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Reynolds RV, Yeung H, Cheng CE, Cook-Bolden F, Desai SR, Druby KM, Freeman EE, Keri JE, Stein Gold LF, Tan JKL, Tollefson MM, Weiss JS, Wu PA, Zaenglein AL, Han JM, Barbieri JS. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol 2024; 90:1006.e1-1006.e30. [PMID: 38300170 DOI: 10.1016/j.jaad.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 12/05/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Acne vulgaris commonly affects adults, adolescents, and preadolescents aged 9 years or older. OBJECTIVE The objective of this study was to provide evidence-based recommendations for the management of acne. METHODS A work group conducted a systematic review and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of evidence and formulating and grading recommendations. RESULTS This guideline presents 18 evidence-based recommendations and 5 good practice statements. Strong recommendations are made for benzoyl peroxide, topical retinoids, topical antibiotics, and oral doxycycline. Oral isotretinoin is strongly recommended for acne that is severe, causing psychosocial burden or scarring, or failing standard oral or topical therapy. Conditional recommendations are made for topical clascoterone, salicylic acid, and azelaic acid, as well as for oral minocycline, sarecycline, combined oral contraceptive pills, and spironolactone. Combining topical therapies with multiple mechanisms of action, limiting systemic antibiotic use, combining systemic antibiotics with topical therapies, and adding intralesional corticosteroid injections for larger acne lesions are recommended as good practice statements. LIMITATIONS Analysis is based on the best available evidence at the time of the systematic review. CONCLUSIONS These guidelines provide evidence-based recommendations for the management of acne vulgaris.
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Affiliation(s)
- Rachel V Reynolds
- Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Howa Yeung
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Carol E Cheng
- Division of Dermatology, Department of Medicine, University of California Los Angeles, Los Angeles, California
| | - Fran Cook-Bolden
- Department of Dermatology, Weill Cornell Medicine, New York, New York
| | - Seemal R Desai
- Innovative Dermatology, Plano, Texas; Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kelly M Druby
- Penn State Health Hampden Medical Center, Enola, Pennsylvania
| | - Esther E Freeman
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonette E Keri
- University of Miami, Miller School of Medicine, Miami, Florida; Miami VA Medical Center, Miami, Florida
| | | | - Jerry K L Tan
- Western University, London, Ontario, Canada; Windsor Clinical Research Inc., Windsor, Ontario, Canada
| | - Megha M Tollefson
- Departments of Dermatology and Pediatrics, Mayo Clinic, Rochester, Minnesota
| | - Jonathan S Weiss
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia; Georgia Dermatology Partners, Snellville, Georgia
| | - Peggy A Wu
- Department of Dermatology, University of California Davis, Sacramento, California
| | - Andrea L Zaenglein
- Departments of Dermatology and Pediatrics, Penn State/Hershey Medical Center, Hershey, Pennsylvania
| | - Jung Min Han
- American Academy of Dermatology, Rosemont, Illinois.
| | - John S Barbieri
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts
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Abukhalil AD, Yousef M, Ammar M, Jaghama W, Al-Shami N, Naseef HA, Rabba AK. Practices, Efficacy, and Reported Side Effects Associated with Isotretinoin Treatment in Palestine. Patient Prefer Adherence 2024; 18:487-501. [PMID: 38414983 PMCID: PMC10898599 DOI: 10.2147/ppa.s442436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 02/13/2024] [Indexed: 02/29/2024] Open
Abstract
Background Isotretinoin is a commonly prescribed medication for the treatment of acne. It is associated with serious side effects that require monitoring and adherence by patients and healthcare providers. No studies have been conducted in Palestine to explore isotretinoin prescribing and utilization. Objective This study aims to evaluate the current clinical practices, adherence to clinical guidelines, efficacy, and reported side effects associated with Isotretinoin treatment in Palestine. Methods A descriptive cross-sectional online questionnaire-based study using social media platforms (eg, Facebook and Telegram) was conducted among Birzeit University students in April 2023. This study included participants aged ≥ 18 years with a history of isotretinoin treatment; subjects with incomplete data were excluded. Statistical significance was set at P < 0.05. SPSS version 27 was used for data analysis. Results A total of 548 participants were included in the study, the majority of most of whom were female (96%). The most predominant side effects were cracked, dry lips and xeroderma (96.2%). Moreover, 12% of participants had depression. Most respondents were educated about medication side effects and only 39.1% were counseled about blood donation. Of the 59 sexually active women, only 4 (6.8%) were asked for a recent pregnancy test. A total of 60.2% of dermatologists adhered to the American Academy of Dermatology (AAD) guidelines, and 48.7% ordered the required laboratory tests before initiating isotretinoin treatment. Only 1.7% of pharmacists followed the FDA-suggested protocols for dispensing isotretinoin to childbearing females. Conclusion Adherence to isotretinoin safety prescribing protocols to provide patient education, monitoring, and ordering of laboratories to ensure patient safety can be improved by adapting policies and protocols in pharmacy and medical practice in Palestine to monitor and enforce adherence when prescribing, dispensing, or taking high-risk medications.
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Affiliation(s)
- Abdallah Damin Abukhalil
- Department of Pharmacy, Faculty of Pharmacy, Nursing, and Health Professions, Birzeit University, West Bank, State of Palestine
| | - Mai Yousef
- Department of Pharmacy, Faculty of Pharmacy, Nursing, and Health Professions, Birzeit University, West Bank, State of Palestine
| | - Marwa Ammar
- Department of Pharmacy, Faculty of Pharmacy, Nursing, and Health Professions, Birzeit University, West Bank, State of Palestine
| | - Weam Jaghama
- Department of Pharmacy, Faculty of Pharmacy, Nursing, and Health Professions, Birzeit University, West Bank, State of Palestine
| | - Ni’meh Al-Shami
- Department of Pharmacy, Faculty of Pharmacy, Nursing, and Health Professions, Birzeit University, West Bank, State of Palestine
| | - Hani A Naseef
- Department of Pharmacy, Faculty of Pharmacy, Nursing, and Health Professions, Birzeit University, West Bank, State of Palestine
| | - Abdullah K Rabba
- Department of Pharmacy, Faculty of Pharmacy, Nursing, and Health Professions, Birzeit University, West Bank, State of Palestine
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Gold S, Siira M, Willner S, Alcid C, Chen SC, Tangpricha V, Goodman M, Escoffery C, Owen-Smith A, Yeung H. Lived Experience of Acne and Acne Treatment in Transgender Patients. JAMA Dermatol 2024; 160:164-171. [PMID: 38170514 PMCID: PMC10765311 DOI: 10.1001/jamadermatol.2023.5355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/02/2023] [Indexed: 01/05/2024]
Abstract
Importance While acne is common in transgender and gender-diverse people and is associated with gender-affirming hormone therapy, little research has examined these factors and their impact in gender minority groups. Objective To examine the lived experiences of acne and acne treatment in transgender and gender-diverse participants. Design, Setting, and Participants This mixed-methods analysis was conducted at a multidisciplinary gender center at a public safety-net hospital and endocrinology and dermatology clinics at a tertiary academic center from January 4, 2021, to April 7, 2022, using semistructured interviews and surveys. Participants were transgender or gender-diverse adults who had received gender-affirming hormone therapy. Data analysis was performed from November 11, 2021, to March 31, 2023. Exposure Current diagnosis of acne. Main Outcomes and Measures Interviews exploring the experience of acne and acne treatment were audio recorded, transcribed verbatim, coded using minority stress theory and the socioecological model, and analyzed using thematic analysis. Themes were triangulated with survey data on gender, self-reported acne severity, skin-specific quality-of-life impact, and treatment experience. Results A total of 32 participants were included in the study (mean [range] age, 32 [18-57] years; 17 transgender men, 11 transgender women, and 4 nonbinary participants). Ten participants (31%) self-rated their skin as currently clear or almost clear, 11 (34%) reported mild acne, and 11 (34%) had moderate to severe acne. Participants described experiences of rejection and bullying related to acne and admitted avoiding social interactions in which they anticipated acne-related discrimination, which led to feelings of depression and anxiety. Acne worsened body appearance dissatisfaction. Transgender women reported acne interfering with feminine gender expression. Transgender men often normalized acne development, sometimes viewing acne positively as an early sign of testosterone action. Most participants tried over-the-counter acne treatments and commonly sought acne treatment advice from physicians, peers, online forums, and social media. Barriers to acne treatments included cost, lack of multidisciplinary care, mistrust toward the health care system, and lack of transgender-specific acne care education. Conclusions and Relevance In this mixed-methods study, transgender and gender-diverse individuals reported experiencing acne-related stigma and facing barriers to acne treatment. Multilevel changes, such as developing strategies to reduce acne stigma, providing transgender-specific acne care education, facilitating multidisciplinary acne care, and expanding transgender-friendly clinical environments, are recommended to reduce the impact of acne in transgender individuals.
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Affiliation(s)
- Sarah Gold
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Meron Siira
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Sigal Willner
- Department of Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Crescent Alcid
- Department of Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Suephy C. Chen
- Department of Dermatology, Duke University School of Medicine and Durham VA Medical Center, Durham, North Carolina
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Michael Goodman
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Cam Escoffery
- Department of Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Ashli Owen-Smith
- Department of Health Policy and Behavioral Sciences, Georgia State University School of Public Health, Atlanta
| | - Howa Yeung
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
- Clinical Resource Hub, Veterans Administration Veterans Integrated Service Network 7 Southeast Network, Decatur, Georgia
- Associate Editor, JAMA Dermatology
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Tan NKW, Tang A, MacAlevey NCYL, Tan BKJ, Oon HH. Risk of Suicide and Psychiatric Disorders Among Isotretinoin Users: A Meta-Analysis. JAMA Dermatol 2024; 160:54-62. [PMID: 38019562 PMCID: PMC10687715 DOI: 10.1001/jamadermatol.2023.4579] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 09/20/2023] [Indexed: 11/30/2023]
Abstract
Importance Isotretinoin is hypothesized to contribute to the development of psychiatric disorders, but the epidemiological association and risk factors associated with psychiatric disorders among isotretinoin users remain unclear. Objective To clarify the absolute and relative risk and risk factors associated with suicide and psychiatric disorders among isotretinoin users. Data Sources PubMed, Embase, Web of Science, and Scopus were searched from inception until January 24, 2023. Study Selection Randomized trials and observational studies were selected if they reported the absolute risk, relative risk, and risk factors for suicide and psychiatric disorders among isotretinoin users. Data Extraction and Synthesis Relevant data were extracted and risk of bias was evaluated at the study level using the Newcastle-Ottawa Scale. Data were pooled using inverse variance-weighted meta-analyses. Heterogeneity was measured using the I2 statistic, and meta-regression analyses were performed. Main Outcomes and Measures Absolute risk (percentage), relative risks (risk ratios [RR]), and risk factors (RR) of suicide and psychiatric disorders among isotretinoin users. Results A total of 25 studies including 1 625 891 participants were included in the review and 24 in the meta-analysis. Among the included studies, participants' average age ranged from 16 to 38 years, and distribution by sex ranged from 0% to 100% male. The 1-year pooled absolute risk from between 2 and 8 studies of completed suicide, suicide attempt, suicide ideation, and self-harm were each less than 0.5%, while that of depression was 3.83% (95% CI, 2.45-5.93; I2 = 77%) in 11 studies. Isotretinoin users were less likely than nonusers to attempt suicide at 2 years (RR, 0.92; 95% CI, 0.84-1.00; I2 = 0%), 3 years (RR, 0.86; 95% CI, 0.77-0.95; I2 = 0%), and 4 years (RR, 0.85; 95% CI, 0.72-1.00; I2 = 23%) following treatment. Isotretinoin was not associated with the risk of all psychiatric disorders (RR, 1.08; 95% CI, 0.99-1.19; I2 = 0%). Study-level meta-regression found that studies with participants of older age reported lower 1-year absolute risk of depression, while those with a higher percentage of male participants reported a higher 1-year absolute risk of completed suicide. Conclusions and Relevance The findings suggest that at a population level, isotretinoin users do not have increased risk of suicide or psychiatric conditions but may instead have a lower risk of suicide attempts at 2 to 4 years following treatment. While these findings are reassuring, clinicians should continue to practice holistic psychodermatologic care and monitor patients for signs of mental distress during isotretinoin treatment.
