Evaluating the therapeutic effects of isotretinoin on patients with coronavirus disease 2019 (COVID-19): A controlled open-label clinical trial

Coronavirus disease 2019 (COVID-19) is still a global health issue with no certain treatment option. So far, various treatments have been suggested among which one can mention isotretinoin. The aim of the present study was to investigate the potential of this medication as a side treatment for COVID-19. This open-label controlled clinical trial with the approval ID of IRCT20190624043993N3 was conducted in Farabi Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran. Considering the inclusion and exclusion criteria, 52 patients diagnosed with COVID-19 were enrolled. The control group only received standard of care (SOC) treatment while the intervention arm received 40 mg per day of isotretinoin along with the SOC. The patients were followed until discharge. The results showed no death among the groups. The hospitalization duration in the intervention and SOC groups were 5.1 ± 2.29 and 5.1 ± 3.44 days, respectively with no statistical difference (P = 0.98). Moreover, the SpO2, pulse rate, respiratory rate, and blood pressure also showed no statistical difference neither at admission nor upon discharge (P > 0.05). The laboratory investigations showed that white blood cells, absolute lymphocyte count, hemoglobin value, and platelet count did not differ between the groups at admission or upon discharge (P > 0.05). According to the results, it seems that isotretinoin didn't act as a potent side therapy in patients with COVID-19. However, due to the small sample size, we suggest further investigations.

Acne treatment challenges - Recommendations of Latin American expert consensus

BACKGROUND

Acne is a chronic inflammatory disorder of the pilosebaceous unit that is associated with a negative impact on quality of life, causing anxiety, depression, and poor self-esteem. The treatment of acne is not simple and presents some new challenges. This article addresses important issues faced by dermatologists on their daily, some of them specific for Latin America.

OBJECTIVE

To discuss daily practice recommendations when managing acne patients.

METHODS

A literature review was conducted by a group of eight experts with extensive experience in the field of acne. The results of the data review were presented at an initial kick-off meeting to align the consensus topics. Two e-surveys using the Delphi methodology and an interim group webinar meeting were held.

RESULTS

The expert panel reached a consensus on all proposed key statements, providing scientific support to help dermatologists and healthcare providers make acne management decisions on topics that can be challenging in the everyday practice of dermatology, such as the characteristics of Generation Z or the importance of the maintenance phase of adult acne treatment.

CONCLUSION

This article provides current recommendations for managing acne patients. The high level of agreement achieved based on the latest evidence supports the best acne therapeutic choices in both established topics and new important issues that have emerged in recent years, such as the impact of social media, Generation Z characteristics, and transgender male patient specifics.

Use of Oral Supplements and Topical Adjuvants for Isotretinoin-Associated Side Effects: A Narrative Review

Acne is a chronic inflammatory disease of the pilosebaceous unit with a multifactorial etiology and is one of the most common conditions treated by dermatologists and primary care physicians. Within an extensive and evolving treatment landscape, oral isotretinoin has demonstrated efficacy for treatment of severe, recalcitrant acne. Several side effects of isotretinoin have been reported, including laboratory abnormalities, mucocutaneous, and musculoskeletal effects, which may reduce compliance and patient satisfaction with treatment. In this narrative review, we aim to review the efficacy and safety profile of oral supplements or topical adjuvant therapies in mitigating isotretinoin-associated mucocutaneous and musculoskeletal side effects. Oral supplements reviewed include omega-3 fatty acids, vitamin E, folic acid and vitamin B12, antihistamines, l-carnitine, biotin, and combined oral supplements. Topical adjuvants include a hyaluronic acid, biosaccharide gum-2, and glycerine gel-cream; a nongreasy, noncomedogenic, fragrance-free moisturizing cream; dexpanthenol; trichloroacetic acid; and a combination cream. Most of the supplements and topical adjuvants demonstrated efficacy with an adequate level of supporting evidence and no reported adverse events, indicating an adequate safety profile. Patients on isotretinoin may benefit from using oral supplements and topical adjuvants to minimize primarily mucocutaneous side effects, increase adherence to treatment, and thereby improve overall outcomes.

Evaluation of the protective effects of curcumin-rich turmeric (Curcuma longa) extract against isotretinoin-induced liver damage in rats

AIM

The aim of this study was to evaluate the protective effect of curcumin-rich turmeric (CRT) extract against isotretinoin (ISO)-induced liver damage through routine biochemical parameters and oxidative stress parameters that indicate liver damage.

MATERIAL AND METHOD

42 albino Wistar rats of 200 g were randomly grouped as Group I: Healthy control, Group II: Sunflower oil, Group III: Curcumin 200 mg/kg, Group IV: ISO control groups (7.5 mg/kg), Group V: Curcumin 50 mg/kg + ISO 7.5 mg/kg, Group VI: Curcumin 100 mg/kg + ISO 7.5 mg/kg, Group VII: Curcumin 200 mg/kg + ISO 7.5 mg/kg. At the end, after the rats were killed, their blood and liver tissues were collected. ALT and AST levels in serum; superoxide dismutase activity (SOD), GSH, and MDA levels in liver tissue were determined.

RESULTS

Our results showed that ALT, AST, and MDA levels increased, and SOD and GSH levels decreased in the ISO-administered group compared to the healthy control group. CRT 50, 100, and 200 mg/kg groups were compared to ISO group. A dose-dependent increase in protective effect was observed. A decrease in ALT, AST, and MDA levels, and an increase in SOD and GSH levels were determined. A protective effect was found at all doses. The best protective effect was in the CRT 200 mg/kg group.

CONCLUSION

CRT extract can be considered a candidate herbal medicine for the elimination of liver damage in individuals using ISO. However, further experimental and clinical validation should be studied.

