Isotretinoin use and subsequent depression and suicide: presenting the evidence

Risk of psychiatric events in women treated with isotretinoin: a self-controlled study with SIDIAP database

BACKGROUND

Since isotretinoin marketing, reports of psychiatric events have been noted. Howeverto date, a relation between these events and acne or isotretinoin treatment has not been clearly established. Our objective was to analyze the incidence of psychiatric events in women receiving isotretinoin.

METHODS

Self-controlled study including women treated with isotretinoin from July 2014 to December 2018. Data source was SIDIAP, a primary health care-based database from Catalonia, Spain. Risk of psychiatric events was analyzed during the isotretinoin exposure and during the previous and posterior periods of non-exposure.

RESULTS

We included 4,738 women in the study, 25.3% of them had history psychiatric disorders prior to receiving isotretinoin. During the follow-up, 782 (16.5%) patients were diagnosed with new mental disorders and 925 (19.5%) received new psychotropic drug prescriptions. We found a trend to an increase of new events when the previous non-exposure and the isotretinoin exposure periods were compared, with no significant differences. Incident psychiatric events during isotretinoin exposure was significantly higher in those patients with previous psychiatric history.

CONCLUSIONS

We cannot conclude any causality between acne and isotretinoin and the appearance of new psychiatric events. However, we contribute to the evidence with a more robust methodological approach, which minimizes the effect of confounding variables.

Isotretinoin and neuropsychiatric side effects: Continued vigilance is needed

Background

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

Methods

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

Results

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

Isotretinoin in Acne Vulgaris Complicated by Underlying Major Depression: A Case Report and Review of Literature

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.

Multiple Vaccinations and the Enigma of Vaccine Injury

A growing number of vaccines are administered at the same time or in close succession, increasing the complexity of assessing vaccine safety. Individual vaccines are assumed to have no other effect than protection against the targeted pathogen, but vaccines also have nonspecific and interactive effects, the outcomes of which can be beneficial or harmful. To date, no controlled trials and very few observational studies have determined the impact of vaccination schedules on overall health. The balance of the risks and benefits from mass vaccination therefore remains uncertain. Recent studies worryingly suggest links between multiple vaccinations and increased risks of diverse multisystem health problems, including allergies, infections, and neuropsychiatric or neurodevelopmental disorders. Here, we propose that, in susceptible persons, multiple vaccinations activate the retinoid cascade and trigger apoptotic hepatitis, leading to cholestatic liver dysfunction, in which stored vitamin A compounds (retinyl esters and retinoic acid) enter the circulation in toxic concentrations; this induces endogenous forms of hypervitaminosis A, with the severity of adverse outcomes being directly proportional to the concentration of circulating retinoids. In very low concentrations, vitamin A and its major metabolite retinoic acid contribute to immune function and to the process of immunization, whereas excess vitamin A increases the risk of adverse events, including common "side-effects" as well as chronic adverse outcomes. The increasing rates of allergy, ear infections, and neurodevelopmental disorders (NDDs) in countries with high rates of vaccination could be related to mass vaccination and to its impact on liver function and vitamin A metabolism, collectively representing endogenous manifestations of hypervitaminosis A. Further studies of health outcomes in vaccinated and unvaccinated groups are urgently needed, to increase understanding of the pathophysiology and treatment of vaccine injury, to identify the risk factors and screen for vaccine injury, to inform public health policy on potential hazards related to vaccination schedules, and to optimize the safety and benefits of vaccines.

Acne in the first three decades of life: An update of a disorder with profound implications for all decades of life

Acne vulgaris is a chronic, inflammatory, skin condition that involves the pilosebaceous follicles and is influenced by a variety of factors including genetics, androgen-stimulation of sebaceous glands with abnormal keratinization, colonization with Cutibacterium acnes (previously called Propionibacterium acnes), and pathological immune response to inflammation. Acne can occur at all ages and this discussion focuses on the first three decades of life. Conditions that are part of the differential diagnosis and/or are co-morbid with acne vulgaris are also considered. Acne in the first year of life includes neonatal acne (acne neonatorum) that presents in the first four weeks of life and infantile acne that usually presents between 3 and 6 months of the first year of life with a range of 3 to 16 months after birth. Acne rosacea is a chronic, inflammatory, skin condition that is distinct from acne vulgaris, typically presents in adults, and has four main types: erythemato-telangiectatic, papulopustular, phymatous and ocular. Treatment options for acne vulgaris include topical retinoids, topical benzoyl peroxide, antibiotics (topical, oral), oral contraceptive pills, isotretinoin, and others. Management must consider the increasing impact of antibiotic resistance in the 21st century. Psychological impact of acne can be quite severe and treatment of acne includes awareness of the potential emotional toll this disease may bring to the person with acne as well as assiduous attention to known side effects of various anti-acne medications (topical and systemic). Efforts should be directed at preventing acne-caused scars and depigmentation on the skin as well as emotional scars within the person suffering from acne.

Psychiatric and Developmental Effects of Isotretinoin (Retinoid) Treatment for Acne Vulgaris

BACKGROUND

An association between isotretinoin (13-cis-retinoic acid, sold under trade names including Accutane [Hoffmann-La Roche Inc, Basel, Switzerland]) and birth defects, depression, and suicide is well documented but controversial. A link to psychosis and exacerbation of bipolar symptoms is less extensively addressed in the literature.

OBJECTIVE

Given recent conceptualization of psychotic disorders as neurodevelopmental, and current interest in possible shared etiology of different neurodevelopmental disorders such as psychosis, autism, and intellectual disability, this review concurrently examines the literature on developmental (primarily teratogenic) and psychiatric side effects of isotretinoin exposure. The goal of concurrent review is to identify shared mechanisms in the literature that may inform future efforts to clarify the neurocognitive and psychiatric effects of isotretinoin exposure at different developmental stages or given different genetic backgrounds.