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Affiliation(s)
- Nicole Kye Wen Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Adelina Tang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | - Hazel H. Oon
- National Skin Centre and Skin Research Institute, Singapore
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Lee SM, Baek JC. Serum Vitamin Levels, Cardiovascular Disease Risk Factors, and Their Association with Depression in Korean Women: A Cross-Sectional Study of a Nationally Representative Sample. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2183. [PMID: 38138286 PMCID: PMC10744936 DOI: 10.3390/medicina59122183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 11/23/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: Serum vitamin levels, cardiovascular disease risk factors, and their association with depression is a complex issue that has been the subject of much research. Therefore, we investigated the relationship between vitamin A, B9, and E levels, cardiovascular risk factors, and depression in premenopausal and menopausal South Korean women. Materials and Methods: This cross-sectional study used the 2016-2018 Korea National Health and Nutrition Examination Survey data. Depression was assessed using a questionnaire to check for symptoms of depression or the Patient Health Questionnaire-9. Blood samples were collected from the antecubital vein in the morning after an overnight fast. Covariates were defined as self-reported physician diagnoses. Well-trained medical staff performed the standard procedures. Statistical analysis was performed using the complex sample analysis method of SPSS, using two separate logistic regression models (model 1: adjusted for age; model 2: adjusted for age, marital status, smoking, and alcohol consumption). Results: A total of 3313 women aged over 20 years were enrolled. The association between vitamin A levels and depression was as follows: lower levels of vitamin A were associated with an increased risk of depression in premenopausal women in model 1 and model 2. The levels of serum vitamins E and B9 were not correlated with depression in premenopausal and postmenopausal women. In the premenopausal group, depression increased in the obesity (model 1: p = 0.037; model 2: p = 0.047) and diabetes mellitus (model 1: p = 0.010; model 2: p = 0.009) groups. The menopausal group with depression had higher rates of stroke (model 1: p = 0.017; model 2: p = 0.039) and myocardial infarction (model 1: p = 0.004; model 2: p = 0.008) than the group without depression. Conclusions: Depression is correlated with lower blood levels of vitamin A in premenopausal women. Vitamin B9 and E levels were not associated with depression independent of menopausal status. Depression is associated with obesity and diabetes mellitus in premenopausal women and with stroke and myocardial infarction in postmenopausal women.
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Affiliation(s)
- Seon Mi Lee
- Department of Obstetrics and Gynecology, Korea University Anam Hospital, 73 Goryeodae-ro, Seongbuk-gu, Seoul 02841, Republic of Korea;
| | - Jong Chul Baek
- Department of Obstetrics and Gynecology, Gyeongsang National University Changwon Hospital, 11 Samjeongja-ro, Seongsan-gu, Changwon-si 51472, Republic of Korea
- Department of Obstetrics and Gynecology, Gyeongsang National University School of Medicine, Jinju 52727, Republic of Korea
- Institute of Medical Science, Gyeongsang National University, Jinju 52727, Republic of Korea
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6
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Gupta N, Gupta M. The Controversies Surrounding Acne and Suicide: Essential Knowledge for Clinicians. Cureus 2023; 15:e43867. [PMID: 37736468 PMCID: PMC10511146 DOI: 10.7759/cureus.43867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/23/2023] Open
Abstract
Over the years, there have been numerous studies linking acne to depression and suicidal thoughts. Although the exact relationship between the two is still unclear, the stigma associated with acne can have a significant impact on an individual's mental health. The critical appraisal of empirical evidence reveals a lack of understanding of the relationship between acne and suicide. Several studies have demonstrated an association between acne and suicide without causal links. Thus, it is clinically important to review the risks associated with isotretinoin and obtain informed consent regarding potential harm. The use of isotretinoin should be limited to cases of severe acne. There have been reports of an increased risk of suicide six months after the completion of isotretinoin treatment, so it is recommended that follow-up monitoring continue for up to one year following the completion of the treatment.
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Affiliation(s)
- Nihit Gupta
- Psychiatry, Dayton Children's Hospital, Dayton, USA
| | - Mayank Gupta
- Psychiatry and Behavioral Sciences, Southwood Psychiatric Hospital, Pittsburgh, USA
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Ding RL, Zheng Y, Bu J. Physiological and Psychological Effects of Isotretinoin in the Treatment of Patients with Acne: A Narrative Review. Clin Cosmet Investig Dermatol 2023; 16:1843-1854. [PMID: 37483471 PMCID: PMC10362870 DOI: 10.2147/ccid.s416267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 07/08/2023] [Indexed: 07/25/2023]
Abstract
Isotretinoin (ISO) is a powerful vitamin A derivative that offers the potential for treatment of permanent remission of acne; however, its potential side effects on both physiological and psychological aspects limit its application. This article reviews the side effects of ISO from physiological and psychological aspects in detail, to better screen the suitable population of ISO and improve the efficiency of clinical treatment. Our findings indicate that ISO may cause teratogenicity, skin reactions, ocular reactions, changes in blood indicators, and occasional acne fulminans. To optimize clinical treatment, more attention should be paid to identifying the specific conditions under which these reactions occur, how severe they are, and how they subside to alleviate patient concerns. Regarding the controversial issue of psychological side effects caused by ISO, researchers should shift their focus to the psychological problems that acne itself may cause.
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Affiliation(s)
- Rui-Lian Ding
- Hospital for Skin Disease, Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, Jiangsu, People’s Republic of China
| | - Yu Zheng
- Hospital for Skin Disease, Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, Jiangsu, People’s Republic of China
| | - Jin Bu
- Hospital for Skin Disease, Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, Jiangsu, People’s Republic of China
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8
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Avedillo-Salas A, Pueyo-Val J, Fanlo-Villacampa A, Navarro-Pemán C, Lanuza-Giménez FJ, Ioakeim-Skoufa I, Vicente-Romero J. Prescribed Drugs and Self-Directed Violence: A Descriptive Study in the Spanish Pharmacovigilance Database. Pharmaceuticals (Basel) 2023; 16:ph16050772. [PMID: 37242555 DOI: 10.3390/ph16050772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/12/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
Self-inflicted violence is a major and growing public health problem and its prediction and prevention is challenging for healthcare systems worldwide. Our aim was to identify prescribed drugs associated with self-directed violent behaviors in Spain. A descriptive, longitudinal and retrospective study of spontaneous reports of adverse drug reactions corresponding to self-directed violence was recorded in the Spanish Pharmacovigilance Database (FEDRA®) from 1984 to 31 March 2021. A total of 710 cases were reported in the study period. The mean age was 45.52 years (range 1-94). There were no gender differences except in children, where most reports were of male children. The main therapeutic groups that were involved included drugs for the nervous system (64.5%) and anti-infectives for systemic use (13.2%). The most commonly reported drugs were varenicline, fluoxetine, lorazepam, escitalopram, venlafaxine, veralipride, pregabalin, roflumilast and bupropion. There were reports of montelukast, hydroxychloroquine, isotretinoin, methylphenidate, infliximab, natalizumab, ribavirin and efavirenz, which were less known to be involved in self-directed violence. This study shows that self-directed violence is a rare adverse drug reaction, and can be related to the use of some medicines. It is important for healthcare professionals to consider this risk in their clinical praxis, implementing person-centred approaches. Further studies are needed, considering comorbidities and potential interactions.
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Affiliation(s)
- Ana Avedillo-Salas
- Department of Pharmacology, Physiology and Legal and Forensic Medicine, Faculty of Medicine, University of Zaragoza, ES-50009 Zaragoza, Spain
| | - Javier Pueyo-Val
- Department of Pharmacology, Physiology and Legal and Forensic Medicine, Faculty of Medicine, University of Zaragoza, ES-50009 Zaragoza, Spain
| | - Ana Fanlo-Villacampa
- Department of Pharmacology, Physiology and Legal and Forensic Medicine, Faculty of Medicine, University of Zaragoza, ES-50009 Zaragoza, Spain
| | - Cristina Navarro-Pemán
- Department of Pharmacology, Physiology and Legal and Forensic Medicine, Faculty of Medicine, University of Zaragoza, ES-50009 Zaragoza, Spain
- Aragon Pharmacovigilance Center, ES-50017 Zaragoza, Spain
| | - Francisco Javier Lanuza-Giménez
- Department of Pharmacology, Physiology and Legal and Forensic Medicine, Faculty of Medicine, University of Zaragoza, ES-50009 Zaragoza, Spain
| | - Ignatios Ioakeim-Skoufa
- Department of Pharmacology, Physiology and Legal and Forensic Medicine, Faculty of Medicine, University of Zaragoza, ES-50009 Zaragoza, Spain
- WHO Collaborating Centre for Drug Statistics Methodology, Department of Drug Statistics, Division of Health Data and Digitalisation, Norwegian Institute of Public Health, NO-0213 Oslo, Norway
- EpiChron Research Group, Aragon Health Research Institute (IIS Aragón), Miguel Servet University Hospital, ES-50009 Zaragoza, Spain
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS), Institute of Health Carlos III (ISCIII), ES-28029 Madrid, Spain
- Drug Utilization Work Group, Spanish Society of Family and Community Medicine (semFYC), ES-08009 Barcelona, Spain
| | - Jorge Vicente-Romero
- Department of Pharmacology, Physiology and Legal and Forensic Medicine, Faculty of Medicine, University of Zaragoza, ES-50009 Zaragoza, Spain
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Layton AM, Ravenscroft J. Adolescent acne vulgaris: current and emerging treatments. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:136-144. [PMID: 36525984 DOI: 10.1016/s2352-4642(22)00314-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 10/05/2022] [Accepted: 10/20/2022] [Indexed: 12/15/2022]
Abstract
Acne vulgaris is one of the commonest inflammatory skin diseases seen worldwide, affecting all ethnicities and races, with a peak prevalence between age 15 years and 20 years. The burden of this condition, and the resulting clinical and psychological sequelae, is substantial. The visual appearance of acne and its sequelae, including scarring and pigment changes, frequently results in psychological and social morbidity because of concerns about appearance. As understanding of the pathophysiology has evolved, approaches to achieving the optimal outcomes with effective treatment regimens continue to emerge. In the past few years, several novel therapeutics have been developed, including new agents aimed at reducing antimicrobial resistance and products with specific actions targeting retinoid receptors and androgen receptors. This Review considers the management approaches of an adolescent with acne vulgaris and reviews treatment options from the evidence base and international expert opinion. Approaches to selecting current treatments and novel and emerging treatment regimens are discussed.
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Affiliation(s)
- Alison M Layton
- Skin Research Centre, Hull York Medical School, University of York, York, UK; Harrogate and District NHS Foundation Trust, Harrogate, UK.
| | - Jane Ravenscroft
- Nottingham University Hospitals NHS Trust, Nottingham, UK; Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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10
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Bray AP, Kravvas G, Skevington SM, Lovell CR. The effects of isotretinoin on serotonin: a prospective pilot study on acne patients. An Bras Dermatol 2022; 97:526-528. [PMID: 35654653 PMCID: PMC9263637 DOI: 10.1016/j.abd.2021.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 11/25/2022] Open
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11
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Chen L, Lu L, Tu S, Zhang T, Du X, Chen L, Zhang M, Li L, Lin H. Efficacy and Safety of 5% Glycolic Acid-based Gel Essence in the Treatment of Mild to Moderate Acne. J Cosmet Dermatol 2022; 21:4482-4489. [PMID: 35182003 DOI: 10.1111/jocd.14865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/12/2022] [Accepted: 02/15/2022] [Indexed: 11/28/2022]
Abstract
The efficacy and safety of commercial low-concentration glycolic acid products on acne were evaluated by recruiting volunteers accompanying mild to moderate acne of different ages and genders, which is a clinical practice for acne. We recruited a total of 30 volunteers according to the inclusion criteria, conducting clinical evaluation and skin physiological index testing, VISIA skin analysis, distributing products, and informing the trial method. Clinical testing and assessment will be carried out in weeks 0, 1, 2, and 4. 27 acne volunteers finished the entire trial. After 4 weeks of using low-concentration glycolic acid products, most subjects experienced significant improvement in their skin lesions and the GAGS score. At the same time, the VISIA test showed that the subjects had an obvious amelioration in facial porphyrins, which was statistically significant, and there was a slight improvement in residual spots and erythema. The skin physiological indexes showed that the skin hydration value increased from 236.2 ± 98.05 to 278.2 ± 90.26 after 14 days. At the end of the test, the skin hydration value dropped to 234.6 ± 81.88. Regarding the melanin and erythema, the value decreased in the 4th week significantly. Repeated use of 5% low-concentration glycolic acid improves the appearance and chromaticity of the treatment site. It increases the brightness L* and reduces the redness a*. This study shows that low concentrations of glycolic acids have a good effect on the treatment of mild to moderate acne. It may pay the way to carry out further large-scale clinical research.