Therapie der okulären Rosazea: Eine systematische Literatur-Übersicht: Treatment of ocular rosacea: a systematic review

Die Rosazea ist eine häufige chronische Hauterkrankung, die sich hauptsächlich im mittleren Bereich des Gesichtes manifestiert. Die okulären Manifestationen der Rosazea wurden bisher nur unzureichend untersucht und bereits die Schätzungen der Prävalenz schwanken erheblich zwischen 6% und 72% der Gesamtpopulation aller Rosazea‐Patienten. Zu den Behandlungsmöglichkeiten der okuläre Rosazea gehören die Lidhygiene, topisch anwendbare antimikrobielle Substanzen, topisch oder oral verabreichte Antibiotika und Vitamin‐A‐Derivate, Cisclosporin‐haltige Emulsionen speziell für das Auge und IPL‐Behandlungen (intense pulsed light). Direkte Vergleiche zwischen den verschiedenen Therapieoptionen fehlen jedoch. Ziel dieser Literatur‐Übersicht ist es, die Wirksamkeit und Nebenwirkungen der verschiedenen Behandlungsmöglichkeiten der okulären Rosazea zu vergleichen. Dazu wurden systematische Datenbankrecherchen in Cochrane, MEDLINE und Embase durchgeführt. Titel, Abstrakt, Volltext und Daten wurden jeweils doppelt durchgesehen. Insgesamt erfüllten 66 Artikel mit einer kumulierten Patientenzahl von 1275 Patienten die Einschlusskriterien. Zu den wirksamsten Behandlungsoptionen zählten topisch anwendbare antimikrobielle Substanzen und die orale Gabe von Antibiotika. Damit konnte bei 91% (n  =  82/90) bzw. 89% (n  =  525/580) der Patienten ein vollständiges oder partielles Ansprechen erzielt werden. Es folgten die IPL‐Behandlung (89%, n  =  97/109 partielles Ansprechen), die Ciclosporin‐Augen‐Emulsion (87% n  =  40/46) und die Lidhygiene (65%, n  =  67/105). Kombinationsbehandlungen führten in 90% der Fälle (n  =  69/77) zu einem vollständigen bzw. partiellen Ansprechen. Diese Ergebnisse deuten darauf hin, dass eine topische Therapie mit antimikrobiellen Substanzen, Antibiotika per os, IPL und Ciclosporin‐haltige Emulsionen die effektivsten Einzelmaßnahmen zur Behandlung der okulären Rosazea darstellen.

A Severe Case of Isotretinoin Induced Eosinophilic Pneumonia and Pericardial Effusion, a Case Report

BACKGROUND

We report a case of a 25-year-old female who presented with fever, rash and general malaise.

CASE PRESENTATION

She was initially diagnosed and treated for peri-/myocarditis, but she deteriorated quickly with the development of extensive bilateral consolidations for which she was mechanically ventilated. Two weeks before admission, she took isotretinoin for less than a week for disfiguring acne. Diagnosis of drug-induced acute eosinophilic pneumoniae (EP) was made after excluding other causes of AEP. Even before starting steroid treatment, the patient improved significantly, which was in alignment with the elimination of the active metabolite of isotretinoin.

CONCLUSION

The presented case underlines the importance of performing a thorough history and consider recently started drugs as the cause of eosinophilic pneumoniae, even if they have not yet been described as a known trigger of drug-induced EP.

The impact of oral isotretinoin on ovarian functions of acne patients complaining of polycystic ovarian syndrome: a prospective study

BACKGROUND

Women have polycystic ovarian syndrome (PCOS) at higher rates than any other endocrine condition with an average incidence rate of 6 to 8%. Acne is an immune mediate common condition frequently affecting adolescents and adults and is often associated with PCOS. The objective of the study was to assess the impact of oral isotretinoin on ovarian functions of acne patients suffering from PCOS. Forty women with a clinical diagnosis of acne as well as PCOS participated in this prospective clinical trial. Participants were given oral doses of isotretinoin ranging from 0.5 to 1 milligram per kilogram (mg/kg), for a total of 120 to 150 mg/kg. To establish baseline values of hormone levels, on days 2-5 of the menstrual cycle, venous blood samples were obtained. Moreover, global acne grading system (GAGS), follicle count, and bilateral ovarian volumes were evaluated both before and after isotretinoin treatment.

RESULTS

A significant reduction in global acne score from pre-treatment levels to post-treatment levels was observed (11.58 ± 5.857 vs. 1.65 ± 1.369). Ovarian volume was significantly reduced from 10.26 ± 1.539 before treatment to 8.74 ± 1.436 after treatment on the right side (P < 0.001) and from 11.08 ± 1.564 before treatment to 9.36 ± 1.479 after treatment on the left side (P < 0.001). A significant reduction in free testosterone level and hirsutism scores were observed after treatment (P < 0.001; P < 0.01 respectively.

CONCLUSION

Isotretinoin may exert beneficial effects in hyperandrogenic women with PCOS and needs to be further evaluated by large multicentre controlled trials.

Practice and attitude of general practitioners towards initiating isotretinoin for acne vulgaris in Fars province, Iran: cross-sectional study

BACKGROUND

Since general practitioners manage acne-related referrals, there needs to be more information in Iran about how drugs such as Isotretinoin are prescribed and the treatment plan. Thus, this study aimed to evaluate general practitioners s' practices and attitudes in prescribing Isotretinoin for acne vulgaris in primary care.

METHODS

This web-based cross-sectional descriptive study was conducted using two questionnaires designed with the target population of GPs working in Fars province in 2021 regarding the prescription of Isotretinoin. Moreover, demographic information, questions about interest in dermatology, and participation in dermatology workshops were gathered.

RESULTS

A total of 308 complete questionnaires were obtained. According to our results, 85 (27.6%) GPs prescribed Isotretinoin in primary care. Based on our results, higher age (OR: 1.042; CI95%: 1.013-1.072; P-value:0.004) and attending dermatological courses (OR: 3.280; CI95%: 1.592-6.755; P-value:0.001) were significantly correlated with more frequent Isotretinoin administration. Among GPs who do not prescribe Isotretinoin, the most common causes are concerns about liver dysfunction (54.7%), teratogenic concerns (37.2%), and lack of familiarity with the drug (31.4%) respectively.