METHODS

Literature was obtained by PubMed search for the term isotretinoin in combination with each of the terms psychosis, psychiatric, and teratogenic. Resulting articles met inclusion criteria for review if they addressed psychiatric side effects of isotretinoin treatment or the neurobehavioral teratology of isotretinoin.

RESULTS

The association of isotretinoin exposure with prenatal developmental toxicity is well established. Although numerous reports also link isotretinoin treatment with psychiatric side effects, this association remains controversial.

CONCLUSIONS

The extent to which isotretinoin influences pediatric and adult development and cognition, and whether and why certain individuals may be susceptible to psychiatric side effects, remains to be clarified. Curr Ther Res Clin Exp. 2019; 80:XXX-XXX).

Gulf War Illness: Unifying Hypothesis for a Continuing Health Problem

An estimated 25%⁻32% of veterans of the 1991 Gulf War continue to experience multiple unexplained health problems known as Gulf War Illness (GWI). GWI encompasses chronic pain, musculoskeletal weakness, headache, fatigue, cognitive deficits, alterations in mood, and numerous multi-system complaints. Most potential exposures implicated in GWI were not well documented but included varying levels of several neurotoxicants as well as the anticholinergic drug pyridostigmine bromide (PB), which was routinely taken as prophylaxis against the nerve agent soman. While some veterans also took chloroquine as an antimalarial agent, the literature suggests an association between receipt of multiple vaccinations prior to or during the conflict (perhaps combined with other exposures), and GWI. In-theater exposures may account for any single individual veteran's ill health but many veterans of the same era who were not deployed overseas also suffer the same or similar symptoms. The features of GWI also overlap with those of fibromyalgia, chronic fatigue syndrome and multiple chemical sensitivity, in all of which liver dysfunction has been documented, suggesting a unifying hypothesis. It is proposed that multiple vaccinations, with concurrent or subsequent exposure to PB or additional chemical insults of a liver-damaging nature, plausibly explain the pathogenesis and the observed chronicity of GWI. The suggested mechanism for GWI is thus a chemically-induced impaired liver function, with the spillage of stored vitamin A compounds ("retinoids") into the circulation in toxic concentrations, resulting in an endogenous chronic form of hypervitaminosis A. Implications of the hypothesis are briefly reviewed.

A Microtube Array Membrane (MTAM) Encapsulated Live Fermenting Staphylococcus epidermidis as a Skin Probiotic Patch against Cutibacterium acnes

Antibiotics without selectivity for acne treatment may destroy the beneficial microbes in the human microbiome that helps to fight Cutibacterium acnes (C. acnes), a bacterium associated with inflammatory acne vulgaris. Probiotic treatment by direct application of live Staphylococcus epidermidis (S. epidermidis) onto the open acne lesions may run the risk of bloodstream infections. Here, we fabricated the polysulfone microtube array membranes (PSF MTAM) to encapsulate probiotic S.epidermidis. We demonstrate that the application of the encapsulation of S. epidermidis in PSF MTAM enhanced the glycerol fermentation activities of S. epidermidis. To mimic the granulomatous type of acne inflammatory acne vulgaris, the ears of mice were injected intradermally with C. acnes to induce the secretion of macrophage inflammatory protein-2 (MIP-2), a murine counterpart of human interleukin (IL)-8. The C. acnes-injected mouse ears were covered with a PST MTAM encapsulated with or without S.epidermidis in the presence of glycerol. The application of S.epidermidis-encapsulated PST MTAM plus glycerol onto the C. acnes-injected mouse ears considerably reduced the growth of C. acnes and the production of MIP-2. Furthermore, no S. epidermidis leaked from PSF MTAM into mouse skin. The S. epidermidis-encapsulated PST MTAM functions as a probiotic acne patch.

Prevalence and predictors of depressive symptoms among attendees of a tertiary care dermatology clinic in Muscat, Oman

BACKGROUND

Various studies have suggested that depression is more prevalent among patients with skin disorders than in the general population. Most of the studies addressing this subject involve Euro-American populations.

OBJECTIVES

The present study aimed to estimate the prevalence of depressive symptoms among patients with dermatological disorders and, then, to decipher the clinical-demographic factors associated with depressive symptoms.

METHODS

A cross-sectional analytical study was conducted among a random sample of patients attending a dermatology clinic in Muscat. The Patient Health Questionnaire-9 (PHQ-9) was used to screen for depressive symptoms. A logistic regression model was used to find the adjusted and unadjusted odds ratios (ORs).

RESULTS

A total of 260 patients participated in this study, with a response rate of 81%. The prevalence of depression symptoms was 24%. According to regression analysis, family history of depression, comorbid medical disorders, and treatment with topicals or isotretinoin were significant predictors of depression (OR = 9.41, 95% confidence interval [CI]: 2.27-39.05, P = 0.002; OR = 2.0, 95% CI: 1.2-3.21, P = 0.05; OR = 2.28, 95% CI: 1.09-4.76, P = 0.028; and OR = 2.78; 95% CI: 1.08-7.19, P = 0.035, respectively).

CONCLUSION

This study indicates that depressive symptoms are common among patients with dermatological disorders in Oman, particularly in those with a family history of depression and medical comorbidities, and those who use a specific dermatological medication. Screening for depression in patients attending dermatology clinics is essential in order to detect and promptly treat patients suffering from depression.