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Affiliation(s)
- Linjiao Chen
- Shenzhen Hospital, Beijing University of Chinese Medicine (Longgang), Shenzhen, 518100, P.R.China
| | - Lingling Lu
- Henan University of Chinese Medicine, Zhengzhou, 450000, P.R.China
| | - Shaozhong Tu
- Shenzhen Hospital, Beijing University of Chinese Medicine (Longgang), Shenzhen, 518100, P.R.China
| | - Tao Zhang
- Shenzhen Hospital, Beijing University of Chinese Medicine (Longgang), Shenzhen, 518100, P.R.China
| | - Xianni Du
- Shenzhen Hospital, Beijing University of Chinese Medicine (Longgang), Shenzhen, 518100, P.R.China
| | - Lifen Chen
- Shenzhen Hospital, Beijing University of Chinese Medicine (Longgang), Shenzhen, 518100, P.R.China
| | - Milin Zhang
- Shenzhen Hospital, Beijing University of Chinese Medicine (Longgang), Shenzhen, 518100, P.R.China
| | - Lihao Li
- Shenzhen Hospital, Beijing University of Chinese Medicine (Longgang), Shenzhen, 518100, P.R.China
| | - Huaner Lin
- Shenzhen Hospital, Beijing University of Chinese Medicine (Longgang), Shenzhen, 518100, P.R.China
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12
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Paljarvi T, McPherson T, Luciano S, Herttua K, Fazel S. Isotretinoin and adverse neuropsychiatric outcomes: retrospective cohort study using routine data. Br J Dermatol 2022; 187:64-72. [PMID: 35174880 PMCID: PMC9543533 DOI: 10.1111/bjd.21049] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/02/2022] [Accepted: 02/06/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Tapio Paljarvi
- Department of Psychiatry Oxford University Warneford Hospital, Headington OX3 7JX Oxford United Kingdom
- Department of Forensic Psychiatry University of Eastern Finland Niuvanniemi Hospital Kuopio Finland
| | - Tess McPherson
- Department of Dermatology Oxford University Hospitals OX3 9DU Oxford United Kingdom
| | - Sierra Luciano
- TriNetX LLC, 125 Cambridgepark Drive, Suite 500 Cambridge MA 02140 USA
| | - Kimmo Herttua
- Department of Public Health University of Southern Denmark Degnevej 14 DK‐6705 Esbjerg Denmark
| | - Seena Fazel
- Department of Psychiatry Oxford University Warneford Hospital, Headington OX3 7JX Oxford United Kingdom
- Oxford Health NHS Foundation Trust, Warneford Hospital, OX3 7JX Oxford United Kingdom
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13
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Lappas AS, Edwards Suarez L, Tzanetakou V, Morton S, Schofield C, Christodoulou NG. Factors associated with increased suicidality risk following referral for isotretinoin commencement. Australas Psychiatry 2022; 30:44-48. [PMID: 34266294 DOI: 10.1177/10398562211029955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To establish whether there is a significant change in suicidality risk following psychiatric assessment for commencement of isotretinoin and identify factors that underpin any potential risk change. METHOD Retrospective cohort study. Suicidality risk was defined as a combination of the following: (i) actual/intended self-harm and/or attempted/completed suicide, and (ii) increased service utilisation associated with suicidal ideation/behaviour. All patients referred to Psychiatry for assessment prior to commencement of isotretinoin between 2014 and 2019 were examined. Inclusion criteria: >16 years of age, assessed for commencement of isotretinoin, complete clinical records. Data were collected by reviewing the Electronic Patient Records. Fifty-seven patients were eligible. We employed descriptive statistics, parametric/non-parametric/normality tests and logistic regression analysis, using socio-demographic and clinical characteristics as independent parameters, and suicidality risk as the dependent parameter. RESULTS Actual/intended self-harm/attempted suicide decreased significantly following assessment without significant change in service utilisation. Female gender, absence of protective factors and assessment by Consultation-Liaison Psychiatry were linked to increased suicidality risk, after controlling for age, ethnicity, recommendation for isotretinoin, and substance misuse. CONCLUSIONS Psychiatric assessment is helpful before commencing isotretinoin. Female gender, and absence of ongoing psychopharmacological and/or psychological intervention and/or regular psychiatric follow-up predict increased suicidality risk among patients assessed for prescription of isotretinoin.
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Affiliation(s)
- Andreas S Lappas
- Nottinghamshire Healthcare NHS Foundation Trust, Duncan MacMillan House, Mapperley, Nottingham, UK.,Swansea Bay University Health Board, Princess of Wales Hospital, Bridgend, UK
| | - Lori Edwards Suarez
- Nottinghamshire Healthcare NHS Foundation Trust, Duncan MacMillan House, Mapperley, Nottingham, UK
| | | | - Sally Morton
- Nottinghamshire Healthcare NHS Foundation Trust, Duncan MacMillan House, Mapperley, Nottingham, UK
| | - Chris Schofield
- Nottinghamshire Healthcare NHS Foundation Trust, Duncan MacMillan House, Mapperley, Nottingham, UK
| | - Nikos G Christodoulou
- Nottinghamshire Healthcare NHS Foundation Trust, Duncan MacMillan House, Mapperley, Nottingham, UK.,University of Nottingham, Medical School, Lenton, Nottingham, UK
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14
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Khardikova SA, Shirshkova VI, Dmitruk VS, Skrylova KA, Kornetova EG, Kornetov AN, Urazova OI, Kolobovnikova YV. Efficacy and tolerability of system isotretinoin and effect of this therapy on the quality of life of patients with severe and moderate acne. VESTNIK DERMATOLOGII I VENEROLOGII 2021. [DOI: 10.25208/vdv1249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Background. The relationship between acne and depression is being actively studied by the medical community. Question is depression a restriction in prescribing or a side effect when using systemic isotretinoin remains controversial. Noteworthy is the presence in the scientific literature of data on the possible positive effect of adequately and timely prescribed acne therapy on the psychoemotional state of patients with this ailment.
Aims. The aim of our study was to evaluate the effectiveness of therapy with systemic isotretinoin in patients with moderate and severe acne, to assess the effect of the therapy on the quality of life of patients, as well as the persistence of remission after the end of the course of therapy with systemic retinoid.
Methods. We observed 32 patients with moderate and severe acne, the average age of patients was 24 years, the duration of the disease was on average 8 years. All patients underwent therapy with systemic isotretinoin (Sotret) at an average daily dose of 0.51.0 mg/kg until a cumulative dose of 120150 mg/kg was reached. The effectiveness and tolerability of the therapy was assessed, as well as the quality of life of patients was assessed using the dermatological index of the quality of life (DQL), the dermatological akne index (DIA), the HADS scale (anxiety and depression scale). The indicators were assessed before the start of therapy, during therapy, at the end of the course of treatment with systemic isotretinoin, and also 12 months after the end of therapy.
Results. 100% of patients achieved clinical remission as a result of treatment with systemic isotretinoin.
Before starting therapy with systemic isotretinoin, the indices were as follows: DQL 18 (1520), HADS 10 (716) and DIA 13 (615) scores. By the end of the therapy, the indices decreased to 1 (01), 2 (04) and 1 (01) points, respectively (p 0.001).
12 months (year) after the end of therapy with systemic isotretinoin, the indices remained at zero or one level in all patients: DQL 1 (01), HADS 0 (01) and CIA 1 (01) points (p 0.001).
Conclusion. A causal relationship between the intake of systemic isotretinoin and the development of depression has not been established. Systemic isotretinoin therapy was effective in all patients (100%), was well tolerated and had a positive effect on the psychoemotional status of patients with acne. 12 months after the end of therapy with the drug Erase, stable remission of the disease was noted in all patients
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15
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Hefez L, Micallef J, Revah-Levy A, Falissard B, Jouve E, Dreno B, Chosidow O. First use of the Adolescent Depression Rating Scale (ADRS) in the management of young people with severe acne treated with isotretinoin: a pilot study of an active monitoring of depressive disorders by dermatologists. Clin Exp Dermatol 2021; 47:709-716. [PMID: 34859487 DOI: 10.1111/ced.15039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 10/26/2021] [Accepted: 11/29/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND During isotretinoin treatment, special attention is required to detect any symptom or change in the mental health of patients. The monitoring is complex for adolescents because of confounding factors such as mood changes associated with adolescence and puberty and the higher psychosocial impairment due to the acne itself. AIM To determine the utility of the Adolescent Depression Rating Scale (ADRS) for monitoring symptoms in adolescents before and during isotretinoin treatment in dermatology real-life practice. METHODS This was a national, multicentre prospective study that enrolled a random sample of dermatologists treating adolescents. An algorithm including ADRS score and its changes between consecutive visits was used. At each visit, dermatologists rated their satisfaction with ADRS and its ease of use, while patients rated the acceptability of the ADRS. RESULTS In total, 70 dermatologists used the algorithm for 1227 visits of 283 adolescents receiving isotretinoin. Of these 70 dermatologists, 80.8% were satisfied/very satisfied with the ADRS, 82.7% considered the use of the ADRS in clinical practice to be easy/very easy and 75% considered that the ADRS enabled them to discuss more easily the risk of depression with their patients. For the patients, acceptability of the ADRS was considered good by 93.8%. CONCLUSIONS The implementation of the ADRS could be valuable in dermatology practice, optimizing the monitoring of patients and the good use of isotretinoin.
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Affiliation(s)
- L Hefez
- Department of Dermatology, Grand Hôpital Est Francilien, Jossigny, France
| | - J Micallef
- Service de Pharmacologie Clinique et Pharmacovigilance, Pharmacometry and Pharmacoepidemiology, Institut de Neurosciences des Systèmes, APHM/INSERM/Aix Marseille University, Marseille, France
| | - A Revah-Levy
- Department of Adolescent Psychiatry, Centre Hospitalier Victor Dupouy, Argenteuil, France.,ECSTRRA team, Statistic And Epidemiological Research Centre Sorbonne Paris Cité (CRESS), INSERM U1153, Université de Paris, Paris, France
| | - B Falissard
- INSERM U669, Paris-Sud 11 University, APHP, Villejuif, France, Paris, France
| | - E Jouve
- Service de Pharmacologie Clinique et Pharmacovigilance, Pharmacometry and Pharmacoepidemiology, Institut de Neurosciences des Systèmes, APHM/INSERM/Aix Marseille University, Marseille, France
| | - B Dreno
- Onco-Dermatology Department, CHU Nantes, CRCINA, Nantes University, Nantes, France
| | - O Chosidow
- Department of Dermatology, APHP, Hôpital Henri-Mondor, Faculté de Santé, Paris-Est, Créteil, France.,Research Group Dynamic, EA7380, Faculté de Santé de Créteil, École Nationale Vétérinaire d'Alfort, USC ANSES, Université Paris-Est Créteil, Créteil, France.,Centre de Preuves de la Société Française de Dermatologie, Paris, France
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16
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Isotretinoin and neuropsychiatric side effects: Continued vigilance is needed. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2021; 6. [PMID: 37168254 PMCID: PMC10168661 DOI: 10.1016/j.jadr.2021.100230] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
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.
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17
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Chandrasekaran S, De Sousa JFM, Paghdar S, Khan TM, Patel NP, Tsouklidis N. Is Isotretinoin in Acne Patients a Psychological Boon or a Bane: A Systematic Review. Cureus 2021; 13:e16834. [PMID: 34513424 PMCID: PMC8407467 DOI: 10.7759/cureus.16834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/02/2021] [Indexed: 11/05/2022] Open
Abstract
Acne vulgaris is a frequently encountered dermatological condition in clinical practice. Isotretinoin is one of the drugs prescribed for this condition. However, it is unclear whether the use of this drug worsens or improves the psychological effects in an acne patient and whether it is advisable to use this drug commonly. This systematic review aims to assess the relationship between Isotretinoin and psychiatric side effects in acne patients. A literature search was conducted using PubMed, Cochrane, and Google Scholar databases in accordance with Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Articles published within the last 10 years were taken into account and a review was conducted on the relevant articles after critical appraisal. Nine studies were finalized for discussion and out of the nine studies, two studies concluded that Isotretinoin could cause psychiatric effects. Five studies showed no association between them. Two studies unexpectedly found that psychiatric symptoms improved because of Isotretinoin use. Lack of adequate sample size and absence of randomized controlled trials are the limitations of this study. To conclude, Isotretinoin can be prescribed as a treatment option for severe acne despite some evidence of link with psychiatric effects. However, bearing the side effects in mind, a detailed evaluation before initiating the drug and a thorough monitoring while using the drug should be done as a standard practice in order to be on the safer side.
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Affiliation(s)
- Savitri Chandrasekaran
- Medicine, Indira Gandhi Medical College and Research Institute, Pondicherry, IND.,Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Joaquim Francisco Maria De Sousa
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Medicine, S.S Institute of Medical Sciences and Research Centre, Davangere, IND.,Emergency Medicine, Healthway Hospitals, Goa, IND
| | - Smit Paghdar
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Internal Medicine, Surat Municipal Institute of Medical Education and Research (SMIMER), Surat, IND
| | - Taheseen M Khan
- Medicine, Mahatma Gandhi Mission (MGM) Medical College, Navi Mumbai, IND.,Psychiatry, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Nishant P Patel
- Internal Medicine, Government Medical College, Surat, IND.,Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Nicholas Tsouklidis
- Pediatrics, Wyckoff Heights Medical Center, Brooklyn, USA.,Health Care Administration, University of Cincinnati Health, Cincinnati, USA.,Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Medicine, Atlantic University School of Medicine, Gros Islet, LCA
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18
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Fallah H, Rademaker M. Isotretinoin for acne vulgaris - an update on adverse effects and laboratory monitoring. J DERMATOL TREAT 2021; 33:2414-2424. [PMID: 34379039 DOI: 10.1080/09546634.2021.1967269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A significant barrier to the usage of isotretinoin has been concerns regarding its adverse effect profile. The dose-dependent mucocutaneous side effects of isotretinoin are well recognised and easily managed, particularly if a lower dose is used. A possible association with depression has gained widespread media attention and is a source of concern for many patients and their carers, but data from prospective studies and recent meta-analyses has been reassuring. Furthermore, there has been much confusion amongst both patients and physicians regarding a possible association with inflammatory bowel disease, as well the ocular and rheumatological adverse effects of isotretinoin. We provide an update on the evidence surrounding the adverse effects of isotretinoin, and discuss practical strategies to prevent and manage these adverse effects. We also discuss appropriate laboratory monitoring for patients taking isotretinoin.