CONCLUSION

The results of this study depicted the reluctance of most physicians to prescribe Isotretinoin and factors such as taking part in supplementary courses under the supervision of dermatologists and following national guidelines that could encourage them to prescribe Isotretinoin.

A new perspective on isotretinoin in pregnancy: Pregnancy outcomes, evaluation of complex phenotypes, and importance of teratological counselling

OBJECTIVES

Teratogens are responsible for 5% of all known causes of congenital anomalies. Isotretinoin, a retinoic acid-derived agent, leads to congenital anomalies in 21-52% of cases when exposure occurs during pregnancy according to studies conducted before 2006. However, rates of congenital anomalies were much lower in later studies. The purpose of this study was to investigate the rates of congenital anomalies in isotretinoin exposure during pregnancy, isotretinoin exposure before pregnancy, and a control group unexposed to any teratogenic agents.

STUDY DESIGN

In this cohort study, we divided pregnant women admitted to our center between 2009 and 2020 into two groups: isotretinoin exposure before and during the pregnancy (n = 77) and isotretinoin exposure before the pregnancy (n = 75). We selected the control group from among the non-teratogen exposed pregnant women with a simple random sampling method. Obstetricians calculated the ages of all pregnancies via ultrasound (USG) (crown-rump diameter for the first trimester; biparietal diameter and femur length for the second trimester). After birth, a pediatric genetics specialist examined all babies. Whole-exome sequencing (WES) was conducted on the babies who displayed complex phenotypes.

RESULTS

Among the isotretinoin exposure before and during the pregnancy, isotretinoin exposure before the pregnancy, and the control groups, there were statistically significant differences in live births (respectively, 64.3 %, 88 %, 93.3 %), congenital anomalies (respectively, 28.6 %, 6.1 %, 1.4 %), miscarriages (respectively, 13 %, 2.7 %, 4 %), terminations (respectively, 32.5 %, 9.3 %, 2.7 %), and premature births (11.9 %, 16.7 %, 2.9 %) (respectively, p < 0.001, p < 0.001, p = 0.014, p < 0.001). We detected novel phenotypical features in five patients.

CONCLUSIONS

Our study demonstrated that study design, long-term follow-up, teratological counseling, and implementation of advanced molecular analysis in complex phenotypes with novel phenotypical features are beneficial for understanding the association of congenital anomalies with isotretinoin exposure. While evaluating congenital anomalies, we detected statistically significant differences between isotretinoin exposure before and during the pregnancy vs control, but we did not detect any statistically significant differences between isotretinoin exposure before the pregnancy and controls. Another finding of the study is that WES might be an efficient way to evaluate complex phenotypes in isotretinoin-exposed babies; however, further research is required.

Ocular side effects of systemic isotretinoin - a systematic review and summary of case reports

Background: Isotretinoin is frequently used for treatment of severe nodulocystic and papulopustular acne, however use is limited by mucocutaneous, ocular, and systemic side effects.Objective: (1) provide a systematic meta-analysis of ocular side effects during isotretinoin use and their corresponding incidences; (2) provide a narrative summary of ocular side effects during isotretinoin use reported in case reports.Methods: A systematic database search using predefined search terms was performed in PubMed, EMBASE, and Scopus from inception to 5 March, 2021. Predetermined inclusion and exclusion criteria were used to select included studies. In total, 53 original studies qualified for meta-analysis, and 41 case reports/series qualified for narrative results.Results: The studies included in the meta-analysis reported incidences of various ocular side effects including dry eye, eye sensitivity, vision changes, and ocular inflammatory conditions. Incidences across studies did vary, leading to considerable heterogeneity. The narrative results summarize more uncommon, but equally important, ocular side effects.Conclusions: Dry eye is the most commonly reported ocular side effect. Other less common, but more serious, ocular side effects including vision changes can occur. We recommend that isotretinoin prescribers monitor for dry eye. Limitations include the heterogeneity of reported incidences of ocular side effects between studies.

Evaluation of recovery time of tear film function and ocular surface after discontinuing oral isotretinoin treatment for acne vulgaris : Correlation between oral isotretinoin and tear film function

PURPOSE

This study aimed to evaluate the recovery time of tear film function and ocular surface after discontinuing systemic isotretinoin treatment.

METHODS

This was a prospective, cross-sectional study. 34 eyes of 17 patients treated with low- dose oral isotretinoin (< 0.5 mg/kg/day) were enrolled. The modified OSDI score, tear break-up time, Schirmer test, and corneal staining were performed in all patients at baseline, during the course of treatment and after withdrawing treatment every two weeks until the result returned to baseline.

RESULTS

Tear breakup time appeared to be the most sensitive and changed significantly at 2 weeks after starting treatment (p < 0.001) and returned to baseline at 4 weeks after withdrawal from treatment (p < 0.001). The Schirmer test results significantly decreased at 6 weeks and returned to baseline at 4 weeks after withdrawal from treatment (p < 0.001). OSDI scores were significantly changed at 6 weeks after treatment (81.8%) and returned to baseline at 2 weeks (54.5%) after withdrawal from treatment. No significant change was found in the MGD. Corneal staining was significantly positive 90.9% 6 weeks after starting treatment and returned to baseline 6 weeks after withdrawal from treatment (p < 0.001).

CONCLUSION

Dry eye disease can return to baseline levels after treatment withdrawal. At least 6 weeks later, they could wear contact lenses again, and it was useful to prepare all patients requiring further ocular surgery.

Community pharmacists' knowledge and awareness about isotretinoin therapy and its dispensing practice in Jordan

A validated self-reported questionnaire was used to evaluate pharmacists' knowledge about isotretinoin and their awareness of isotretinoin dispensing practice. The majority were not able to recognize the initial dose of isotretinoin, the potential side effects such as dyslipidemia and liver toxicity, the potential interaction with tetracycline and Vitamin A and the contraindications of isotretinoin. Around 41.3 % of the pharmacists dispensed isotretinoin without a prescription, and the majority did not recognize that isotretinoin should be dispensed for only 30 days, should not be dispensed without an emphasis on the appropriate indication, and did not know the appropriate duration of isotretinoin therapy. Male gender and postgraduate degree were associated with better awareness, while increased work experience and postgraduate degree were associated with better knowledge about isotretinoin therapy. Nevertheless, both male and female pharmacists demonstrated equivalent knowledge levels. The current study demonstrates the need to implement educational programs to improve pharmacists' knowledge and awareness about isotretinoin and its dispensing practice.