The 5-HT1A receptor in Major Depressive Disorder

Major Depressive Disorder (MDD) is a highly prevalent psychiatric diagnosis that is associated with a high degree of morbidity and mortality. This debilitating disorder is currently one of the leading causes of disability nationwide and is predicted to be the leading cause of disease burden by the year 2030. A large body of previous research has theorized that serotonergic dysfunction, specifically of the serotonin (5-HT) 1A receptor, plays a key role in the development of MDD. The purpose of this review is to describe the evolution of our current understanding of the serotonin 1A (5-HT1A) receptor and its role in the pathophysiology MDD through the discussion of animal, post-mortem, positron emission tomography (PET), pharmacologic and genetic studies.

Isotretinoin updates

Acne vulgaris is a chronic inflammatory disease of pilosebaceous follicles commonly affecting adolescents and young adults. This disease has a profound psychological impact on affected individuals and treatment has been shown to significantly improve both self-esteem and quality of life. Isotretinoin is an effective medication used primarily in severe cystic acne patients. Over the past 30 years, this medication has revolutionized the treatment of acne. However, despite its popularity there are numerous side effects associated with its use. Most of its side effects are predictable and dose dependent, which has led to the development of variable dose regimens. Unfortunately, rare but significant side effects (e.g., depression, inflammatory bowel disease) do occur and necessitate careful monitoring to improve clinical outcomes and minimize potential adverse events.

Inflammatory Acne in the Asian Skin Type III Treated with a Square Pulse, Time Resolved Spectral Distribution IPL System: A Preliminary Study

BACKGROUND AND AIMS

Acne remains a severe problem for both patients and clinicians. Various approaches using photosurgery and phototherapy have been reported with varying degrees of success and robustness of results. An improved intense pulsed light (IPL) system has become available with interesting beam characteristic which might improve IPL treatment of inflammatory acne in the Asian skin, Fitzpatrick type III/IV.

SUBJECTS AND METHODS

The 18 study subjects comprised 15 females and 3 males with active mild to moderately severe inflammatory acne (mean age 25.3 ± 7.70 yr, range 17-47 yr, Burton scale 1-4, all Fitzpatrick type III Asian skin). They were treated once (8 subjects) or twice (10 subjects) with an IPL system offering both square pulse and time resolved spectral distribution technologies (420 nm cut-off filter, 30 ms pulse, 8 - 12 J/cm(2), 2-3 passes). Clinical photography was taken at baseline and at 4 weeks after the final treatment. Percentage of acne clearance was assessed by an independent dermatological panel and graded from zero to 5, 5 being total clearance.

RESULTS

All subjects completed the study. Post-treatment side effects were mild and transient, with virtually no downtime or postinflammatory hyperpigmentation (PIH) experienced by any subject. All subjects had some improvement and no exacerbation was seen in any subject. Clearance was evaluated by the panel as grade 4 in 5 subjects, grade 3 in 8, grade 2 in 4 and grade 1 in 1, so that 14 of 18 subjects (78%) had clearance of at least 60%. Patient evaluation was in general slightly better than that of the panel.

CONCLUSIONS

The special beam characteristics of the IPL system used in the present preliminary study achieved good to very good results in the treatment of acne in the Fitzpatrick type III Asian skin without PIH induction. The results suggested that acne treatment in the Asian skin using this system is both safe and effective, and merits larger population studies to further optimize parameters and standardize top-up treatments.

Retinoic acid induces changes in electrical properties of adult neurons in a dose- and isomer-dependent manner

The electrical activity of neurons is known to play a role in neuronal development, as well as repair of adult nervous tissue. For example, the extension of neurites and motility of growth cones can be modulated by changes in the electrical firing of neurons. The vitamin A metabolite retinoic acid also plays a critical role during nervous system development and is also known to elicit regenerative responses, namely the induction, enhancement, and directionality of neurite outgrowth. However, no studies have previously reported the ability of retinoic acid to modify the electrical activity of neurons. In this study, we determined whether retinoic acid might exert effects on the nervous system by altering the electrical properties of neurons. Using cultured adult neurons from Lymnaea stagnalis, we showed that acute application of retinoic acid can rapidly elicit changes in neuronal firing properties. Retinoic acid caused the presence of atypical firing behavior such as rhythmic bursting and altered the shape of action potentials, causing increases in half-amplitude duration and decay time. Retinoic acid also caused cell silencing, whereby neuronal activity was halted within an hour. These effects of retinoic acid were shown to be both dose and isomer dependent. We then showed that the effects of retinoic acid on cell firing (but not silencing) were significantly reduced in the presence of an retinoid X receptor pan-antagonist HX531. This study suggests that some of the effects of retinoic acid during neuronal development or regeneration might possibly occur as a result of changes in electrical activity of neurons.

Systemic treatment of severe forms of acne: experience of using Isotretinoin in the Russian Federation

The article presents the results of a large-scale Russian program of the follow-up and treatment of acne patients with Isotretinoin (Roaccutane). The analysis of the results included information about 1,349 acne patients. In 71% of patients, the therapy was initiated at the dose of 0.5-1.0 mg/kg of the body weight. The average duration of treatment was 21.5±0.16 weeks while the average course dose was 119.9±0.8 mg/kg of the body weight. As many as 96% of patients achieved a positive result; women demonstrated a higher improvement rate than men. On the whole, Roaccutane was well-tolerated while adverse effects included dry lips (43.4%), dry skin in different areas (12.45%), retinoid dermatitis (6.45%), epistaxis (2.45%), conjunctivitis (1.41%) and hoarseness (0.22%). The Russian experience of using Roaccutane confirmed high efficacy of the systemic therapy for severe forms of acne.