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Affiliation(s)
- Haady Fallah
- The University of Sydney, Sydney, Australia.,Concord Repatriation General Hospital, Sydney, Australia.,The Skin Hospital, Sydney, Australia
| | - Marius Rademaker
- Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand
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19
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Isotretinoin in Acne Vulgaris Complicated by Underlying Major Depression: A Case Report and Review of Literature. Case Rep Psychiatry 2021; 2021:9942327. [PMID: 34336344 PMCID: PMC8286202 DOI: 10.1155/2021/9942327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 06/23/2021] [Indexed: 11/17/2022] Open
Abstract
We relay the case of a teenage female with severe facial acne vulgaris and a past psychiatric history of major depressive disorder who presented to the emergency department with a primary complaint of ongoing suicidal ideation. Defining features of this case stem from the patient endorsing that her suicidal ideation was a result of her severe acne and the coinciding social perturbation it caused. Additionally, the patient reported that just four months prior to the current presentation, her dermatologist started her on isotretinoin therapy for the management of acne vulgaris. To the best of the authors' knowledge, there have been no reported cases which describe a teenage female presenting with active suicidal ideation secondary to severe acne vulgaris while concurrently undergoing treatment with isotretinoin. Given the controversial but reported association between isotretinoin and increased suicidality, we considered the appropriateness of continuing this medication for our patient. We then conducted a literature search evaluating the evidence concerning this association. In what follows, we present a unique case report and provide a thorough review of the evidence-or lack thereof-surrounding the relationship between isotretinoin and suicidality. Additionally, the authors aim to provide recommendations for the management of future patients who may present under similar circumstances.
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20
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Barbieri JS, Fulton R, Neergaard R, Nelson MN, Barg FK, Margolis DJ. Patient Perspectives on the Lived Experience of Acne and Its Treatment Among Adult Women With Acne: A Qualitative Study. JAMA Dermatol 2021; 157:1040-1046. [PMID: 34319378 DOI: 10.1001/jamadermatol.2021.2185] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction Acne often persists into adulthood in women. However, few studies have specifically explored the lived experience of acne in adult populations. Objective To examine the lived experience of acne and its treatment among a cohort of adult women. Design, Setting, and Participants A qualitative analysis was conducted from free listing and open-ended, semistructured interviews of patients at a large academic health care system (University of Pennsylvania Health System) and a private practice (Dermatologists of Southwest Ohio). Fifty women 18 to 40 years of age with moderate to severe acne participated in interviews conducted between August 30, 2019, and December 31, 2020. Main Outcomes and Measures Free-listing data from interviews were used to calculate the Smith S, a measure of saliency for each list item. Semistructured interviews were examined to detect themes about patient perspectives regarding their acne and its treatment. Results Fifty participants (mean [SD] age, 28 [5.38] years; 24 [48%] White) described acne-related concerns about their appearance that affected their social, professional, and personal lives, with many altering their behavior because of their acne. Depression, anxiety, and social isolation were commonly reported. Participants described successful treatment as having completely clear skin over time or a manageable number of blemishes. Many participants described frustration with finding a dermatologist with whom they were comfortable and with identifying effective treatments for their acne. Conclusions and Relevance The results of this qualitative study suggest that women with acne have strong concerns about appearance and experience mental and emotional health consequences and disruption of their personal and professional lives. In addition, many patients describe challenges finding effective treatments and accessing care. Future trials to understand the optimal treatment approaches for women with acne are needed to improve outcomes in this population.
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Affiliation(s)
- John S Barbieri
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Rachel Fulton
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Rebecca Neergaard
- Mixed Methods Research Lab, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Maria N Nelson
- Mixed Methods Research Lab, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Frances K Barg
- Mixed Methods Research Lab, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - David J Margolis
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
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21
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Al-Radideh O, Chan KH, Gupta S, Slim J, Bellary S. Concurrent Serotonin Syndrome and Prolong QT Interval Induced by Paroxetine Overdose With Isotretinoin. Cureus 2021; 13:e14497. [PMID: 34007750 PMCID: PMC8121124 DOI: 10.7759/cureus.14497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The use of serotonergic drugs has increased in the last decade especially selective serotonin reuptake inhibitors (SSRIs) with increased indications. Serotonin syndrome (SS) and QT prolongation are serious adverse reactions of SSRI use, they usually occur with concomitant use of two or more serotonergic medication. Herein, we are presenting an interesting unique case of SS and prolongation of QT interval after a suicidal attempt in a patient on isotretinoin with paroxetine overdosing. The prolongation of QT interval observed in this case could be related to isotretinoin synergistic effect. The risk of suicide and side effects of SSRI with isotretinoin, especially in patient with psychiatric illness would be a huge concern. This case hopes to raise the awareness of the risks when prescribing SSRI and isotretinoin in this group of patients.
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Affiliation(s)
- Omar Al-Radideh
- Internal Medicine, Saint Michael's Medical Center, Newark, USA
| | - Kok Hoe Chan
- Internal Medicine, Saint Michael's Medical Center, Newark, USA
| | - Shawn Gupta
- Internal Medicine, Saint Michael's Medical Center, Newark, USA
| | - Jihad Slim
- Infectious Diseases, Saint Michael's Medical Center, Newark, USA
| | - Sharath Bellary
- Pulmonary/Critical Care, Saint Michael's Medical Center, Newark, USA
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22
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Fenton C, Kang C. Isotretinoin is key in treating acne vulgaris. DRUGS & THERAPY PERSPECTIVES 2021. [DOI: 10.1007/s40267-021-00817-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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23
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Ugonabo N, Love E, Wong PW, Rieder EA, Orlow SJ, Kim RH, Nagler AR. Psychiatric disorders and suicidal behavior in patients with acne prescribed oral antibiotics versus isotretinoin: Analysis of a large commercial insurance claims database. J Am Acad Dermatol 2021; 85:878-884. [PMID: 33727021 DOI: 10.1016/j.jaad.2021.01.107] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 01/09/2021] [Accepted: 01/28/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The association between isotretinoin and psychiatric disturbance, including depression and suicidal behavior, is controversial. OBJECTIVE To investigate whether acne patients prescribed isotretinoin or antibiotics were more likely to have psychiatric disorders and/or engage in suicidal behavior. METHODS Retrospective cohort study using the IBM MarketScan Research Databases, which contain commercial insurance claims in the United States, to identify acne patients who were prescribed isotretinoin or oral antibiotics between 2011 and 2017 and who were diagnosed with psychiatric disorders or suicidal behavior. RESULTS A total of 72,555 patients were included in the study. Patients in the general population were 1.47 times more likely to be diagnosed with suicidal ideation or attempt compared to acne patients prescribed isotretinoin (adjusted odds ratio [OR] 1.47; confidence interval [95% CI], 1.27, 1.70; P < .0001). The general population (adjusted OR 0.87; 95% CI, 0.84, 0.89; P < .0001) and acne patients prescribed antibiotics (adjusted OR 0.88; 95% CI, 0.85, 0.91; P < .0001) were less likely to have a psychiatric diagnosis compared to acne patients prescribed isotretinoin. The prevalence of suicidal behavior during isotretinoin treatment was lower (0.10%; P = .082) than in the year prior to isotretinoin treatment (0.22%) and in the year following treatment (0.34%; P = .004). LIMITATIONS The study excluded individuals with public insurance and those who were uninsured, and the data in the study relied on the accuracy of the medical coding. CONCLUSIONS Compared to the general population, acne patients prescribed isotretinoin were less likely to engage in suicidal behavior. Further exploration into the slight increase in suicidal behavior seen in isotretinoin patients 1 year after therapy is warranted.
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Affiliation(s)
- Nkemjika Ugonabo
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Elyse Love
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Priscilla W Wong
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Evan A Rieder
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Seth J Orlow
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Randie H Kim
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Arielle R Nagler
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York.
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24
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Cryotherapy plus low-dose oral isotretinoin vs cryotherapy only for the treatment of anogenital warts: a randomized clinical trial. Arch Dermatol Res 2021; 313:815-827. [PMID: 33433720 DOI: 10.1007/s00403-020-02182-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/18/2020] [Accepted: 12/18/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Anogenital warts are a common human papillomavirus infection. They cause emotional distress, especially when they are in the anogenital region. Cryotherapy is a first-line treatment. Previous clinical trials and case series have reported variable results with retinoids (isotretinoin) as adjuvant therapy. OBJECTIVE To determine the safety and efficacy of low-dose oral isotretinoin as adjuvant treatment of anogenital warts. METHODS Forty-six patients with anogenital warts were randomly assigned to isotretinoin + cryotherapy (n = 23) or only cryotherapy (n = 23). Patients were allocated via an interactive web-based randomization system. Evaluators were blinded to treatments. Isotretinoin 20 mg/daily + cryotherapy or cryotherapy were prescribed for 6 weeks. Patients were followed for 4 months. Genotyping of lesions was performed before treatment started. Dermatology Life Quality Index (DLQI) and Columbia-Suicide Severity Rating Scale (C-SSRS) were measured at the beginning and end of therapy. All patients completed the study. RESULTS Both Groups had 50% clearance at the end of treatment. Recurrence in the combined group was not significantly lower than in the cryotherapy group (P = 0.59). Improvement was observed in the DLQI of all patients in both groups (P = 0.001). No suicidal intention was detected with the C-SSRS. Two patients (one in each group) had liver function test abnormalities after treatment. CONCLUSION Combined therapy showed a slight not significant efficacy for anogenital warts in Hispanic patients. Low-dose isotretinoin seems to be safe even when it is used with cryotherapy on anogenital warts. TRIAL REGISTRATION On April 25, 2019 with registration number DE19-00004, CONBIOÉTICA-19-CEI-001-20160404. Prospectively registered.
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25
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Barbieri JS, Shin DB, Wang S, Margolis DJ, Takeshita J. Association of Race/Ethnicity and Sex With Differences in Health Care Use and Treatment for Acne. JAMA Dermatol 2020; 156:312-319. [PMID: 32022834 DOI: 10.1001/jamadermatol.2019.4818] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Our understanding of potential racial/ethnic, sex, and other differences in health care use and treatment for acne is limited. Objective To identify potential disparities in acne care by evaluating factors associated with health care use and specific treatments for acne. Design, Setting, and Participants This retrospective cohort study used the Optum deidentified electronic health record data set to identify patients treated for acne from January 1, 2007, to June 30, 2017. Patients had at least 1 International Classification of Diseases, Ninth Revision (ICD-9) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) code for acne and at least 1 year of continuous enrollment after the first diagnosis of acne. Data analysis was performed from September 1, 2019, to November 20, 2019. Main Outcomes and Measures Multivariable regression was used to quantify associations between basic patient demographic and socioeconomic characteristics and the outcomes of health care use and treatment for acne during 1 year of follow-up. Results A total of 29 928 patients (median [interquartile range] age, 20.2 [15.4-34.9] years; 19 127 [63.9%] female; 20 310 [67.9%] white) met the inclusion criteria for the study. Compared with non-Hispanic white patients, non-Hispanic black patients were more likely to be seen by a dermatologist (odds ratio [OR], 1.20; 95% CI, 1.09-1.31) but received fewer prescriptions for acne medications (incidence rate ratio, 0.89; 95% CI, 0.84-0.95). Of the acne treatment options, non-Hispanic black patients were more likely to receive prescriptions for topical retinoids (OR, 1.25; 95% CI, 1.14-1.38) and topical antibiotics (OR, 1.35; 95% CI, 1.21-1.52) and less likely to receive prescriptions for oral antibiotics (OR, 0.80; 95% CI, 0.72-0.87), spironolactone (OR, 0.68; 95% CI, 0.49-0.94), and isotretinoin (OR, 0.39; 95% CI, 0.23-0.65) than non-Hispanic white patients. Male patients were more likely to be prescribed isotretinoin than female patients (OR, 2.44; 95% CI, 2.01-2.95). Compared with patients with commercial insurance, those with Medicaid were less likely to see a dermatologist (OR, 0.46; 95% CI, 0.41-0.52) or to be prescribed topical retinoids (OR, 0.82; 95% CI, 0.73-0.92), oral antibiotics (OR, 0.87; 95% CI, 0.79-0.97), spironolactone (OR, 0.50; 95% CI, 0.31-0.80), and isotretinoin (OR, 0.43; 95% CI, 0.25-0.75). Conclusions and Relevance The findings identify racial/ethnic, sex, and insurance-based differences in health care use and prescribing patterns for acne that are independent of other sociodemographic factors and suggest potential disparities in acne care. In particular, the study found underuse of systemic therapies among racial/ethnic minorities and isotretinoin among female patients with acne. Further study is needed to confirm and understand the reasons for these differences.