Awareness of isotretinoin use and safety in Saudi Arabia: A nationwide cross-sectional study

Introduction

Acne is a prevalent skin condition that affects numerous adolescents and adults worldwide. The most effective treatment for acne is isotretinoin, but its usage is associated with a wide range of adverse effects, and regular monitoring is necessary. Hence, appropriate usage with awareness of potential side effects is crucial. This study aimed to assess the knowledge and awareness of isotretinoin use and safety among individuals with acne in Saudi Arabia.

Methods

A national cross-sectional survey was conducted through an online self-administered questionnaire distributed via social media platforms. The questionnaire consisted of 27 questions in multiple-choice and Likert scale formats, covering demographics, patient awareness of isotretinoin use and side effects, satisfaction with clinical consultation and information provided. Descriptive statistics were used to summarize data.

Results

1315 participants completed the survey, of which most were female (74.1%), single (67.5%), and aged 18-25 years (48.9%). Dryness and teratogenicity were the most commonly known side effects of isotretinoin use (85.5% and 64.9% respectively). However, most participants were unaware of other side effects, such as psychiatric disorders (62.9%), altered liver enzyme concentrations (65.2%), hyperlipidemia (68.1%), anemia (92.4%), and decreased platelet count (96%). Moreover, 36% of sexually active females initiated isotretinoin without contraception. Regarding satisfaction with the information provided during clinical consultation, 63.2% of participants were very satisfied or satisfied. Doctors were the primary source of information (86.8%), followed by the internet (17.8%). Only 45% were informed to avoid blood donation during and after treatment for at least two months.

Conclusion

The study highlights the significance of providing patients with comprehensive information about the potential side effects of isotretinoin, including the need to use contraception and avoid blood donation during and after treatment. Effective communication between physicians and patients is critical in ensuring the safe and effective use of isotretinoin.

Clinical pharmacist role in improving the knowledge and outcomes in patients using isotretinoin: A randomized, controlled study

Objective

To evaluate the role of a clinical pharmacist in improving knowledge and outcomes among isotretinoin users.

Methods

Patients were randomly assigned to an intervention group (received education about isotretinoin by a clinical pharmacist in addition to the physician) and a control group (received routine education by the physician), then followed for three months. Patients' knowledge about isotretinoin optimal use, and side effects and their management and other outcomes were measured in both groups at baseline and at follow up after three months using a validated questionnaire.

Results

Two-hundred and three patients completed the study; 103 were in the intervention group and 100 in the control group. The knowledge improvement between baseline score and follow-up score was greater in the intervention group (mean = 2.835 ± 1.329) compared to the control group (mean = 0.530 ± 0.784) with mean differences = -2.30495, P < 0.001.

Conclusion

Implementing clinical pharmacy services in dermatology clinics can positively increase patients' level of knowledge about isotretinoin, which could reduce the severity of its side effects. Therefore, improving patients' quality of life, and improvement in acne.

Practice implications

Implementing clinical pharmacist services to patients using isotretinoin is feasible in an outpatient setting. Clinical pharmacist counseling and education improve the medication knowledge among patients who use isotretinoin.

Readability of iPledge materials for isotretinoin education in English and Spanish

iPledge is a program meant to reduce the incidence of pregnancy in patients using isotretinoin, a teratogenic acne medication. Adherence to the iPledge program is essential in preventing pregnancy complications among isotretinoin users. We present an analysis of the readability of both English and Spanish patient education materials published by iPledge. Readability grade levels for twelve iPledge documents were compared using both Lexile and graph-based methods (English: Fry; Spanish: Gilliam-Peña-Mountain). In both English and Spanish, aggregate Lexile grade levels are written below the 6th grade level; however, approximately one-third of pages are written above the 6th grade level. Aggregate graph-based grade levels are written above the 6th grade level as well. This suggests that iPledge materials should be rewritten at a lower grade level. Doing so may allow more patients to understand and utilize the important information presented in iPledge.

Oral isotretinoin in the treatment of juvenile acne and psychiatric adverse effects - a systematic review

PURPOSE

Acne vulgaris is a very prevalent dermatological condition, especially among adolescents and young adults up to 25 years old, classifying it as juvenile acne. One of the most effective treatments for severe acne is isotretinoin, a derivative of retinoic acid. Despite its high efficacy, this drug has been linked to several side effects including psychiatric adverse alterations, such as anxiety, depression and even suicide. With this systematic review we aim to determine if it is possible to establish a causal relation between oral isotretinoin in the treatment of juvenile acne and the appearance of psychiatric adverse effects.

MATERIALS AND METHODS

We searched two distinct databases, PubMed and Web of Science, and considered the work published between January 2000 and November 2021.

RESULTS

Out of the 599 identified articles, we included 19 studies in this systematic review. Globally, the results we found do not support an association between the use of isotretinoin for acne treatment and mental side effects and the safety of this drug appears to be assured. However, the individual characteristics of each adolescent and their environment should be considered; the personal and family history of mental disorders are pointed out as red flags we should look out for when treating these patients.

CONCLUSION

Despite this being a highly debated topic, especially among the dermatology community, more studies with larger populations and randomised controlled trials are necessary to increase the strength of the evidence presented.

Systemic isotretinoin therapy and central macular and choroidal thicknesses in acne vulgaris: is there any association?

PURPOSE

To investigate the effect of oral isotretinoin therapy on central macular thickness (CMT) thickness and choroidal thickness (CT) using optical coherence tomography (OCT).