Breastfeeding, retinoids, and postpartum depression: a new theory

Postpartum depression (PPD) is an international public health problem affecting at least 1 in 8 mothers. Known risk factors include: giving birth to a preterm or low birth weight infant, babies with greater symptoms of illness at age 4-6 weeks, formula feeding, younger maternal age, smoking, and fatigue. Prolonged breastfeeding is associated with a reduced risk of PPD but the mechanisms are not well understood. Interventions for PPD focusing on psychosocial risk factors have been largely unsuccessful, suggesting that the condition has a mainly biological basis. The hypothesis proposed for consideration is that breastfeeding protects against PPD by maintaining endogenous retinoids (vitamin A-related compounds) below a threshold concentration. In fact, breast milk is rich in retinoids; pregnant women accumulate retinoids in liver and breast in preparation for lactation; there is increasing evidence that retinoids in higher concentration are associated with cognitive disturbances and mood disorders, including depression and suicide; and prolonged lactation reduces maternal stores of retinoids. Consistent with this hypothesis, it is estimated that an amount of vitamin A is transferred from mother to infant during the first six months of exclusive breastfeeding equivalent to 76% of a dose known to cause acute vitamin A poisoning in an adult. Breastfeeding may thus have evolutionary-adaptive functions for both mother and infant, transferring vital nutrients to an infant unable to feed itself, yet at the same time providing a natural means of reducing potentially toxic concentrations of retinoids in the mother.

Mefloquine use, psychosis, and violence: a retinoid toxicity hypothesis

Mefloquine use has been linked to severe gastrointestinal and neuropsychiatric adverse effects, including cognitive disturbances, anxiety, depression, psychosis, and violence. The adverse effects of the drug are thought to result from the secondary consequences of hepatocellular injury; in fact, mefloquine is known to cause a transient, anicteric chemical hepatitis. However, the mechanism of mefloquine-associated liver damage and the associated neuropsychiatric and behavioral effects of the drug are not well understood. Mefloquine and other 8-amino-quinolines are the only antimalarial drugs that target the liver-stage malaria parasites, which selectively absorb vitamin A from the host. Vitamin A is also stored mainly in the liver, in potentially poisonous concentrations. These observations suggest that both the therapeutic effectiveness of mefloquine and its adverse effects are related to the ability of the 8-aminoquinolines to alter the metabolism of retinoids (vitamin A and its congeners). Several lines of evidence support the hypothesis that mefloquine neurotoxicity and other adverse effects reflect an endogenous form of hypervitaminosis A due to a process involving: mefloquine-induced dehydrogenase inhibition; the accumulation of retinoids in the liver; retinoid-induced hepatocellular damage; the spillage of stored retinoids into the circulation; and the transport of these compounds to the gut and brain in toxic concentrations. The retinoid hypothesis could be tested clinically by comparing cases of mefloquine toxicity and untreated controls in terms of retinoid profiles (retinol, retinyl esters, percent retinyl esters, and retinoic acid). Subject to such tests, retinoid profiling could provide an indicator for assessing mefloquine-associated adverse effects.

Mood changes, depression and suicide risk during isotretinoin treatment: a prospective study

BACKGROUND

Depression and mood changes appear as potentional side effects of isotretinoin in the Summary of Product Characteristics. There have been many studies treating this topic but in most cases not identifying any significant depression or suicide risk. To further investigate this issue, we conducted a prospective, uncontrolled study to evaluate mood changes and suicidal ideations in patients receiving isotretinoin therapy.

METHODS

One-hundred patients were included in our single center, no-blind, and no controlled prospective study. All patients completed the Beck's Depression Inventory, Version II (BDI-II) before the treatment, following the first month of the treatment and then every third month until finishing the isotretinoin therapy. All questionnaires were checked by a psychiatrist. Suicidal ideations were monitored. Statistical analysis of BDI-II scores was performed.

RESULTS

All patients completed the study. Before the treatment, six percent of the patients had suffered from depressive symptoms. During the isotretinoin treatment, we did not find any deterioration of depression problems in any of these patients. On the contrary, in most patients the depressive symptoms disappeared. Symptoms of depression occurred in two patients, in which case coexisting situational factors were found to be the cause. No occurrence of suicidal ideations was found.

CONCLUSIONS

We did not find any depressive symptoms or suicide risk caused by isotretinoin. On the contrary, a statistically significant improvement of BDI-II scores was found. In our opinion, patients have to be informed about the risk of depression but emphasizing the fact that it is very rare.

Important controversies associated with isotretinoin therapy for acne

Isotretinoin is a remarkably effective drug for severe, recalcitrant acne vulgaris. Soon after the drug's release in the early 1980s, a number of important adverse effects were reported subsequently leading to a variety of medical and medicolegal controversies. Three of these controversies will be highlighted concerning the putative role of isotretinoin in (1) depression and suicide, (2) inflammatory bowel disease, and (3) iPledge and pregnancy prevention programs. It appears that a very small subset of patients receiving isotretinoin for acne are at risk for depression, which is very manageable provided there is adequate patient awareness of the possibility, maximum communication between the patient and physician, and cessation of therapy if clinically important depression occurs (after which the depression rapidly resolves in a week or less). Multiple controlled studies actually suggest a very favorable effect of isotretinoin on depression and anxiety common in the population requiring isotretinoin. With regard to inflammatory bowel disease, in just one study, only ulcerative colitis association with isotretinoin reached statistical significance. The actual incidence of this association is strikingly low. Finally, it is clear that even the most recent pregnancy prevention program (iPledge) is no more successful than prior programs; there will likely always be a small number of female patients becoming pregnant while receiving isotretinoin for acne vulgaris.