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Affiliation(s)
- John S Barbieri
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Daniel B Shin
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Shiyu Wang
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - David J Margolis
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Junko Takeshita
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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26
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Layton AM, Thiboutot D, Tan J. Reviewing the global burden of acne: how could we improve care to reduce the burden? Br J Dermatol 2020; 184:219-225. [PMID: 32770673 DOI: 10.1111/bjd.19477] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2020] [Indexed: 01/09/2023]
Abstract
Acne (also known as acne vulgaris) remains the most common inflammatory dermatosis treated worldwide, as estimated by global skin disease prevalence studies. Latest reports suggest that the prevalence may be increasing in adolescents and adults, particularly female adults. The concept of 'burden of skin disease' is multidimensional and can be difficult to quantify in light of different healthcare systems across the globe. In acne, the resulting burden may vary according to patient demographics, access to treatments and duration of the disease. The visible nature of acne, symptoms and sequelae all contribute physically and psychosocially to the overall burden of disease, as do the costs required for management. Acne typically presents in adolescence at a time of significant transition. Profound effects on functional status have been demonstrated, along with a strong impact on interpersonal relationships, social functioning and mental health. The high prevalence of acne also presents an economic burden for society. The widespread and prolonged use of antibiotics introduces a potential added burden through resulting antimicrobial resistance. A James Lind Alliance Acne Priority Setting Partnership has identified numerous areas to inform future research, which would help to improve acne management and reduce the burden. The lack of standardized assessments is a major issue in acne trials and challenges the ability to compare treatments and perform meta-analyses. This paper reviews the current literature on burden of acne, identifies areas of treatment uncertainties and summarizes the work of the Acne Core Outcome Research Network as a means of supporting a reduction in the burden of disease.
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Affiliation(s)
- A M Layton
- Hull York Medical School, York University, Heslington, York, UK.,Harrogate and District NHS Foundation Trust, Harrogate, North Yorkshire, UK
| | - D Thiboutot
- Department of Dermatology, The Pennsylvania State University, 500 University Drive, Hershey, 17033, PA, USA
| | - J Tan
- Department of Medicine, Western University, Windsor Campus, ON, Canada
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27
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Dréno B, Araviiskaia E, Kerob D, Andriessen A, Anfilova M, Arenbergerova M, Forero Barrios OL, Bukvić Mokos Z, Haedersdal M, Hofmann MA, Khamaysi Z, Kosmadaki M, Lesiak A, Roó E, Zbranca‐Toporas A, Wiseman MC, Zimmo S, Guerin L, Fabbrocini G. Nonprescription acne vulgaris treatments: Their role in our treatment armamentarium-An international panel discussion. J Cosmet Dermatol 2020; 19:2201-2211. [PMID: 32426933 PMCID: PMC7496538 DOI: 10.1111/jocd.13497] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/12/2020] [Accepted: 05/14/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Acne vulgaris (acne), a common inflammatory skin disorder, has its peak incidence between 14 and 19 years of age, with girls frequently developing acne earlier than boys. Over recent years, persistent acne is becoming more prevalent in adult women. OBJECTIVES This review and panel discussion addresses challenges in acne management, particularly in adult women. The role which nonprescription acne treatment can play is explored when used as monotherapy or as an adjunctive treatment for acne of all severity. METHODS The best available evidence on nonprescription acne treatment was coupled with the opinion of an international expert panel of dermatologists to adopt statements and recommendations discussed in this review. RESULTS All severity of acne has a significant burden on patients. Addressing environmental factors that are important for the individual with acne may help to educate, prevent, effectively manage, and maintain acne, as per the panel. They agreed that the adult female acne population has unique needs because of their aging skin and social environment. Nonprescription acne treatment products may help to balance the efficacy and tolerability of prescription acne treatment. Currently, there are no specific guidelines for how to use nonprescription acne treatment products in these patients. CONCLUSION The panel agreed that guidelines including nonprescription acne treatment either as monotherapy for mild acne or in combination with prescription treatments for more severe acne would address a significant unmet need.
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Affiliation(s)
- Brigitte Dréno
- Cell Therapy and Gene Therapy UnitDepartment of Dermato‐OncologyThe Faculty of MedicineUniversity of NantesNantesFrance
| | - Elena Araviiskaia
- Department of Dermatology & VenereologyFirst Pavlov State Medical University of Saint PetersburgSaint PetersburgRussia
| | - Delphine Kerob
- International Medical RelationsLaboratoire VichyChevilly‐LarueFrance
| | | | - Maryna Anfilova
- Department of Skin and Venereal DiseasesNational Pirogov Memorial Medical UniversityVinnytsyaUkraine
| | - Monika Arenbergerova
- Department of Dermato‐VenereologyThird Faculty of MedicineCharles University and University Hospital of Kralovske VinohradyPragueCzech Republic
| | | | - Zrinka Bukvić Mokos
- Department of Dermatology and VenereologySchool of Medicine University of ZagrebUniversity Hospital Center ZagrebZagrebCroatia
| | | | - Maja A. Hofmann
- Department of Dermatology, Venereology, and AllergyCharité‐UniversitätsmedizinBerlinGermany
| | - Ziad Khamaysi
- Department of DermatologyRambam Medical Center and Ruth & Bruce Rappaport Faculty of MedicineTechnionHaifaIsrael
| | | | | | - Elia Roó
- Clider‐Clínica DermatológicaMadridSpain
| | - Anca Zbranca‐Toporas
- Department of Biomedical SciencesFaculty of BioengineeringUniversity of Medicine and Pharmacy Grigore T.PopaIasiRomania
| | - Marni C. Wiseman
- Departments of Medicine and DermatologyUniversity of ManitobaWinnipegMBCanada
| | | | - Lucie Guerin
- L'Oréal Research and InnovationChevilly‐LarueFrance
| | - Gabriella Fabbrocini
- Department of Clinical Medicine and Surgery, DermatologySection of DermatologyUniversity of Naples Federico IINaplesItaly
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28
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Bagatin E, Costa CS. The use of isotretinoin for acne - an update on optimal dosing, surveillance, and adverse effects. Expert Rev Clin Pharmacol 2020; 13:885-897. [PMID: 32744074 DOI: 10.1080/17512433.2020.1796637] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Acne is a chronic, inflammatory, and immune mediated disease of pilosebaceous unit, highly prevalent in adolescents. It involves face, trunk, and back; may leave scars and affect quality of life. Early, effective, and safe treatment is the key for disease resolution. Oral isotretinoin is the unique treatment for cure or prolonged remission for moderate and severe acne, preventing psychosocial impact and scars. It inhibits sebaceous glands activity and has anti-inflammatory and immunoregulatory properties. AREAS COVERED We performed a comprehensive literature search on PubMed database, up to March 2020, regarding oral isotretinoin for acne treatment. We synthetized data about acne pathogenesis and mechanism of action, efficacy, and safety of isotretinoin. EXPERT OPINION This drug is effective, despite common, controllable, and reversible mucocutaneous side effects. Serious adverse events are rare and represent individual reactions. Teratogenicity is the most severe, requiring rigorous control. We believe that no other therapeutic option, even topicals combined to oral antibiotics accomplish same results. Recurrence after treatments other than isotretinoin is the rule, prolonging risk of scars, compromising skin appearance, and causing emotional distress in teenagers. If there is no absolute contraindication, isotretinoin should be the first line treatment for moderate to severe inflammatory acne.
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Affiliation(s)
- Edileia Bagatin
- Department of Dermatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, EPM/UNIFESP , Sao Paulo, SP, Brazil
| | - Caroline Sousa Costa
- Department of Specialized Medicine, Discipline of Dermatology, Universidade Federal do Piauí, UFPI , Teresina, PI, Brazil
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29
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Landis MN. Optimizing Isotretinoin Treatment of Acne: Update on Current Recommendations for Monitoring, Dosing, Safety, Adverse Effects, Compliance, and Outcomes. Am J Clin Dermatol 2020; 21:411-419. [PMID: 32107726 DOI: 10.1007/s40257-020-00508-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Acne vulgaris is the most common skin disease treated by dermatologists. It can be severe and result in permanent scars. Isotretinoin is the most effective treatment for acne and has the potential for long-term clearance. Prescribing and monitoring protocols can vary widely among prescribers. Recent studies, reports, and consensus statements help shed light on optimizing the use of isotretinoin for acne. A recent literature review is summarized in this article to help the practitioner optimize isotretinoin use for acne. The article outlines the advantages and disadvantages of standard, high-dose, and low-dose isotretinoin regimens; discusses the current status of controversies surrounding isotretinoin (including depression/suicide, pregnancy, and inflammatory bowel disease); reviews monitoring recommendations and treatment for hypertriglyceridemia and elevated transaminase levels; and discusses common adverse effects seen with isotretinoin, along with their treatment and prevention.
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Affiliation(s)
- Megan N Landis
- Department of Medicine (Dermatology), University of Louisville School of Medicine, Louisville, KY, USA.
- The Dermatology and Skin Cancer Center of Southern Indiana, Corydon, IN, USA.
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30
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31
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Droitcourt C, Poizeau F, Kerbrat S, Balusson F, Drezen E, Happe A, Travers D, Oger E, Dupuy A. Isotretinoin and risk factors for suicide attempt: a population-based comprehensive case series and nested case-control study using 2010-2014 French Health Insurance Data. J Eur Acad Dermatol Venereol 2019; 34:1293-1301. [PMID: 31587374 DOI: 10.1111/jdv.16005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/20/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although the causal role of isotretinoin in suicidal behaviour is controversial, suicide attempts (SA) do occur among patients taking isotretinoin. OBJECTIVES To describe patient profiles and the management of isotretinoin among patients who committed or attempted suicide under treatment. To assess the risk factors for SA under isotretinoin. METHODS We performed a comprehensive case series of suicides and SAs under isotretinoin, and a case-control study, using Nationwide French Health Insurance database. The main analysis compared cases (subjects with a SA during a course of isotretinoin) to controls, individually matched for age, gender and rank of the current course; controls were to be exposed to isotretinoin at the index date (date of SA for the corresponding cases). The patients' psychiatric history at isotretinoin initiation was studied. In a secondary analysis, patients who continued their isotretinoin treatment after their SA were compared to patients who discontinued it. RESULTS In all, 328 018 subjects started a course of isotretinoin between 1 January 2010 and 31 December 2014 and 184 patients were hospitalized for a SA; half of them had a psychiatric history at initiation. In the multivariate analysis, psychiatric history and history of anxiety alone were risk factors for SA [Odds ratio (OR), 18.21; 95% confidence interval (CI), 9.96-33.30 and 4.78; 95% CI, 2.44-9.33, respectively]. Among 176 cases of SA with sufficient follow-up, 103 (58.5%) carried on with their treatment after their SA. Treatment initiation by a dermatologist was inversely associated with the continuation of the treatment after a SA (OR, 0.38; 95% CI, 0.18-0.80). CONCLUSIONS Suicide attempts under isotretinoin are rare events, and our results suggest that most of the patients concerned have a risk-prone profile detectable at the time of treatment initiation. The risk-benefit ratio of continuing isotretinoin after a SA warrants further careful evaluation.
