment” group (OT; n = 24). The Zung depression or anxiety scales (with cut-off points), two locally developed scales for depression (GeDepr) and anxiety (Ansilet) (without cut-off points) and clinical global impression scales of acne severity were administered at baseline and at weeks 6 and 12 of treatment. Data was analyzed with the chi-squared test and covariance analysis.

RESULTS: Gender distribution, age, marital status and education level did not differ between both treatment groups. The frequency of depression, as defined by the Zung scale cut-off points was similar in the ITT and in the non-ITT groups: Weeks 6 and 12: 8.3% in both groups, P = 0.9. The frequency of anxiety was similar in the groups as well: Week 6: ITT = 8.3%; OT = 0.0%, P > 0.05; week 12: ITT = 11.1%, OT = 4.2%, P > 0.05. The scores in both scales’ sets did not differ between the treatment groups at any evaluation time point (P > 0.05). Five ITT-treated subjects (13.8%) and two from the OT-treated group (8.3%) developed clinically significant anxiety and/or depression during treatment (P > 0.05).

CONCLUSION: Our study confirms the safety of ITT regarding psychological side effects in regular dermatological patients. Susceptible subjects may exist but their identification requires additional strategies.

Acne vulgaris

Acne vulgaris is a chronic inflammatory disease - rather than a natural part of the life cycle as colloquially viewed - of the pilosebaceous unit (comprising the hair follicle, hair shaft and sebaceous gland) and is among the most common dermatological conditions worldwide. Some of the key mechanisms involved in the development of acne include disturbed sebaceous gland activity associated with hyperseborrhoea (that is, increased sebum production) and alterations in sebum fatty acid composition, dysregulation of the hormone microenvironment, interaction with neuropeptides, follicular hyperkeratinization, induction of inflammation and dysfunction of the innate and adaptive immunity. Grading of acne involves lesion counting and photographic methods. However, there is a lack of consensus on the exact grading criteria, which hampers the conduction and comparison of randomized controlled clinical trials evaluating treatments. Prevention of acne relies on the successful management of modifiable risk factors, such as underlying systemic diseases and lifestyle factors. Several treatments are available, but guidelines suffer from a lack of data to make evidence-based recommendations. In addition, the complex combination treatment regimens required to target different aspects of acne pathophysiology lead to poor adherence, which undermines treatment success. Acne commonly causes scarring and reduces the quality of life of patients. New treatment options with a shift towards targeting the early processes involved in acne development instead of suppressing the effects of end products will enhance our ability to improve the outcomes for patients with acne.

The impact of acne vulgaris on quality of life and psychic health in young adolescents in Greece. Results of a population survey

BACKGROUND

Acne vulgaris can severely affect social and psychological functioning.

OBJECTIVE

The aim of this study was to investigate the impact of acne vulgaris and its severity on Quality of Life of young adolescents in Greece.

METHODS

We conducted a questionnaire based survey among 1560 adolescent between the ages of 11 and 19 years old and 1531 of these were completed. Adolescents with acne filled all the questions including the Children Dermatology Life Quality Index. Adolescents without acne filled the questions about age, family history of acne, stress and smoking. Data were analyzed with Pearson Chi Square test.

RESULTS

Acne prevalence was 51.2% affecting both sexes equally. Self reported mild acne was present in 71.2% and moderate-severe acne in 28.8% of the study population. The mean age of the study population was 15.77y. The median score of Children Dermatology Life Quality Index was 4.02. The impact of acne on quality of life is associated with the severity of the acne (p<0.0001). Patients with moderate/severe acne experience greater psychosocial and emotional impairment (p<0.0001). Body image is modified proportionally to the severity of acne (p<0.0001). Symptoms and treatment of acne are factors that also influence their quality of life. Girls and boys are equally affected. Stress and heredity are correlated with acne and its severity (p<0.0001). We didn't find any correlation between smoking and acne.