Isotretinoin use and the risk of inflammatory bowel disease: a population-based cohort study

Limited evidence suggests that isotretinoin may be associated with inflammatory bowel disease (IBD). To explore this association, we conducted a retrospective population-based cohort study in British Columbia, Canada, among participants who were newly treated with isotretinoin or topical acne medications. The entire population of untreated provincial residents aged 12-29 years served as the reference group. During the 12-year study period, we identified 46,922 participants treated with isotretinoin, 184,824 treated with a topical acne medication, and 1,526,946 untreated individuals. Compared with untreated individuals, we observed no significant association between isotretinoin use and IBD (rate ratio (RR) 1.14; 95% confidence interval (CI) 0.92-1.41). As expected, we found no association with topical acne medications (RR 1.11; 95% CI 0.99-1.24). In prespecified secondary analyses, isotretinoin was associated with IBD among individuals aged 12-19 years (RR 1.39; 95% CI 1.03-1.87) and topical acne medications were associated with ulcerative colitis (RR 1.19; 95% CI 1.00-1.42). Our primary analyses found no association between isotretinoin and IBD. In prespecified secondary analyses, some evidence was found of associations with isotretinoin as well as topical acne medications, suggesting a possible association between IBD and acne itself. Additional research is needed to explore this possibility.

Management of acne scarring, part II: a comparative review of non-laser-based, minimally invasive approaches

Acne scarring is a commonly encountered yet extremely challenging problem to treat for the dermatologist. As acne scarring can lead to significant psychological distress and low self-esteem, it is of utmost importance to have effective and satisfying treatments in the physician's armamentarium. However, many treatments are unsatisfying, leading to patient disappointment and frustration. Although early treatment of acne lesions and inflammation with isotretinoin is beneficial in preventing acne scarring, many patients still present with troubling noticeable scars. Despite the advances in pharmacology and technology, scar treatment still remains suboptimal and is tainted with several adverse effects. However, some treatments can provide benefits. This review article exhaustively discusses and analyzes the various minimally invasive approaches to the treatment of acne scarring with an emphasis on pharmacologic agents, such as isotretinoin for atrophic acne scars and corticosteroids and chemotherapeutic drugs for hypertrophic scars. Intralesional injections of corticosteroids are efficacious in reducing keloid scar formation in addition to preventing recurrence following surgical excision. In-office and minimally invasive procedural management, including chemical peels, dermabrasion, tissue augmentation, and punch excision is also discussed. Superficial chemical peels are efficacious in treating atrophic scars with relatively few adverse effects and complications. Although dermabrasion is used less often with the advent of laser resurfacing, this technique remains as a viable option for those with atrophic scars. Post-inflammatory hyperpigmentation can be managed successfully with topical agents such as azelaic acid and hydroquinone. The efficacy of various treatment modalities is highlighted with a focus on choosing the correct modalities for specific scar types.

Retinoic acid and affective disorders: the evidence for an association

OBJECTIVE

Isotretinoin (13-cis-retinoic acid), approved by the US Food and Drug Administration for the treatment of acne, carries a black box warning related to the risk of depression, suicide, and psychosis. Retinoic acid, the active form of vitamin A, regulates gene expression in the brain, and isotretinoin is its 13-cis isomer. Retinoids represent a group of compounds derived from vitamin A that perform a large variety of functions in many systems, in particular the central nervous system, and abnormal retinoid levels can have neurologic effects. Although infrequent, proper recognition and treatment of psychiatric side effects in acne patients is critical given the risk of death and disability. This article reviews the evidence for isotretinoin's relationships with depression and suicidality.

DATA SOURCES

The PsycINFO, MEDLINE, and PubMed searchable database indexes were searched for articles published in the English language from 1960 to June 2010 using the key words isotretinoin, retinoids, retinoic acid, depression, depressive disorders, and vitamin A. Evidence examined includes (1) case reports; (2) temporal association between onset of depression and exposure to the drug; (3) challenge-rechallenge cases; (4) class effect (other compounds in the same class, like vitamin A, having similar neuropsychiatric effects); (5) dose response; and (6) biologically plausible mechanisms.

STUDY SELECTION

All articles in the literature related to isotretinoin, depression, and suicide were reviewed, as well as articles related to class effect, dose response, and biologic plausibility.

DATA EXTRACTION

Information from individual articles in the literature was extracted, including number of episodes of depression, suicidality, suicide, psychosis, violence and aggression, past psychiatric history, time of onset in relation to isotretinoin usage, medication dosage, duration of treatment, and dechallenge and challenge history.

RESULTS

The literature reviewed is consistent with associations of isotretinoin administration with depression and with suicide in a subgroup of vulnerable individuals.

CONCLUSIONS

The relationship between isotretinoin and depression may have implications for a greater understanding of the neurobiology of affective disorders.

Effective monitoring of isotretinoin safety in a pediatric dermatology population: a novel "patient symptom survey" approach

BACKGROUND

Assessment of adverse effects in pediatric patients on oral isotretinoin has not been standardized and the exact incidence is unknown.

OBJECTIVE

Our goal was to determine the usefulness of an isotretinoin symptom survey as a screening tool for assessment and quantification of adverse effects, including psychiatric symptoms, during isotretinoin treatment in a pediatric population of different age groups.

METHODS

We performed a retrospective chart review on a random sample of patients treated with isotretinoin at a tertiary pediatric dermatology clinic where patients completed an isotretinoin symptom survey at each visit. Responses were stratified by age group and psychiatric history.

RESULTS

The charts of 102 patients, representing 123 courses of isotretinoin and 760 treatment-months, were reviewed. A total of 722 (95.0%) symptom surveys were complete and 38 (5.0%) were incomplete/missing. Recorded side effects were similar to published adult data; dry lips/dry skin were reported in 94.25% and 72.13% of treatment-months of isotretinoin, respectively. Psychiatric symptoms were reported in 1.65%, with no statistical difference between patients with or without a mental health history. Patients aged 11 to 15 years had similar side-effect profiles to those aged 16 to 21 years. Impaired night vision, nosebleeds, and dry/bloodshot eyes were more common in the older age group.