METHODS

CT and CMT thickness of 43 eyes were evaluated at baseline, the third, and sixth month of isotretinoin therapy by spectral-domain OCT. For assessment of CT, OCT measurements were obtained at the fovea with six additional measurements at adjacent locations (at 500-1000 µm temporal to the fovea and 500-1000 µm nasal to the fovea).

RESULTS

Forty-three eyes from 43 patients with acne vulgaris, including 33 females (76.7%), who had a mean age of 24.81 ± 6.60 years, completed the study. The mean CMT was 231.49 ± 19.52 at the baseline and significantly decreased to 229.0 ± 19.57 (p = 0.02) and 229.28 ± 18.83 after three and six months, respectively (p < 0.03). The change in the macular thicknesses measured at four quadrants and choroidal thicknesses were not statistically significant during the study (p > 0.05).

CONCLUSION

The result of our study demonstrated choroidal thickness change is not significant in patients with acne vulgaris after systemic isotretinoin therapy during six months of follow-up. The decreased CMT amount was 2.2 microns; even if statistically significant, this amount is clinically insignificant.

Dendrimer-conjugated isotretinoin for controlled transdermal drug delivery

BACKGROUND

In the present study, we aimed to develop a novel isotretinoin delivery model for treating skin diseases, revealing its potential advantages in drug delivery and targeted therapy. Using a self-assembly strategy, we grafted a dendrimer, based on a well-defined branched structure for nanomedical devices, with a well-defined nanoarchitecture, yielding spherical, highly homogeneous molecules with multiple surface functionalities. Accordingly, a self-assembled dendrimer-conjugated system was developed to achieve the transdermal delivery of isotretinoin (13cRA-D).

RESULTS

Herein, 13cRA-D showed remarkable controlled release, characterized by slow release in normal tissues but accelerated release in tissues with low pH, such as sites of inflammation. These release characteristics could abrogate the nonteratogenic side effects of isotretinoin and allow efficient skin permeation. Moreover, 13cRA-D exhibited high therapeutic efficacy in acne models. Based on in vitro and in vivo experimental results, 13cRA-D afforded better skin penetration than isotretinoin and allowed lesion targeting. Additionally, 13cRA-D induced minimal skin irritation.

CONCLUSION

Our findings suggest that 13cRA-D is a safe and effective isotretinoin formulation for treating patients with skin disorders.

Environmentally friendly stability-indicating HPLC method for the determination of isotretinoin in commercial products and solubility samples

In this study, an environmentally friendly "high-performance liquid chromatography (HPLC)" assay to quantify isotretinoin (ITN) in commercial products and solubility samples is designed and verified. A Nucleodur reverse-phase C18 column was used as the stationary phase to identify ITN. The ecologically friendly mobile phase was composed of ethyl acetate and ethanol (50:50 v/v), and it was delivered at a flow rate of 1.0 mL/min. ITN was measured at 354 nm in wavelength. The current HPLC method had a determination coefficient of 0.9994 and was linear in the 0.2-80 μg/g range. The current protocol for ITN measurement was also rapid (retention time = 2.78 min), accurate (%recoveries = 98.60-101.52), precise (% uncertainties = 0.71-0.98), and sensitive. According to the AGREE methodology, the current procedure received an outstanding greenness profile with an AGREE score of 0.76. By determining ITN in commercial products and solubility samples, the applicability of the current approach was proven. ITN was discovered to be present in 98.43% and 100.84%, respectively, of commercial capsule brands A and B. The ITN's solubility in numerous eco-friendly solvents was successfully measured. Under different stress conditions, the current approach was able to distinguish between its degradation products, demonstrating its stability-indicating characteristics. These findings indicated that ITN in procured capsules and solubility samples might be regularly tested by the suggested approach.

The Effect of Oral Isotretinoin Therapy on Meibomian Gland Characteristics in Patients with Acne Vulgaris

INTRODUCTION

The aim of the study was to determine the effect of oral isotretinoin therapy on the functional and morphological condition of the anterior segment of the eye, with particular emphasis on the meibomian glands.

METHODS

Twenty-four patients (48 eyes) with a diagnosis of acne vulgaris were involved in the survey. All patients underwent a thorough ophthalmological examination at three time points: before therapy, 3 months after the start of therapy, and 1 month after the completion of isotretinoin therapy. The physical examination included the following elements: blink rate, analysis of the lid margin abnormality score (LAS), tear film break-up time (TFBUT) and Schirmer's test, meibomian gland loss (MGL), and the evaluation of the meibum quality score (MQS) and meibum expressibility score (MES). Additionally, the total score of an ocular surface disease index (OSDI) questionnaire was analysed.

RESULTS

In comparison with pretreatment values, significant increases in OSDI during and after the treatment (p = 0.003 and p = 0.004, respectively) were observed. Substantial deterioration during the treatment was observed for MGL (p < 0.0001), MQS (p < 0.001) and LAS (p < 0.0001), while an improvement in those parameters after isotretinoin cessation was observed (p = 0.006, p = 0.02 and p = 0.0003, respectively). The frequency of using artificial eye drops was positively associated with MGL during (Spearman's rank correlation coefficient (Rs) =  + 0.31; p = 0.03) and after the cessation of the therapy (Rs =  + 0.28; p = 0.04). Meibomian gland atrophy correlated significantly with MQS during (Rs =  + 0.29; p = 0.04) and after treatment (Rs =  + 0.38; p = 0.008). The decrease in TFBUT values correlated with increased LAS (Rs = - 0.31; p = 0.03) during the course of isotretinoin usage. We found no changes in Schirmer's test or blink rates.

CONCLUSION

Isotretinoin therapy leads to increased ocular complaints related to lipid tear film component dysfunction. This is due to reversible changes in meibomian gland morphology and function observed during drug usage.

Treatment of Acne with Isotretinoin Should Be Avoided in Patients with Hidradenitis Suppurativa "Conglobata Phenotype"

BACKGROUND

Acne conglobata (AC) and nodulocystic acne have long been confused clinically, despite the presentation and the response to treatment being different. AC and hidradenitis suppurativa (HS) resemble each other; a subtype of HS called "conglobata phenotype" has recently been reported in a large Dutch cohort. Acne vulgaris and HS are often associated. Isotretinoin is typically ineffective in treating HS and may even aggravate it, but it is often indispensable in treating acne vulgaris.