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Affiliation(s)
- C Droitcourt
- Department of Dermatology, CHU Rennes, Rennes, France.,INSERM CIC 1414, Université de Rennes, Rennes, France.,EA 7449 REPERES 'Pharmacoepidemiology and Health Services Research', Université de Rennes, Rennes, France.,Pharmacovigilance, Pharmacoepidemiology and Drug Information Departments, PEPS Research Consortium, Rennes, France
| | - F Poizeau
- Department of Dermatology, CHU Rennes, Rennes, France.,EA 7449 REPERES 'Pharmacoepidemiology and Health Services Research', Université de Rennes, Rennes, France.,Pharmacovigilance, Pharmacoepidemiology and Drug Information Departments, PEPS Research Consortium, Rennes, France
| | - S Kerbrat
- EA 7449 REPERES 'Pharmacoepidemiology and Health Services Research', Université de Rennes, Rennes, France.,Pharmacovigilance, Pharmacoepidemiology and Drug Information Departments, PEPS Research Consortium, Rennes, France
| | - F Balusson
- EA 7449 REPERES 'Pharmacoepidemiology and Health Services Research', Université de Rennes, Rennes, France
| | - E Drezen
- EA 7449 REPERES 'Pharmacoepidemiology and Health Services Research', Université de Rennes, Rennes, France
| | - A Happe
- EA 7449 REPERES 'Pharmacoepidemiology and Health Services Research', Université de Rennes, Rennes, France.,Pharmacovigilance, Pharmacoepidemiology and Drug Information Departments, PEPS Research Consortium, Rennes, France
| | - D Travers
- Department of Psychiatry, CHU Rennes, Rennes, France
| | - E Oger
- EA 7449 REPERES 'Pharmacoepidemiology and Health Services Research', Université de Rennes, Rennes, France.,Pharmacovigilance, Pharmacoepidemiology and Drug Information Departments, PEPS Research Consortium, Rennes, France
| | - A Dupuy
- Department of Dermatology, CHU Rennes, Rennes, France.,EA 7449 REPERES 'Pharmacoepidemiology and Health Services Research', Université de Rennes, Rennes, France.,Pharmacovigilance, Pharmacoepidemiology and Drug Information Departments, PEPS Research Consortium, Rennes, France
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32
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Affleck AG, Stewart AM, Nicolson J, Salmon N. Isotretinoin and mental health: a survey of Scottish Dermatology Society members. Clin Exp Dermatol 2019; 45:476-478. [PMID: 31730241 DOI: 10.1111/ced.14140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 11/04/2019] [Accepted: 11/12/2019] [Indexed: 11/27/2022]
Affiliation(s)
- A G Affleck
- Department of Dermatology, Ninewells Hospital, NHS Tayside, Dundee, UK
| | - A M Stewart
- Liaison Psychiatry, Carseview Centre, Dundee, UK
| | - J Nicolson
- University of Dundee School of Medicine, Dundee, UK
| | - N Salmon
- Department of Dermatology, Ninewells Hospital, NHS Tayside, Dundee, UK
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33
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Affiliation(s)
- Rosalind Ashton
- King's College London School of Medical Education, St. John's Institute of Dermatology, London, United Kingdom
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34
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Singer S, Tkachenko E, Sharma P, Barbieri JS, Mostaghimi A. Psychiatric Adverse Events in Patients Taking Isotretinoin as Reported in a Food and Drug Administration Database From 1997 to 2017. JAMA Dermatol 2019; 155:1162-1166. [PMID: 31268488 DOI: 10.1001/jamadermatol.2019.1416] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Isotretinoin is a highly effective medication for severe acne. Although no causal link between isotretinoin and psychiatric adverse effects has been established, widespread media reporting of depression and suicidality with use of isotretinoin have raised concerns in both patients and clinicians and generated numerous cases of costly litigation. Objective To evaluate reports of psychiatric adverse events associated with isotretinoin use submitted to the US Food and Drug Administration from January 1, 1997, through December 31, 2017. Design, Setting, and Participants This retrospective study evaluated reports of psychiatric adverse events with isotretinoin as the primary suspect drug in the US Food and Drug Administration's Adverse Event Reporting System from 1997 through 2017. Publicly available data on number of patients enrolled in the iPLEDGE program were used to calculate rates of completed suicide per 100 000 patients enrolled in iPLEDGE in 2009 and 2010. All data were analyzed between July 1, 2018, and January 31, 2019. Main Outcomes and Measures The main outcomes were frequency and type of psychiatric adverse events in patients taking isotretinoin. Secondary analyses were stratification by age and sex and evaluation of completed suicide rates. Results Between 1997 and 2017, 17 829 psychiatric adverse events with isotretinoin use were reported to the US Food and Drug Administration, with depressive disorders, emotional lability, and anxiety disorders reported most frequently. Of these events, 8936 (50.1%) were reported among men and 8362 (46.9%) among women; the sex of the individual was not reported for 531 events (3.0%). Of the 13 553 reports that included patient age, the mean (SD) age was 22.1 (8.6) years. More than half (52.5%) of all events occurred in 10- to 19-year-old individuals. Whereas depression and anxiety were reported equally between sexes, eating disorders were more common in females (58 of 85 [68.2%]), while attention-deficit/hyperactivity disorder (55 of 83 events [66.3%]) and completed suicides (290 of 368 [78.8%]) were more common in males. The rates of completed suicide were 8.4 and 5.6 suicides per 100 000 patients enrolled in iPLEDGE in 2009 and 2010, respectively. Conclusions and Relevance Although depressive disorders and suicidality were frequently reported with isotretinoin use, these reports must be considered in the context of elevated rates of depression and suicide among patients with acne at large. These data suggest that the rate of completed suicide in patients taking isotretinoin may be lower than that of the general US population. Many psychiatric adverse events unrelated to depression and suicidality were also reported, but it is unclear if they were a result of isotretinoin therapy. Although no causal link between isotretinoin and psychiatric risk has been established, patients taking the drug appear vulnerable to psychiatric concerns. Mandated monthly iPLEDGE visits may provide an opportunity to screen patients for psychiatric conditions and improve outcomes.
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Affiliation(s)
- Sean Singer
- Medical student, Harvard Medical School, Boston, Massachusetts.,Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth Tkachenko
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Medical student, University of Massachusetts Medical School, Worcester
| | - Priyank Sharma
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - John S Barbieri
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Arash Mostaghimi
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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35
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Pitman A, Tham SG, Hunt IM, Webb RT, Appleby L, Kapur N. Access to means of lethal overdose among psychiatric patients with co-morbid physical health problems: Analysis of national suicide case series data from the United Kingdom. J Affect Disord 2019; 257:173-179. [PMID: 31301620 DOI: 10.1016/j.jad.2019.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/28/2019] [Accepted: 06/29/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Many physical health problems are associated with elevated suicide risk whilst also providing access to means of overdose. We aimed to investigate whether psychiatric patients with physical co-morbidities who die by suicide were more likely than those without co-morbidities to self-poison with non-psychotropic medications. METHODS We analysed data on 14,648 psychiatric patients who died by suicide in England & Wales during 2004-2015, as recorded by the National Confidential Inquiry into Suicide and Safety in Mental Health. Using logistic regression models adjusted for age, gender, ethnicity, and primary drug dependence/misuse we compared patients diagnosed with physical co-morbidities versus those without to assess whether a greater proportion of the former had died by overdose, and medication prescribed to treat such disorders (e.g. opioids, insulin). RESULTS 24% (n = 3525) were recorded as having physical co-morbidity. A greater proportion of these individuals died by self-poisoning than those without physical co-morbidity (37% vs. 20%, p < .001; adjusted OR 2.47; 95% CI 2.26-2.70), and they were more likely to have used medications for a physical health disorder in overdose (50% vs. 34%; adjusted OR 2.10; 95% CI 1.80-2.46), particularly opioids (30% vs. 22%; p < .001), paracetamol/opioid compounds (11% vs. 7%, p < .001) and insulin (4% vs. 1%, p < .001). LIMITATIONS Use of survey data may have resulted in under-reporting of physical health problems and/or overdose medications. CONCLUSIONS Overdose, rather than hanging, is the leading cause of suicide among psychiatric patients with physical co-morbidities, particularly using non-psychotropic medications. There is potential for means restriction in preventing suicide among these patients.
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Affiliation(s)
- Alexandra Pitman
- UCL Division of Psychiatry, University College London, UK; Camden & Islington NHS Foundation Trust, St Pancras Hospital, London NW1 0PE, UK.
| | - Su-Gwan Tham
- Centre for Mental Health and Safety, University of Manchester, UK
| | - Isabelle M Hunt
- Centre for Mental Health and Safety, University of Manchester, UK
| | - Roger T Webb
- Centre for Mental Health and Safety, University of Manchester, UK; Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, UK; NIHR Greater Manchester Patient Safety Translational Research Centre, UK
| | - Louis Appleby
- Centre for Mental Health and Safety, University of Manchester, UK
| | - Nav Kapur
- Centre for Mental Health and Safety, University of Manchester, UK; Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, UK; NIHR Greater Manchester Patient Safety Translational Research Centre, UK; Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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Erdoğan Y, Erturan İ, Aktepe E, Akyıldız A. Comparison of Quality of Life, Depression, Anxiety, Suicide, Social Anxiety and Obsessive-Compulsive Symptoms Between Adolescents with Acne Receiving Isotretinoin and Antibiotics: A Prospective, Non-randomised, Open-Label Study. Paediatr Drugs 2019; 21:195-202. [PMID: 31175639 DOI: 10.1007/s40272-019-00340-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The effects of isotretinoin on suicide, social anxiety and obsessive-compulsive symptoms in adolescents with acne have not been sufficiently investigated. OBJECTIVE This study aimed to evaluate the quality of life, depression, anxiety, suicide, social anxiety, and obsessive-compulsive symptoms of adolescents receiving systemic isotretinoin and antibiotic treatments at baseline and at 3 months. METHODS The study included a total of 102 adolescents using isotretinoin (n = 60) and antibiotics (n = 42). The Acne Quality of Life Scale (AQLS), Hospital Anxiety and Depression Scale (HADS), Suicide Probability Scale (SPS), Liebowitz Social Anxiety Scale (LSAS), and Maudsley Obsessive-Compulsive Question List (MOCQL) were administered to both groups at baseline and at 3 months. In order to exclude patients with comorbid psychiatric disorders, the patients were evaluated at the beginning of the study with the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL). RESULTS There were no significant differences in the mean age, gender distribution, educational level, and family history of mental illness between the two groups. There were significant decreases in the Global Acne Grading System scores, visual analogue scale scores, AQLS scores, total and subscale scores of LSAS, and total and subscale scores of MOCQL at 3 months compared with baseline in both groups. However, there were no significant changes in the total and subscale scores of HADS and total and subscale scores of SPS at 3 months compared with baseline in both groups. CONCLUSION We found that neither isotretinoin nor antibiotic treatment affected the levels of depression, anxiety, and suicide in acne patients. Moreover, both isotretinoin and antibiotic treatment were shown to improve the quality of life, social anxiety, and obsessive-compulsive symptoms in acne patients. However, clinicians should be careful about psychiatric side effects in patients using isotretinoin. Further studies with a larger number of cases and with a longer follow-up period are needed to investigate the complex effects of isotretinoin on the central nervous system.
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Affiliation(s)
- Yakup Erdoğan
- Department of Child and Adolescent Psychiatry, Suleyman Demirel University Faculty of Medicine, Isparta, Turkey
| | - İjlal Erturan
- Department of Dermatology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey.
| | - Evrim Aktepe
- Department of Child and Adolescent Psychiatry, Suleyman Demirel University Faculty of Medicine, Isparta, Turkey
| | - Abdulbaki Akyıldız
- Department of Child and Adolescent Psychiatry, Suleyman Demirel University Faculty of Medicine, Isparta, Turkey
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Droitcourt C, Nowak E, Rault C, Happe A, Le Nautout B, Kerbrat S, Balusson F, Poizeau F, Travers D, Sapori JM, Lagarde E, Rey G, Guillot B, Oger E, Dupuy A. Risk of suicide attempt associated with isotretinoin: a nationwide cohort and nested case-time-control study. Int J Epidemiol 2019; 48:1623-1635. [DOI: 10.1093/ije/dyz093] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Isotretinoin is the only effective treatment for severe acne. An isotretinoin-related suicide risk is still debated and under scrutiny by regulatory agencies. Our objectives were: to assess the risk of suicide attempt before, during and after isotretinoin treatment; to detect any potential triggering effect of isotretinoin initiation on suicide attempt.
Methods
We implemented a cohort and nested case-time-control study of subjects treated with oral isotretinoin (course or initiation) aged 10–50 years, using the Nationwide French Health Insurance data (2009–2016). The main outcome was hospitalized suicide attempt. Standardized incidence ratios for hospitalized suicide attempts were calculated before, during and after isotretinoin treatment. The number of isotretinoin initiations was compared in risk and control periods of 2 months using a case-time-control analysis.
Results
In all, 443 814 patients (median age 20.0 years; interquartile range 17.0–27.0 years) were exposed to isotretinoin, amounting to 244 154 person-years, with a marked seasonality for treatment initiation. Compared with the French general population, the occurrence of suicide attempts under isotretinoin treatment was markedly lower, with a standardized incidence ratio of 0.6 [95% confidence interval (CI) = 0.53–0.67]; the same applied, to a lesser extent, before and after isotretinoin treatment. In the case-time-control analysis, among cases of suicide attempt, 108 and 127 isotretinoin initiations were observed in the risk and control periods respectively (i.e. 0–2 months and 2–4 months before the date of suicide attempt). The comparison with the 1199 and 1253 initiations observed among matched controls in the same two periods yielded a case-time-control odds ratio of 0.89 (95% CI = 0.68–1.16). A sensitivity analysis using three-month periods and a complementary analysis adding completed suicides for case definition showed consistent results.