CONCLUSION

Acne affects Quality of Life of young adolescents in Greece. The impact is proportional to the severity of acne. More severe acne is associated with greater effect on quality of life with implications for self esteem, body image and relationships with others.

Psychodermatological disorders: recognition and treatment

Many dermatological disorders have a psychosomatic or behavioral aspect. Skin and brain continually interact through psychoneuroimmunoendocrine mechanisms and through behaviors that can strongly affect the initiation or flaring of skin disorders. It is important to consider these mind-body interactions when planning treatments for specific skin disorders in individual patients. Mind-influencing therapeutic options that can enhance treatment of skin disorders include standard psychotropic drugs, alternative herbs and supplements, the placebo effect, suggestion, cognitive-behavioral methods, biofeedback, and hypnosis. When individual measures do not produce the desired results, combinations of drugs or addition of non-drug therapies may be more successful. Psychophysiological skin disorders may respond well to non-drug and drug therapies that counteract stress. Treatment of primary psychiatric disorders often results in improvement of associated skin disorders. Psychiatric disorders secondary to skin disorders may also require treatment. Therapeutic options for each of these are discussed.

Acne's relationship with psychiatric and psychological morbidity: results of a school-based cohort study of adolescents

BACKGROUND

There is a considerable number of studies linking acne with psychological and psychiatric morbidities, although this literature is not entirely consistent and is largely cross-sectional in methodology.

OBJECTIVE

This study aims to establish the relationship of acne and psychological and psychiatric morbidity in adolescents in a community setting and, via a longitudinal methodology, provide evidence for causality in the relationship.

METHODS

The study was a 12-month cohort study. Two hundred and forty-four students in Years 8, 9 and 11 (ages 14-17) at four Australian high schools were assessed at baseline 6 months and 12 months. Presence and severity of acne were assessed, along with a number of psychological and psychiatric morbidities and personality traits (depression, anxiety, overall psychiatric morbidity, self-consciousness, neuroticism and introversion/extraversion) and other demographic variables.

RESULTS

Of the 244 participating students, 209 (86%) completed all three rounds of data collection. A further 26 (11%) completed two rounds. The study failed to demonstrate an association of the presence of acne or of acne severity with the examined measures of psychological and psychiatric morbidity, and no evidence for an effect of acne in their causation.

CONCLUSION

The relationship of acne and psychological morbidities found in previous health care settings was not found in this community sample. This may be due to differences between community and clinical acne populations. Other possible reasons for this finding are attenuation of psychological morbidity in subjects in this study by successful acne treatment, and the role of personality traits in the complex relationship between acne and psychological morbidities. It is suggested that this relationship would be best investigated by means of longer-term cohort studies enlisting subjects at an early age, prior to the onset of acne.

Isotretinoin and psychopathology: a review

Isotretinoin, a synthetic oral retinoid that is used against severe nodulocystic acne, has been associated with various psychiatric side effects such as depression, suicidality and psychotic symptoms. A great number of reports on its effects have been published since its introduction into the market. However, a causal relationship has not been established and the link between isotretinoin use and psychiatric events remains controversial. The present paper reviews the available evidence regarding the association of isotretinoin and psychiatric side effects. All published material reporting psychiatric side effects following isotretinoin treatment, including case reports, case series, reports from adverse drug event reporting systems, prospective surveys and retrospective case-control studies, are presented. In addition, the neurobiology of the retinoids and possible biological mechanisms that may lead to psychopathology are described.

Depression and Skin Disease

The occurrence of depression in association with dermatologic disease is common. Psychiatric disturbance is reported in approximately 30% of dermatology patients. Depression can have varied presentations and is more relevant clinically in dermatology patients during critical psychosocial periods of development. Early recognition and treatment of depression associated with skin disorders can lead to improved therapeutic outcomes and may avert disastrous outcomes, including suicide.