OBJECTIVE

The aim of the study was to assess whether isotretinoin may be used safely in adults with both HS and acne vulgaris and when it might be contraindicated.

MATERIALS AND METHODS

Belgian HS patients from the European Registry for Hidradenitis Suppurativa Registry (ERHS) reporting a history of severe acne of the face and/or the back, and who have ever used isotretinoin for their acne, were all selected. Patients whose acne worsened on isotretinoin were compared to patients whose acne did not worsen (improvement or no change).

RESULTS

Among the 82 selected patients, 10 (12.2%) report that their acne was aggravated while taking isotretinoin, while 72 (87.8%) report that their acne was not aggravated on isotretinoin. Of the 10 HS patients whose acne worsened with isotretinoin, 9 (90%) were men (p = 0.04) and 8 (80%) were HS "conglobata phenotype" (p < 0.001). In contrast, 47 (65.3%) of the 72 patients whose acne did not worsen on isotretinoin belonged to the HS "regular phenotype" (p = 0.01). On multivariate analysis, the item most strongly associated with poor response to isotretinoin was the HS "conglobata phenotype," followed by body mass index (BMI) (worse response to isotretinoin if BMI >25 kg/m2). Additionally, of 26 patients who received isotretinoin while their HS had already started, only 6 (23.1%) reported isotretinoin effectiveness on their HS.

CONCLUSION

Subject to confirmation by larger studies, our study suggests that isotretinoin should be avoided in the treatment of acne in HS patients with the HS "conglobata phenotype," as it may worsen the acne, likewise being male or having a BMI above 25 seems to increase this risk of a bad therapeutic outcome. Patients with an HS "regular phenotype" appear to be at a reduced risk of isotretinoin treatment worsening their acne.

Isotretinoin treatment upregulates the expression of p53 in the skin and sebaceous glands of patients with acne vulgaris

The transcriptomic regulation induced by isotretinoin (13-cis retinoic acid) is still a matter of debate as short-term exposures of immortalized sebocytes with isotretinoin produced conflicting results. Based on translational evidence, it has been hypothesized that oral isotretinoin treatment upregulates the expression of the transcription factor p53. Twenty-five patients suffering from acne vulgaris were treated with isotretinoin (0.6 mg/kg body weight) for 6 weeks. Biopsies from back skin were taken before and after isotretinoin treatment for the determination of p53 expression by immunohistochemical staining, quantification of p53 protein concentration by enzyme-linked immunosorbent assay and TP53 gene expression by quantitative reverse transcription real time PCR. Fifteen socio-demographically cross-matched healthy volunteers served as controls. Isotretinoin treatment significantly increased the nuclear expression of p53 in sebaceous glands of treated patients compared to pre-treatment levels and p53 levels of untreated controls. Furthermore, the p53 protein and gene expression significantly increased in the skin after treatment. The magnitude of p53 expression showed an inverse correlation to acne severity score and body mass index. Under clinical conditions, isotretinoin induced the expression of p53, which controls multiple transcription factors involved in the pathogenesis of acne vulgaris including FoxO1, androgen receptor and critical genes involved in the induction of autophagy and apoptosis. Increased p53-FoxO1 signalling enhanced by systemic isotretinoin treatment explains the underlying transcriptomic changes causing sebum suppression but also the adverse effects associated with systemic isotretinoin therapy.

Effectiveness of the repurposed drug isotretinoin in an experimental murine model of Chagas disease

Benznidazole and nifurtimox are the drugs currently used for the treatment of Chagas disease, however its side effects may affect patient adherence. In the search for new alternative therapies, we previously identified isotretinoin (ISO), an FDA-approved drug widely used for the treatment of severe acne through a drug repurposing strategy. ISO shows a strong activity against Trypanosoma cruzi parasites in the nanomolar range, and its mechanism of action is through the inhibition of T. cruzi polyamine and amino acid transporters from the Amino Acid/Auxin Permeases (AAAP) family. In this work, a murine model of chronic Chagas disease (C57BL/6 J mice), intraperitoneally infected with T. cruzi Nicaragua isolate (DTU TcI), were treated with different oral administrations of ISO: daily doses of 5 mg/kg/day for 30 days and weekly doses of 10 mg/kg during 13 weeks. The efficacy of the treatments was evaluated by monitoring blood parasitemia by qPCR, anti-T. cruzi antibodies by ELISA, and cardiac abnormalities by electrocardiography. No parasites were detected in blood after any of the ISO treatments. The electrocardiographic study of the untreated chronic mice showed a significant decrease in heart rate, while in the treated mice this negative chronotropic effect was not observed. Atrioventricular nodal conduction time in untreated mice was significantly longer than in treated animals. Mice treated even with ISO 10 mg/kg dose every 7 days, showed a significant reduction in anti-T. cruzi IgG levels. In conclusion, the intermittent administration of ISO 10 mg/kg would improve myocardial compromise during the chronic stage.

Topical Isotretinoin (TMB-001) Treatment for 12 Weeks Did Not Result in Clinically Relevant Laboratory Abnormalities in Participants with Congenital Ichthyosis in the Phase 2b CONTROL Study

INTRODUCTION

Treatment with oral retinoids can be effective in patients with congenital ichthyosis (CI) but may be associated with clinically significant laboratory changes. In this Phase 2b CONTROL study analysis, we characterize the effects of TMB-001, a novel topical isotretinoin formulation, on laboratory values in participants with X-linked recessive (XLRI) and autosomal recessive lamellar (ARCI-LI) ichthyosis at 12 weeks.

METHODS

A randomized, double-blind, vehicle-controlled, Phase 2b study was conducted with participants ≥ 9 years of age with confirmed XLRI and ARCI-LI. Participants were randomized 1:1:1 and stratified by CI subtype to receive TMB-001 0.05%:TMB-001 0.1%:vehicle twice daily for 12 weeks. Laboratory analyses were performed at screening and Week 12.