LIMITATIONS

This was a retrospective chart review, with known limitations. The study was performed at a tertiary referral center for pediatric dermatology, possibly allowing patient selection bias.

CONCLUSIONS

The isotretinoin symptom survey appears to be an effective screening tool to standardize monitoring of isotretinoin side effects in the pediatric population.

Distribution of retinoic acid receptor-α immunoreactivity in the human hypothalamus

Retinoids, a family of molecules that is derived from vitamin A, are involved in a complex signaling pathway that regulates gene expression and controls neuronal differentiation in the central nervous system. The physiological actions of retinoids are mainly mediated by retinoic acid receptors. Here we describe the distribution of retinoic acid receptor α (RARα) in the human hypothalamus by immunohistochemistry. RARα immunoreactivity showed a widespread pattern throughout the hypothalamus, with high density in the suprachiasmatic nucleus (SCN), paraventricular nucleus (PVN), supraoptic nucleus (SON), infundibular nucleus and medial mamillary nucleus. No staining was observed in the sexually dimorphic nucleus of preoptic area, tuberomamillary nucleus and lateral hypothalamic area. RARα was co-localized with vasopressin (AVP) neurons in the SCN, PVN and SON, and co-localized with corticotropin releasing hormone (CRH) neurons in the PVN. These findings provide a neurobiological basis for the participation of retinoids in the regulation of various hypothalamic functions. As shown earlier, the co-localization of RARα in CRH neurons suggests that retinoids might directly modulate the hypothalamus-pituitary-adrenal axis in the PVN, which may have implications for the stress response and its involvement in mood disorders. Functional studies in the other sites of RARα localization have to follow in the future.

Systemic but not local administration of retinoic acid reduces early transcript levels of pro-inflammatory cytokines after experimental spinal cord injury

Early rises of pro-inflammatory cytokines play a key role in tissue damage and has detrimental consequences for functional outcome after spinal cord injury (SCI). All-trans retinoic acid (RA) has been shown to be a therapeutic agent reducing cytokine expression in vitro, but its use may be limited due to adverse side effects associated with systemic delivery. Local delivery of RA may circumvent adverse side effects, but may simultaneously reduce the therapeutic benefits of the therapy. Here, we investigated whether local or systemic RA treatment differentially affected pro-inflammatory cytokine expression early after rat SCI. Pro-inflammatory cytokines IL-1β, IL-6 and TNFα were investigated at 6h after moderate contusion injury of the thoracic (T9) spinal cord, when mRNA levels are known to peak. Rats were either treated with intrathecal RA (0, 2.5, 10, or 100ng) or received an intraperitoneal injection of RA (15mg/kg bodyweight). Surprisingly intrathecal RA up to amounts of 100ng did not attenuate SCI-induced increases in gene-expression of pro-inflammatory cytokines. In contrast, intraperitoneal RA rendered a 60%, 35% and 58% reduction of IL-1β, IL-6 and TNFα mRNA levels, respectively. Although local doses higher than 100ng RA may reduce pro-inflammatory cytokine gene-expression, such doses precipitate and possibly increase risks of adverse side effects. We conclude that in contrast to systemic delivery, intrathecal administration of RA up to doses of 100ng is ineffective in reducing early pro-inflammatory cytokine gene-expression. Future studies are required to investigate the effects of single intraperitoneal RA treatment on long-term SCI outcome.

13-Cis-retinoic acid decreases hypothalamic cell number in vitro

13-Cis-retinoic acid (13-cis-RA) causes depression-related behavior in mice. Hypothalamic dysregulation has been implicated in clinical depression. In fact, apoptosis of hypothalamic neurons may lead to depression after myocardial infarction. Our objective was to determine if 13-cis-RA affects cultured hypothalamic cell number. Treatment of GT1-7 hypothalamic cells with 10μM 13-cis-RA for 48h decreased cell growth to 45.6±13% of control. To determine if this decrease in cell number was due to 13-cis-RA acting as an oxidant, cells were treated with 13-cis-RA and ascorbic acid or butylated hydroxyanisole (BHA) for 24 or 48h. Neither antioxidant alleviated the inhibitory affects of 13-cis-RA. In addition, 13-cis-RA treatment did not increase superoxide anion production, indicating 13-cis-RA was not acting as an oxidant. To determine if 13-cis-RA was acting via retinoic acid receptors (RARs) to decrease cell number, GT1-7 cells were treated with 13-cis-RA and the RAR pan-antagonist, AGN 193109. Treatment with the RAR-antagonist blocked the ability of 13-cis-RA to decrease cell number, indicating this phenomenon was a RAR-independent mechanism. We hypothesize that the ability of 13-cis-RA to decrease hypothalamic cell number may contribute to the increased depression-related behaviors observed in mice.

Evaluation of depressive symptoms in acne patients treated with isotretinoin

BACKGROUND

There have been concerns about the association between isotretinoin therapy and depressive symptoms.

OBJECTIVE

The objective of this study is to evaluate whether there is an association between isotretinoin therapy and the onset of depression.

METHODS

A total of 50 patients with moderate to severe recalcitrant acne and 30 healthy volunteer people were enrolled in the study. Depressive symptoms and anxiety status were assessed at baseline and then 1 and 4 months after the initiation of isotretinoin treatment.