Catecholamines increase in the urine of non-segmental vitiligo especially during its active phase

Neural factors appear to play a major role in the pathogenesis of vitiligo. To investigate the possible correlation between vitiligo and peripheral monoaminergic system activity, we used high-pressure liquid chromatography and electrochemical detector methods to evaluate the basal urine excretion values of catecholamines [norepinephrine (NE), epinephrine and dopamine (DA)], their relative metabolites [3-methoxy-4-hydroxyphenylglycol (MHPG), normetanephrine (NMN), metanephrine (MN), vanilmandelic acid (VMA) and homovanillic acid], as well as 5-hydroxyindoleacetic acid (5-HIAA), in 35 healthy subjects and in 70 patients, suffering from non-segmental vitiligo at different stages of the disease. Levels of NE, DA, NMN, MN, MHPG, VMA and 5-HIAA were found to be significantly higher in patients than in controls. The patients with progressive vitiligo (n = 56) presented increased urinary excretion values for all parameters (in particular, NE levels) than other patients. Interestingly, in patients at its more recent vitiligo onset (<1 yr), NE values were different to those of subjects affected from 1 to 5 yr and from 6 to 10 yr. This result was confirmed by the significant negative relationship detected between NE excretion values and disease duration. In both vitiligo and control groups, significant correlations were found between monoamines as well as between these monoamines and their metabolites. The increase in catecholamine turnover, mainly occurring at the onset of the disease, is probably due to the stress associated with the appearance of lesions. Moreover, considering that these compounds readily produce toxic free-radicals and that vitiliginous subjects have a defective free radical defence mechanism, they may also contribute to the disappearance of melanocytes in the early phases of vitiligo.

Nonablative radiofrequency for active acne vulgaris: the use of deep dermal heat in the treatment of moderate to severe active acne vulgaris (thermotherapy): a report of 22 patients

BACKGROUND

Acne vulgaris is an exceedingly common condition in adolescence and may extend into adult life in some individuals. Even though this condition is at times minimized, it has been found to have a profound impact in the quality of life of many affected individuals. Acne scarring can be even more of a source of psychological and social problems than active acne is, and when inadequately treated, the latter can lead to the former. Moderate and severe acne vulgaris usually require a regimen of systemic and/or topical medications, which are given for several months or even years and frequently require multiple visits to the physician office, the laboratory, etc. This results in loss of time at school and considerable expense. Side effects from medications and the frequent need to use alternative drugs when there is no response to medical treatment are possible.

OBJECTIVE

To evaluate the role of a novel medical device that uses radiofrequency as a source of energy to produce volumetric tissue heating, while sparing the epidermis, allowing for a procedure with no down time and no postoperative care required.

METHODS

Twenty-two patients, 10 women and 12 men, ranging in age from 16 to 28, with moderate to severe, scarring, cystic, active, acne vulgaris participated. Only nine of these patients were on concomitant medical treatment such as oral antibiotics or topical agents. All 22 patients were treated with a new nonablative radiofrequency unit, which delivers a concomitant spray of cryogen for epidermal sparing. One session was done in 20 patients and two sessions in 2 patients. The average fluence per energy delivery was 72 J/cm2. Follow-up ranged from 1 to 8 months. Patient questionnaires and active acne lesion counts were used to evaluate the response to treatment.

RESULTS

Excellent response was seen in 82% (n=18). Modest response was seen in 9% (n=2), and no response was seen in 9% (n=2); t-test on active lesion counts before treatment and after treatment was less than 0.009004. No side effects were identified on any of these patients. No down time from the procedure was seen. Only topical anesthesia, ELA-Max 5% (Ferndale Labs, Ferndale, MI) was used; 59% of patients were on no acne medication before, during, or after the procedure.

CONCLUSIONS

Nonablative radiofrequency appears to be a new safe and effective treatment alternative for moderate to severe acne vulgaris. Further research is in progress to evaluate this treatment modality in a larger number of patients.