Conclusion
Compared with the general population, a lower risk of suicide attempt was observed among patients exposed to isotretinoin and there was no evidence for a triggering effect of isotretinoin initiation on suicide attempt. A selection of patients at lower risk for suicidal behaviour and appropriate treatment management could explain these findings. Risk management plans should therefore be maintained.
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Affiliation(s)
- Catherine Droitcourt
- Univ Rennes, EA 7449 REPERES [Pharmacoepidemiology and Health Services Research]
- PEPS Research Consortium (Pharmacoepidemiology for Health Product Safety), Rennes, France
- Department of Dermatology, CHU Rennes, Rennes, France
- INSERM, CIC 1414, Rennes, France
| | - Emmanuel Nowak
- PEPS Research Consortium (Pharmacoepidemiology for Health Product Safety), Rennes, France
- University of Bretagne Loire, University of Brest, France
- INSERM CIC 1412, CHRU Brest, Brest, France
| | - Caroline Rault
- Univ Rennes, EA 7449 REPERES [Pharmacoepidemiology and Health Services Research]
- PEPS Research Consortium (Pharmacoepidemiology for Health Product Safety), Rennes, France
| | - André Happe
- Univ Rennes, EA 7449 REPERES [Pharmacoepidemiology and Health Services Research]
- PEPS Research Consortium (Pharmacoepidemiology for Health Product Safety), Rennes, France
| | - Béranger Le Nautout
- Univ Rennes, EA 7449 REPERES [Pharmacoepidemiology and Health Services Research]
- PEPS Research Consortium (Pharmacoepidemiology for Health Product Safety), Rennes, France
| | - Sandrine Kerbrat
- Univ Rennes, EA 7449 REPERES [Pharmacoepidemiology and Health Services Research]
- PEPS Research Consortium (Pharmacoepidemiology for Health Product Safety), Rennes, France
| | - Frédéric Balusson
- Univ Rennes, EA 7449 REPERES [Pharmacoepidemiology and Health Services Research]
- PEPS Research Consortium (Pharmacoepidemiology for Health Product Safety), Rennes, France
| | - Florence Poizeau
- Univ Rennes, EA 7449 REPERES [Pharmacoepidemiology and Health Services Research]
- PEPS Research Consortium (Pharmacoepidemiology for Health Product Safety), Rennes, France
- Department of Dermatology, CHU Rennes, Rennes, France
| | - David Travers
- Department of Psychiatry, CHU Rennes, Rennes, France
| | | | - Emmanuel Lagarde
- INSERM, ISPED, Bordeaux Population Health Research Center INSERM U219 – “Injury Epidemiology Transport Occupation” Team, Bordeaux Cedex, France
| | | | - Bernard Guillot
- Department of Dermatology, CHU Montpellier, Montpellier, France
| | - Emmanuel Oger
- Univ Rennes, EA 7449 REPERES [Pharmacoepidemiology and Health Services Research]
- PEPS Research Consortium (Pharmacoepidemiology for Health Product Safety), Rennes, France
| | - Alain Dupuy
- Univ Rennes, EA 7449 REPERES [Pharmacoepidemiology and Health Services Research]
- PEPS Research Consortium (Pharmacoepidemiology for Health Product Safety), Rennes, France
- Department of Dermatology, CHU Rennes, Rennes, France
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Scailteux LM, Droitcourt C, Balusson F, Nowak E, Kerbrat S, Dupuy A, Drezen E, Happe A, Oger E. French administrative health care database (SNDS): The value of its enrichment. Therapie 2019; 74:215-223. [DOI: 10.1016/j.therap.2018.09.072] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 09/07/2018] [Indexed: 01/15/2023]
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Bray AP, Kravvas G, Skevington SM, Lovell CR. Is there an association between isotretinoin therapy and adverse mood changes? A prospective study in a cohort of acne patients. J DERMATOL TREAT 2019; 30:796-801. [PMID: 30717601 DOI: 10.1080/09546634.2019.1577545] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Adam P Bray
- Bristol Dermatology Centre, University Hospitals Bristol NHS Foundation Trust , Bristol , UK
| | - Georgios Kravvas
- Bristol Dermatology Centre, University Hospitals Bristol NHS Foundation Trust , Bristol , UK
| | - Suzanne M Skevington
- Manchester Centre for Health Psychology, School of Psychological Sciences, University of Manchester , Manchester , UK
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Costa CS, Bagatin E, Martimbianco ALC, da Silva EMK, Lúcio MM, Magin P, Riera R. Oral isotretinoin for acne. Cochrane Database Syst Rev 2018; 11:CD009435. [PMID: 30484286 PMCID: PMC6383843 DOI: 10.1002/14651858.cd009435.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Acne vulgaris, a chronic inflammatory disease of the pilosebaceous unit associated with socialisation and mental health problems, may affect more than 80% of teenagers. Isotretinoin is the only drug that targets all primary causal factors of acne; however, it may cause adverse effects. OBJECTIVES To assess efficacy and safety of oral isotretinoin for acne vulgaris. SEARCH METHODS We searched the following databases up to July 2017: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO and LILACS. We updated this search in March 2018, but these results have not yet been incorporated in the review. We also searched five trial registries, checked the reference lists of retrieved studies for further references to relevant trials, and handsearched dermatology conference proceedings. A separate search for adverse effects of oral isotretinoin was undertaken in MEDLINE and Embase up to September 2013. SELECTION CRITERIA Randomised clinical trials (RCTs) of oral isotretinoin in participants with clinically diagnosed acne compared against placebo, any other systemic or topical active therapy, and itself in different formulation, doses, regimens, or course duration. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 31 RCTs, involving 3836 participants (12 to 55 years) with mild to severe acne. There were twice as many male participants as females.Most studies were undertaken in Asia, Europe, and North America. Outcomes were generally measured between eight to 32 weeks (mean 19.7 weeks) of therapy.Assessed comparisons included oral isotretinoin versus placebo or other treatments such as antibiotics. In addition, different doses, regimens, or formulations of oral isotretinoin were assessed, as well as oral isotretinoin with the addition of topical agents.Pharmaceutical companies funded 12 included trials. All, except three studies, had high risk of bias in at least one domain.Oral isotretinoin compared with oral antibiotics plus topical agentsThese studies included participants with moderate or severe acne and assessed outcomes immediately after 20 to 24 weeks of treatment (short-term). Three studies (400 participants) showed isotretinoin makes no difference in terms of decreasing trial investigator-assessed inflammatory lesion count (RR 1.01 95% CI 0.96 to 1.06), with only one serious adverse effect found, which was Stevens-Johnson syndrome in the isotretinoin group (RR 3.00, 95% CI 0.12 to 72.98). However, we are uncertain about these results as they were based on very low-quality evidence.Isotretinoin may slightly improve (by 15%) acne severity, assessed by physician's global evaluation (RR 1.15, 95% CI 1.00 to 1.32; 351 participants; 2 studies), but resulted in more less serious adverse effects (67% higher risk) (RR 1.67, 95% CI 1.42 to 1.98; 351 participants; 2 studies), such as dry lips/skin, cheilitis, vomiting, nausea (both outcomes, low-quality evidence).Different doses/therapeutic regimens of oral isotretinoinFor our primary efficacy outcome, we found three RCTs, but heterogeneity precluded meta-analysis. One study (154 participants) reported 79%, 80% and 84% decrease in total inflammatory lesion count after 20 weeks of 0.05, 0.1, or 0.2 mg/kg/d of oral isotretinoin for severe acne (low-quality evidence). Another trial (150 participants, severe acne) compared 0.1, 0.5, and 1 mg/kg/d oral isotretinoin for 20 weeks and, respectively, 58%, 80% and 90% of participants achieved 95% decrease in total inflammatory lesion count. One RCT, of participants with moderate acne, compared isotretinoin for 24 weeks at (a) continuous low dose (0.25 to 0.4 mg/kg/day), (b) continuous conventional dose (0.5 to 0.7 mg/kg/day), and (c) intermittent regimen (0.5 to 0.7 mg/kg/day, for one week in a month). Continuous low dose (MD 3.72 lesions; 95% CI 2.13 to 5.31; 40 participants; one study) and conventional dose (MD 3.87 lesions; 95% CI 2.31 to 5.43; 40 participants; one study) had a greater decrease in inflammatory lesion counts compared to intermittent treatment (all outcomes, low-quality evidence).Fourteen RCTs (906 participants, severe and moderate acne) reported that no serious adverse events were observed when comparing different doses/therapeutic regimens of oral isotretinoin during treatment (from 12 to 32 weeks) or follow-up after end of treatment (up to 48 weeks). Thirteen RCTs (858 participants) analysed frequency of less serious adverse effects, which included skin dryness, hair loss, and itching, but heterogeneity regarding the assessment of the outcome precluded data pooling; hence, there is uncertainty about the results (low- to very-low quality evidence, where assessed).Improvement in acne severity, assessed by physician's global evaluation, was not measured for this comparison.None of the included RCTs reported birth defects. AUTHORS' CONCLUSIONS Evidence was low-quality for most assessed outcomes.We are unsure if isotretinoin improves acne severity compared with standard oral antibiotic and topical treatment when assessed by a decrease in total inflammatory lesion count, but it may slightly improve physician-assessed acne severity. Only one serious adverse event was reported in the isotretinoin group, which means we are uncertain of the risk of serious adverse effects; however, isotretinoin may result in more minor adverse effects.Heterogeneity in the studies comparing different regimens, doses, or formulations of oral isotretinoin meant we were unable to undertake meta-analysis. Daily treatment may be more effective than treatment for one week each month. None of the studies in this comparison reported serious adverse effects, or measured improvement in acne severity assessed by physician's global evaluation. We are uncertain if there is a difference in number of minor adverse effects, such as skin dryness, between doses/regimens.Evidence quality was lessened due to imprecision and attrition bias. Further studies should ensure clearly reported long- and short-term standardised assessment of improvement in total inflammatory lesion counts, participant-reported outcomes, and full safety accounts. Oral isotretinoin for acne that has not responded to oral antibiotics plus topical agents needs further assessment, as well as different dose/regimens of oral isotretinoin in acne of all severities.
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Affiliation(s)
- Caroline S Costa
- Universidade Federal de São PauloEmergency Medicine and Evidence Based MedicineRua Napoleão de Barros, 865São PauloSao PauloBrazil04024‐002
| | - Ediléia Bagatin
- Universidade Federal de São PauloDepartment of DermatologyRua Borges Lagoa, 508São PauloSão PauloBrazil04038‐000
| | - Ana Luiza C Martimbianco
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeCochrane BrazilRua Borges Lagoa, 564 cj 63São PauloSPBrazil04038‐000
| | - Edina MK da Silva
- Universidade Federal de São PauloEmergency Medicine and Evidence Based MedicineRua Napoleão de Barros, 865São PauloSao PauloBrazil04024‐002
| | - Marília M Lúcio
- Universidade Federal de São PauloBrazilian Cochrane CentreRua Pedro de Toledo, 598São PauloSão PauloBrazil04039‐001
| | - Parker Magin
- The University of NewcastleDiscipline of General Practice, School of Medicine and Public HealthNewbolds Buiding, University of Newcastle,University DriveNewcastleAustralia2308
| | - Rachel Riera
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeCochrane BrazilRua Borges Lagoa, 564 cj 63São PauloSPBrazil04038‐000
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Barbieri JS, Spaccarelli N, Margolis DJ, James WD. Approaches to limit systemic antibiotic use in acne: Systemic alternatives, emerging topical therapies, dietary modification, and laser and light-based treatments. J Am Acad Dermatol 2018; 80:538-549. [PMID: 30296534 DOI: 10.1016/j.jaad.2018.09.055] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 09/27/2018] [Accepted: 09/28/2018] [Indexed: 12/21/2022]
Abstract
Acne is one of the most common diseases worldwide and affects ∼50 million individuals in the United States. Oral antibiotics are the most common systemic agent prescribed for the treatment of acne. However, their use might be associated with a variety of adverse outcomes including bacterial resistance and disruption of the microbiome. As a result, multiple treatment guidelines call for limiting the use of oral antibiotics in the treatment of acne, although actual prescribing often does not follow these guidelines. In this review, the rationale for concerns regarding the use of oral antibiotics for the management of acne is reviewed. In addition, we will discuss our approach to complying with the intent of the guidelines, with a focus on novel topical agents, dietary modification, laser and light-based modalities, and systemic medications, such as spironolactone, combined oral contraceptives, and oral isotretinoin.