RESULTS

We detected improvement in Beck Depression Inventory (BDI) and State and Trait Anxiety Inventory (STAI) scores in acne patients after isotretinoin therapy. Statistically significant improvement in depressive symptoms began at the first month. Improvement in anxiety was detected later than the improvement in depressive symptoms and a statistically significant difference was detected between the first and the second follow-up.

CONCLUSIONS

Our results provide no relationship between isotretinoin use and depression in acne patients.

The involvement of retinoic acid receptor-alpha in corticotropin-releasing hormone gene expression and affective disorders

BACKGROUND

Corticotropin-releasing hormone (CRH) is considered the central driving force in the stress response and plays a key role in the pathogenesis of depression. Retinoic acid (RA) has been suggested by clinical studies to be associated with affective disorders.

METHODS

First, hypothalamic tissues of 12 patients with affective disorders and 12 matched control subjects were studied by double-label immunofluorescence to analyze the expression of CRH and retinoic acid receptor-alpha (RAR-alpha). Second, critical genes involved in the RA signaling pathways were analyzed in a rat model of depression. Finally, the regulatory effect of RAR-alpha on CRH gene expression was studied in vitro.

RESULTS

We found that the expression of RAR-alpha was colocalized with CRH neurons in human hypothalamic paraventricular nucleus (PVN). The density of RAR-alpha-immunoreactive neurons and CRH-RAR-alpha double-staining neurons was significantly increased in the PVN of patients with affective disorders. The ratio of the CRH-RAR-alpha double-staining neurons to the CRH-immunoreactive neurons in affective disorder patients was also increased. Recruitment of RAR-alpha by the CRH promoter was observed in the rat hypothalamus. A dysregulated RA metabolism and signaling was also found in the hypothalamus of a rat model for depression. Finally, in vitro studies demonstrated that RAR-alpha mediated an upregulation of CRH gene expression.

CONCLUSIONS

These results suggest that RAR-alpha might contribute to regulating the activity of CRH neurons in vivo, and the vulnerable character of the critical proteins in RA signaling pathways might provide novel targets for therapeutic strategies for depression.

On the association between low resting heart rate and chronic aggression: retinoid toxicity hypothesis

Low resting heart rate is a strong and consistent predictor of conduct disorder and chronic aggression. Explanations such as fearlessness and low arousal-induced stimulus-seeking have been offered, assuming a causal association between the phenomena, but the origin of low heart rate and its significance for understanding aggression and violence remain obscure. Retinoids (vitamin A and its congeners) play important roles in embryogenesis and neural development. Several lines of evidence also suggest a causal role of retinoids in aggression as well as cognitive and mood disorders. The hypothesis is proposed that retinoid overexpression in utero induces, via a noradrenergic-to-cholinergic switch, alterations in cardiac functioning and hemodynamics resulting in low resting heart rate, brain structural and functional changes, minor physical anomalies, and persistent aggression. Retinoid toxicity occurring early in pregnancy could represent a final common pathway by which various prenatal challenges result in conduct disorder and chronic aggression (e.g., maternal cigarette smoking, alcohol consumption, drug use, exposure to environmental chemicals, stress, trauma or infection). Implications of the model for understanding related aspects of chronic aggression are discussed, as well as strategies for prevention and treatment.

Impaired redox state and respiratory chain enzyme activities in the cerebellum of vitamin A-treated rats

Vitamin A is a micronutrient that participates in the maintenance of the mammalian cells homeostasis. However, excess of vitamin A, which may be achieved through increased intake of the vitamin either therapeutically or inadvertently, induces several deleterious effects in a wide range of mammalian cells, including neuronal cells. Vitamin A is a redox-active molecule, and it was previously demonstrated that it induces oxidative stress in several cell types. Therefore, in the present work, we investigated the effects of vitamin A supplementation at clinical doses (1000-9000IU/(kgday)) on redox environment and respiratory chain activity in the adult rat cerebellum. Glutathione-S-transferase (GST) enzyme activity was also measured here. The animals were treated for 3, 7, or 28 days with vitamin A as retinol palmitate. We found increased levels of molecular markers of oxidative damage in the rat cerebellum in any period analyzed. Additionally, vitamin A supplementation impaired cerebellar mitochondrial electron transfer chain (METC) activity. GST enzyme activity was increased in the cerebellum of rats chronically treated with vitamin A. Based on our results and data previously published, we recommend more caution in prescribing vitamin A at high doses even clinically, since there is a growing concern regarding toxic effects associated to vitamin A intake.

13-cis-retinoic acid alters the cellular morphology of slice-cultured serotonergic neurons in the rat

Retinoids influence cellular processes such as differentiation, proliferation and apoptosis via retinoic acid receptor (RAR) and retinoid X receptor (RXR), and have therapeutic applications in several cancers and dermatologic diseases. Recent reports indicate that depression occasionally occurs in patients using the acne drug Accutane, the active component of which is 13-cis-retinoic acid (13-cis-RA). Although impairment of serotonin (5-HT)-expressing neurons, including morphologic changes, is thought to be associated with depressive symptoms, the effects of 13-cis-RA on 5-HT neurons have not been examined. The present study demonstrated that 13-cis-RA alters the morphology of 5-HT neurons in cultured rat midbrain slices. The 13-cis-RA-induced changes were partially blocked by RXR and RAR antagonists. Furthermore, cotreatment with RAR and RXR agonists altered the morphology of 5-HT neurons to a greater extent than the individual application of each agonist. The morphologic changes were completely blocked by RXR antagonist, whereas RAR antagonist partially blocked the effects. These results suggest that 13-cis-RA exerts its action on slice-cultured 5-HT neurons, at least in part, through specific retinoid receptors. Moreover, RXR has a greater influence on the morphology of 5-HT neurons than RAR. The receptor-mediated actions of 13-cis-RA presented here may provide a clue for further research on depression associated with the use of 13-cis-RA.