RESULTS

Among 33 enrolled participants (TMB-001 0.05% n = 11, TMB-001 0.1% n = 10, and vehicle n = 12), 52% had ARCI-LI and 48% had XLRI. At 12 weeks, there were single reports of anemia, neutropenia, leukopenia, lymphocytosis, and leukocytosis after vehicle treatment; neutropenia was reported in one participant receiving TMB-001 0.1%. There were single reports of abnormal biochemistry values-liver enzymes, creatinine, urea nitrogen, hyperkalemia, and hyperproteinemia-across treatment cohorts. Non-fasting hyperglycemia was observed in three participants receiving TMB-001 0.1% and one participant receiving vehicle. Urinalysis abnormalities reported in > 1 participant included urobilinogen (TMB-001 0.1% n = 2, vehicle n = 2), protein (TMB-001 0.1% n = 3, vehicle n = 2), and leukocyte esterase (TMB-001 0.1% n = 2). Laboratory parameter changes were asymptomatic and did not require study discontinuation or drug withdrawal.

CONCLUSION

There were no clinically significant laboratory changes in participants receiving TMB-001 isotretinoin ointment through 12 weeks of treatment, which differs from reported results for systemic isotretinoin.

TRIAL REGISTRATION

NCT04154293.

Optimal laboratory testing protocol for patients with acne taking oral isotretinoin

BACKGROUND

Isotretinoin is a widely prescribed drug for various dermatological conditions, especially acne. Blood tests are routinely performed to monitor its side effects. However, the optimal testing schedule remains controversial.

AIM

To evaluate the laboratory monitoring tests and schedules of patients with acne taking isotretinoin to determine the most efficient testing regimen.

METHODS

We retrospectively reviewed electronic medical records from the Dermatology Department of Dongguk University Ilsan Hospital from 2005 to 2020 for patients prescribed isotretinoin for acne who underwent monthly blood tests.

RESULTS

Aspartate aminotransferase (AST), alanine aminotransferase (ALT), and triglyceride (TG) levels significantly changed between 5 and 6 mo when the total prescription period and dose variables were considered altogether. The high-density lipoprotein level also significantly changed between 5 and 6 mo. However, low-density lipoprotein (LDL) and total cholesterol levels significantly changed between 1 and 2 mo.

CONCLUSION

We recommend testing AST, ALT, and TG levels once every 5 to 6 mo. We also suggest testing LDL and total cholesterol levels during the first and second months.

academic medical center

Systemic isotretinoin is a highly effective treatment for severe and refractory acne but carries risk for serious adverse effects such as teratogenicity. The risk mitigation system used in the United States, iPLEDGE, requires all patients on isotretinoin therapy to complete monthly tasks including follow-up visits with their prescriber, and patients with childbearing potential must additionally undergo monthly pregnancy testing. Female patients seeking isotretinoin are disproportionately affected by iPLEDGE-related barriers and have historically been prescribed isotretinoin less than male patients. The onset of the COVID-19 pandemic and updated regulations permitting at-home pregnancy testing and telehealth for monthly follow-up visits presented an opportunity to study the impact of these changes on the isotretinoin gender gap. We performed a single-center analysis to determine whether gender differences in isotretinoin prescription changed at our institution at the beginning of the pandemic. We found that male predominance of isotretinoin prescriptions was greater during the pandemic compared to pre-pandemic (odds ratios: 4.13 vs. 2.86). Furthermore, male patients were more likely to utilize telehealth compared to in-person visits for isotretinoin follow-up relative to female patients (odds ratios: 6.00 vs. 3.62). Despite the newly introduced flexibilities of telehealth and remote pregnancy testing, gender inequity in receiving isotretinoin treatment persists.

Therapeutic inertia during isotretinoin treatment of juvenile acne by dermatologists, paediatricians and general practitioners

BACKGROUND

Isotretinoin is an effective treatment for severe juvenile acne, but it appears to be underused in relation to the recommendations. Therapeutic inertia is defined as a failure to initiate or intensify treatment even when warranted by the recommendations. The aim of this study was to investigate therapeutic inertia among dermatologists (D), paediatricians (P), and general practitioners (GPs) in initiating isotretinoin for moderate-to-very severe juvenile acne.

METHODS

Data were collected using a questionnaire distributed to French physicians through medical societies via Internet. The questions explored the role in inertia of factors related to physicians, patients, parents, and the healthcare system, and evaluated barriers and facilitators to prescribing isotretinoin.

RESULTS

In all, 768 physicians responded to the survey (528 D, 178P, and 61 GPs; mean age: 51 years; women: 78 %). Their responses revealed that 99 % of dermatologists felt comfortable prescribing isotretinoin, compared with 8 % and 15 % of paediatricians and GPs (p < 0.05); 93 % of dermatologists were aware of the current guidelines compared with 37 % of paediatricians and GPs. Under 50 % of the physicians had received training on acne in the previous 3 years, regardless of specialty. The most frequently identified factors for inertia were concerns over the psychological consequences of the treatment in adolescents, exclusive requests from parents, and patient unavailability. Paediatricians reported having insufficient knowledge of current recommendations, a lack of training, and a tendency to anticipate poor compliance. Paediatricians and GPs considered that access to first-time prescriptions and peer-to-peer exchanges would constitute facilitating factors in their use of isotretinoin.

DISCUSSION

Concerns over the psychiatric consequences of isotretinoin in adolescents, the need for frequent follow-up, and lack of continuing medical education were identified as factors favouring inertia in the initiation of isotretinoin treatment in patients with moderate-to-very severe juvenile acne, particularly among paediatricians and GPs. Potential strategies to overcome these barriers include regular training, simplified recommendations in French, and access to first-time prescription for paediatricians and GPs.