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Affiliation(s)
- John S Barbieri
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
| | - Natalie Spaccarelli
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - David J Margolis
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - William D James
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Affiliation(s)
- Andrea L Zaenglein
- From the Departments of Dermatology and Pediatrics, Penn State Hershey Medical Center, Pennsylvania State University College of Medicine, Hershey
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Thomazini BF, Dolder MAH. Effect of 60 and 90 days of isotretinoin treatment on the structure of the small intestine mucosa in young male Wistar rats. Interdiscip Toxicol 2018; 10:45-51. [PMID: 30123036 PMCID: PMC6096859 DOI: 10.1515/intox-2017-0007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 05/16/2017] [Indexed: 11/15/2022] Open
Abstract
Isotretinoin is a substance used in cases of severe acne and acne resistant to other treatments. This skin disease affects patients of all ages and can interfere with social life, especially in adolescents. The drug acts by suppressing sebaceous gland activity and creating an inhospitable environment for Propionibacterium acne. The integrity of the small intestine is important for correct nutrition and patient treatment. We intended to assess the small intestine structure after treatment with 5 mg/kg isotretinoin solution and after a period without the drug, which could be considered a rest period. Young male Wistar rats (n=24) were separated into 4 groups (n=6): C: water; D0: soybean oil; D5a: 5 mg/kg; D5b: 5 mg/kg for 60 days followed by 30 days of rest period. Soybean oil was used to dilute the drug and it was offered daily by gavage. The animals were euthanized and the duodenum, jejunum and ileum were collected for analysis with light and scanning electron microscopy. The treatment stimulated tissue proliferation in the jejunum and ileum but had no significant effect in the duodenum. The results also showed a modification in goblet cell frequency in the duodenum and ileum. A further finding was that some modifications disappeared during the rest period. The protocol showed that the small intestine was somewhat altered by the treatment yet no lasting damage was caused.
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Affiliation(s)
- Bruna Fontana Thomazini
- Department of Structural and Functional Biology, Biology Institute, State University of Campinas, Campinas - SP, Brazil
| | - Mary Anne Heidi Dolder
- Department of Structural and Functional Biology, Biology Institute, State University of Campinas, Campinas - SP, Brazil
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Bagatin E, Florez-White M, Arias-Gomez MI, Kaminsky A. Algorithm for acne treatment: Ibero-Latin American consensus. An Bras Dermatol 2018; 92:689-693. [PMID: 29166508 PMCID: PMC5674704 DOI: 10.1590/abd1806-4841.20177003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 05/25/2017] [Indexed: 02/01/2023] Open
Abstract
Acne is a chronic, immune-mediated, inflammatory disease with high prevalence
among adolescents. By compromising face, thorax and back, with the risk of
permanent scars, it has a negative impact on the quality of life. Effective,
safe and early treatment is the key to remission, while decreasing the risk of
physical and/or emotional sequelae. The Iberian-Latin American Group of Acne
Studies joined professionals with expertise and developed a practical
therapeutic algorithm, adapted to the reality of Latin American countries, Spain
and Portugal. This article intends to disseminate it with an updated review on a
rational, safe and effective acne treatment.
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Affiliation(s)
- Ediléia Bagatin
- Department of Dermatology - Escola Paulista de Medicina - Universidade Federal de São Paulo (EPM-Unifesp) - São Paulo (SP), Brazil
| | - Mercedes Florez-White
- Department of Dermatology, "Herbert Wertheim" College of Medicine- Florida International University - Florida, USA
| | | | - Ana Kaminsky
- Department of Dermatology, School of Medicine. Universidad de Buenos Aires, Argentina
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Thorlacius L, Cohen AD, Gislason GH, Jemec GB, Egeberg A. Increased Suicide Risk in Patients with Hidradenitis Suppurativa. J Invest Dermatol 2018; 138:52-57. [DOI: 10.1016/j.jid.2017.09.008] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/30/2017] [Accepted: 09/01/2017] [Indexed: 01/06/2023]
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Oliveira JM, Sobreira G, Velosa J, Telles Correia D, Filipe P. Association of Isotretinoin With Depression and Suicide: A Review of Current Literature. J Cutan Med Surg 2017; 22:58-64. [DOI: 10.1177/1203475417719052] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acne vulgaris, a condition that can affect people at any age, is the most common cause of referral to a dermatologist. Isotretinoin (ITT) is the most effective treatment available, but serious adverse effects, including a possible association with depression and suicide, limit its use. We review the current literature regarding the association of ITT with depression and suicide. Case reports and database studies show a clear association, and this association is biologically plausible. Although prospective studies have opposite results, limitations make them unsuitable to identify a subgroup of patients who may be at risk of developing depression or suicidal ideation with ITT. Overall, it seems some people might be at risk, particularly those with a personal or family history of mental disorder, but further studies are needed to identify those patients who would benefit from an early referral to a mental health professional when ITT is initiated. Currently, no conclusions can be drawn, and it seems appropriate to regularly screen all patients on ITT for depressive symptoms and suicidal ideation and promptly refer them to a mental health professional if any are found.
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Affiliation(s)
| | | | - Jorge Velosa
- Dr Nélio Mendonça Hospital, Funchal, Portugal
- Beatriz Ângelo Hospital, Loures, Portugal
| | - Diogo Telles Correia
- Santa Maria Hospital, Lisbon, Portugal
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Paulo Filipe
- Santa Maria Hospital, Lisbon, Portugal
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
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Le Moigne M, Bulteau S, Grall-Bronnec M, Gerardin M, Fournier JP, Jonville-Bera AP, Jolliet P, Dreno B, Victorri-Vigneau C. Psychiatric disorders, acne and systemic retinoids: comparison of risks. Expert Opin Drug Saf 2017; 16:989-995. [PMID: 28657366 DOI: 10.1080/14740338.2017.1344641] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The link between isotretinoin, treatment of a severe form of acne, and psychiatric disorders remains controversial, as acne itself could explain the occurrence of psychiatric disorders. This study aims at assessing the disproportionality of psychiatric adverse events reported with isotretinoin in the French National PharmacoVigilance Database, compared with other systemic acne treatments and systemic retinoids. MATERIALS AND METHODS Data were extracted from the French National PharmacoVigilance Database for systemic acne treatments, systemic retinoids and drugs used as comparators. Each report was subjected to double-blind analysis by two psychiatric experts. A disproportionality analysis was performed, calculating the number of psychiatric ADRs divided by the total number of notifications for each drug of interest. RESULTS Concerning acne systemic treatments: all 71 reports of severe psychiatric disorders involved isotretinoin, the highest proportion of mild/moderate psychiatric adverse events was reported with isotretinoin (14.1%). Among systemic retinoids, the highest proportion of severe and mild/moderate psychiatric events occurred with isotretinoin and alitretinoin. CONCLUSION Our study raises the hypothesis that psychiatric disorders associated with isotretinoin are related to a class effect of retinoids, as a signal emerges for alitretinoin. Complementary studies are necessary to estimate the risk and further determine at-risk populations.
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Affiliation(s)
- M Le Moigne
- a Dermato-Oncology Unit , University Hospital Hôtel-Dieu , Nantes , France
| | - S Bulteau
- b Addictology and Psychiatry Department , 'Behavioral Addictions/Complex Affective Disorders' Clinical Investigation Unit , Nantes , France
| | - Marie Grall-Bronnec
- b Addictology and Psychiatry Department , 'Behavioral Addictions/Complex Affective Disorders' Clinical Investigation Unit , Nantes , France.,c INSERM UMR 1246 , University of Nantes and Tours , Nantes et Tours , France
| | - M Gerardin
- d Clinical Pharmacology Department , CEIP, University Hospital Hôtel-Dieu , Nantes , France
| | | | - A P Jonville-Bera
- c INSERM UMR 1246 , University of Nantes and Tours , Nantes et Tours , France.,f Regional Pharmacovigilance Center, Department of Clinical Pharmacology , University Hospital of Tours , Tours , France
| | - Pascale Jolliet
- c INSERM UMR 1246 , University of Nantes and Tours , Nantes et Tours , France.,d Clinical Pharmacology Department , CEIP, University Hospital Hôtel-Dieu , Nantes , France
| | - Brigitte Dreno
- a Dermato-Oncology Unit , University Hospital Hôtel-Dieu , Nantes , France
| | - C Victorri-Vigneau
- c INSERM UMR 1246 , University of Nantes and Tours , Nantes et Tours , France.,d Clinical Pharmacology Department , CEIP, University Hospital Hôtel-Dieu , Nantes , France
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Gould TD, Georgiou P, Brenner LA, Brundin L, Can A, Courtet P, Donaldson ZR, Dwivedi Y, Guillaume S, Gottesman II, Kanekar S, Lowry CA, Renshaw PF, Rujescu D, Smith EG, Turecki G, Zanos P, Zarate CA, Zunszain PA, Postolache TT. Animal models to improve our understanding and treatment of suicidal behavior. Transl Psychiatry 2017; 7:e1092. [PMID: 28398339 PMCID: PMC5416692 DOI: 10.1038/tp.2017.50] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 01/16/2017] [Accepted: 02/01/2017] [Indexed: 02/08/2023] Open
Abstract
Worldwide, suicide is a leading cause of death. Although a sizable proportion of deaths by suicide may be preventable, it is well documented that despite major governmental and international investments in research, education and clinical practice suicide rates have not diminished and are even increasing among several at-risk populations. Although nonhuman animals do not engage in suicidal behavior amenable to translational studies, we argue that animal model systems are necessary to investigate candidate endophenotypes of suicidal behavior and the neurobiology underlying these endophenotypes. Animal models are similarly a critical resource to help delineate treatment targets and pharmacological means to improve our ability to manage the risk of suicide. In particular, certain pathophysiological pathways to suicidal behavior, including stress and hypothalamic-pituitary-adrenal axis dysfunction, neurotransmitter system abnormalities, endocrine and neuroimmune changes, aggression, impulsivity and decision-making deficits, as well as the role of critical interactions between genetic and epigenetic factors, development and environmental risk factors can be modeled in laboratory animals. We broadly describe human biological findings, as well as protective effects of medications such as lithium, clozapine, and ketamine associated with modifying risk of engaging in suicidal behavior that are readily translatable to animal models. Endophenotypes of suicidal behavior, studied in animal models, are further useful for moving observed associations with harmful environmental factors (for example, childhood adversity, mechanical trauma aeroallergens, pathogens, inflammation triggers) from association to causation, and developing preventative strategies. Further study in animals will contribute to a more informed, comprehensive, accelerated and ultimately impactful suicide research portfolio.
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Affiliation(s)
- T D Gould
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Pharmacology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - P Georgiou
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - L A Brenner
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Rocky Mountain Mental Illness Research Education and Clinical Center, Denver, CO, USA
- Military and Veteran Microbiome Consortium for Research and Education, U.S. Department of Veterans Affairs, Washington, DC, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - L Brundin
- Center for Neurodegenerative Science, Van Andel Research Institute, Grand Rapids, MI, USA
| | - A Can
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Psychology, Notre Dame of Maryland University, Baltimore, MD, USA
| | - P Courtet
- Department of Emergency Psychiatry and Post Acute Care, CHU Montpellier, Montpellier, France
- Université Montpellier, Inserm U1061, Montpellier, France
| | - Z R Donaldson
- Department of Molecular, Cellular, and Developmental Biology, University of Colorado Boulder, Boulder, CO, USA
- Department of Psychology, University of Colorado, Boulder, Boulder, CO, USA
- Department of Neuroscience, University of Colorado Boulder, Boulder, CO, USA
| | - Y Dwivedi
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - S Guillaume
- Department of Emergency Psychiatry and Post Acute Care, CHU Montpellier, Montpellier, France
- Université Montpellier, Inserm U1061, Montpellier, France
| | - I I Gottesman
- Department of Psychology, University of Minnesota, Minneapolis, MN, USA
- Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, USA
| | - S Kanekar
- Department of Psychiatry, University of Utah, Salt Lake City, UT, USA
| | - C A Lowry
- Rocky Mountain Mental Illness Research Education and Clinical Center, Denver, CO, USA
- Military and Veteran Microbiome Consortium for Research and Education, U.S. Department of Veterans Affairs, Washington, DC, USA
- Department of Integrative Physiology and Center for Neuroscience, University of Colorado Boulder, Boulder, CO, USA
- Department of Physical Medicine and Rehabilitation and Center for Neuroscience, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - P F Renshaw
- Rocky Mountain Mental Illness Research Education and Clinical Center, Denver, CO, USA
- Department of Psychiatry, University of Utah, Salt Lake City, UT, USA
| | - D Rujescu
- Department of Psychiatry, University of Halle-Wittenberg, Halle, Germany
| | - E G Smith
- Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
| | - G Turecki
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - P Zanos
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - C A Zarate
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - P A Zunszain
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - T T Postolache
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
- Rocky Mountain Mental Illness Research Education and Clinical Center, Denver, CO, USA
- Military and Veteran Microbiome Consortium for Research and Education, U.S. Department of Veterans Affairs, Washington, DC, USA
- VISN 5 Mental Illness Research Education and Clinical Center, Baltimore MD, USA
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Tan JKL, Shear N. Oral isotretinoin: ensuring safe use while not limiting access to those who need it. CMAJ 2017; 189:E510. [PMID: 28385900 DOI: 10.1503/cmaj.732920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Jerry K L Tan
- Dermatologist, Faculty of Medicine, Western University, London, Ont
| | - Neil Shear
- Professor, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ont
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