Depression and suicidal behavior in acne patients treated with isotretinoin: a systematic review

Isotretinoin (13-cis retinoic acid) is an effective treatment for severe cystic or recalcitrant acne vulgaris; however, concerns have been raised regarding its potential association with depression and suicidal behavior. We sought to explore the proposed relationship between isotretinoin use and the risk of depression and attempted and completed suicide in patients with acne vulgaris by performing a systematic literature search for studies reporting primary data on depression and suicidal behavior in patients treated with isotretinoin for acne vulgaris. Nine studies met the qualifying criteria for our analysis. Rates of depression among isotretinoin users ranged from 1% to 11% across studies, with similar rates in oral antibiotic control groups. Overall, studies comparing depression before and after treatment did not show a statistically significant increase in depression diagnoses or depressive symptoms. Some, in fact, demonstrated a trend toward fewer or less severe depressive symptoms after isotretinoin therapy. This decrease was particularly evident in patients with pretreatment scores in the moderate or clinical depression range. No correlation between isotretinoin use and suicidal behavior was reported, although only one retrospective study presented data on this topic. Although the current literature does not support a causative association between isotretinoin use and depression, there are important limitations to many of the studies. The available data on suicidal behavior during isotretinoin treatment are insufficient to establish a meaningful causative association.

Effects of retinoic acids on the dendritic morphology of cultured hippocampal neurons

Vitamin A-derived retinoic acids (RAs) are known to exert a variety of biological actions, including modulatory effects on cell differentiation and apoptosis. A recent study has demonstrated that 13-cis-RA and all-trans-RA suppressed neurogenesis in the dentate gyrus of the hippocampus in adult mice. The present experiments were performed to see whether 13-cis-RA and all-trans-RA could alter the dendritic morphology of cultured hippocampal neurons via RA receptors: retinoic acid receptor (RAR) and retinoid X receptor (RXR). High doses of 13-cis-RA and all-trans-RA exerted a negative effect on the cultured hippocampal neurons, while a low dose of 13-cis-RA but not all-trans-RA caused a positive effect. The negative changes induced by 13-cis-RA and all-trans-RA were antagonized by RXR antagonists and RAR antagonists, respectively. The positive changes induced by a low dose of 13-cis-RA were blocked by both RXR antagonists and RAR antagonists. These results suggest that RAs at high concentrations cause a negative effect on the dendritic morphology of cultured hippocampal neurons through RA receptors, while RAs at low concentrations exert a positive influence on cultured hippocampal neurons.

Retinoid-mediated regulation of mood: possible cellular mechanisms

Vitamin A and its derivatives, the retinoids, have long been studied for their ability to alter central nervous system (CNS) development. Increasingly, it is recognized that sufficient levels of retinoids may also be required for adult CNS function. However, excess dietary vitamin A, due to the consumption of supplements or foods rich in vitamin A, has been reported to induce psychosis. In addition, 13-cis-retinoic acid (13-cis-RA, isotretinoin), the active ingredient in the acne treatment Accutane, has been reported to cause adverse psychiatric events, including depression and suicidal ideation. Nevertheless, epidemiological studies have reported no consistent link between Accutane use and clinical depression in humans. Using an animal model, we have recently shown that 13-cis-RA induces an increase in depression-related behavior. Impairments in spatial learning and memory have also been demonstrated following 13-cis-RA treatment in mice. This review focuses on the behavioral and possible cellular effects of retinoid deficiency or excess in the adult brain in relation to altered mood. Specifically, we discuss the effect of retinoids on depression-related behaviors and whether norepinephrinergic, dopaminergic, or serotonergic neurotransmitter systems may be impaired. In addition, we consider the evidence that adult neurogenesis, a process implicated in the pathophysiology of depression, is reduced by retinoid signaling. We suggest that 13-cis-RA treatment may induce depression-related behaviors by decreasing adult neurogenesis and/or altering the expression of components of serotonergic neurotransmitter system, thereby leading to impaired serotonin signaling.

The neurobiology of retinoic acid in affective disorders

Current models of affective disorders implicate alterations in norepinephrine, serotonin, dopamine, and CRF/cortisol; however treatments targeted at these neurotransmitters or hormones have led to imperfect resolution of symptoms, suggesting that the neurobiology of affective disorders is incompletely understood. Until now retinoids have not been considered as possible contributors to affective disorders. Retinoids represent a family of compounds derived from vitamin A that perform a large number of functions, many via the vitamin A product, retinoic acid. This signaling molecule binds to specific retinoic acid receptors in the brain which, like the glucocorticoid and thyroid hormone receptors, are part of the nuclear receptor superfamily and regulate gene transcription. Research in the field of retinoic acid in the CNS has focused on the developing brain, in part stimulated by the observation that isotretinoin (13-cis retinoic acid), an isomer of retinoic acid used in the treatment of acne, is highly teratogenic for the CNS. More recent work has suggested that retinoic acid may influence the adult brain; animal studies indicated that the administration of isotretinoin is associated with alterations in behavior as well as inhibition of neurogenesis in the hippocampus. Clinical evidence for an association between retinoids and depression includes case reports in the literature, studies of health care databases, and other sources. A preliminary PET study in human subjects showed that isotretinoin was associated with a decrease in orbitofrontal metabolism. Several studies have shown that the molecular components required for retinoic acid signaling are expressed in the adult brain; the overlap of brain areas implicated in retinoic acid function and stress and depression suggest that retinoids could play a role in affective disorders. This report reviews the evidence in this area and describes several systems that may be targets of retinoic acid and which contribute to the pathophysiology of depression.