Clinical Factors Affecting the Effectiveness of 1550-nm Erbium-Doped Fractional Photothermolysis Laser for Individual Atrophic Acne Scar Types

INTRODUCTION

Although non-ablative fractional resurfacing is frequently used for atrophic acne scars, few studies have examined clinical factors affecting the effectiveness of non-ablative fractional laser in individual atrophic acne scar types (icepick, rolling, and boxcar scars). Herein, we evaluated the clinical factors affecting the effect of non-ablative fractional laser for individual atrophic acne scar types using objective assessment tools.

METHODS

Thirty-one patients who had been treated by 1550-nm erbium-doped fractional laser for atrophic acne scars were retrospectively reviewed. Icepick, rolling, and boxcar scars were counted using photographs, and acne scar reduction efficiency (ASRE%; the percentage reduction of post-acne scar count from baseline counts) was calculated.

RESULTS

The median count of each scar type was significantly reduced at the end of the final session. Boxcar scars responded better (median ASRE 59.2%) than rolling (ASRE 40.6%, p = 0.017) and icepick scars (ASRE 19.1%, p = 0.010). Concomitant isotretinoin use resulted in a greater ASRE and a significantly greater improvement in icepick scars. Patients aged 25 years or younger showed a higher ASRE, with a greater improvement in boxcar scars.

CONCLUSION

1550-nm fractional laser treatment for atrophic acne scars was more effective in patients who were younger and taking isotretinoin concurrently.

Early acne scar intervention with 1064 nm picosecond laser in patients receiving oral isotretinoin: a randomized split-face controlled pilot study

Early acne scar intervention is important. Oral isotretinoin is widely used in patients with moderate to severe acne. Picosecond laser has shown a promising effect on scar clearance. However, there is a lack of reports on the efficacy and safety of early acne scar management by using 1064-nm picosecond laser in patients receiving low-dose oral isotretinoin. Twenty-four patients with atrophic acne scars of Fitzpatrick skin type III to V were enrolled. All patients were receiving low-dose oral isotretinoin (0.12-0.22 mg/kg/day) during the treatment. The face of the participants was randomly assigned to receive 2 sessions of fractional picosecond 1064 nm Nd: YAG laser (FxPico) treatment and 2 follow-ups, with an interval of 1 month (month 0-3). Clinical efficacy and safety were assessed by photographs, ECCA grading scale, the number of scar lesions melanin and erythema indexes (MI and EI), TEWL, DLQI, and patient satisfaction and the adverse events were recorded on every visit. FxPico significantly decreased the ECCA score and showed higher improvement in the ECCA score. FxPico treated side achieved a significant reduction in all acne scar types, while only boxcar scars and rolling scars showed higher improvement. TEWL but not MI or EI were significantly improved. DLQI and patient satisfaction were higher with the FxPico-treated side than control side. No adverse effects were observed and all the side effects observed were temporary and tolerable. Early intervention by FxPico on patients receiving low-dose oral isotretinoin is a safe and effective modality to improve atrophic acne scars.

Oral Isotretinoin Treatment in Rhinoplasty: A Review

The achievement of best outcome in rhinoplasty is very important for both of the patients and plastic surgeons. Since the skin characteristics (e.g. nasal thickness and sebaceous hypertrophy) has clear role on the result, many related interventions have been proposed in recent decades to gain an appropriate result. Accordingly, isotretinoin firstly introduced to treat some type of acne, has been suggested controversially to be used in rhinoplasty. Although the early uncertain studies implied on its side effects, the recent more powerful studies and evidences indicate that isotretinoin is remarkably effective to obtain proper outcome. Nevertheless, its prescription to patients need to be evaluated and personalized. More discussion on this regard are presented in the text.

Toxicity, Genotoxicity, and Carcinogenicity of Isotretinoin

BACKGROUND

Acne is a chronic inflammatory disease mainly observed in adolescence, but it can also be seen during the neonatal, infantile, pre-pubertal, and adult periods. Isotretinoin (13-cis-retinoic acid) is a first-generation retinoid and is the most effective treatment for acne vulgaris.

OBJECTIVE

The present study has been systematically designed to figure out the toxic, genotoxic, and carcinogenic activities of isotretinoin.

METHODS

In this study, a systematic approach was followed by focusing on the possible links between these topics. The search of the databases was carried out author in accordance with the guidelines of the Centre for Reviews and Dissemination (2009) developed by York University National Institute of Health Research. The search was concentrated on the Web of Science, PubMed, Science Direct, Scopus, EBSCO Host, and Google Scholar databases.

RESULTS

Isotretinoin was found as a toxic agent in all studies. All researchers proposed that apoptosis is the only pathway of adverse effects of isotretinoin. However, genotoxicity, teratogenicity, and carcinogenicity information of isotretinoin is very limited and controversial.

CONCLUSION

More detailed studies need to clarify the genotoxic and carcinogenic potential of isotretinoin. Patients should be informed correctly, the risks of treatment should be explained, and awareness should be raised.

Evaluation of optic nerve head in patients with small optic disc using oral isotretinoin

BACKGROUND

Isotretinoin has a number of neurological and ocular side effects, but its effect on the optic nerve has not been demonstrated.

PURPOSE

To investigate the effect of oral isotretinoin therapy on the peripapillary retinal nerve fibre layer thickness (RNFL) in patients with small optic disc area using optical coherence tomography (OCT).

METHODS

This retrospective study included 55 patients taking 40 mg/day oral isotretinoin. The patients were grouped according to optic disc area. Patients with small optic disc area were included in group 1 and the others in group 2. RNFL thickness was measured by spectral domain OCT before the treatment, at the third month of the treatment, and at the third month after treatment.

RESULTS

RNFL increased significantly in group1 in the third month of treatment compared to that before the treatment (P < 0.001); no significant change was observed in group 2 (P < 0.244).

DISCUSSION

Oral isotretinoin treatment may be effective in patients with small optic nerve head. The presence of a small optic disc may increase the risk of adverse effects such as decreased dark adaptation, reduced vision, headache, or photophobia.

CONCLUSION

Evaluating the optic disc size before initiation of oral isotretinoin treatment may assist in planning patient treatment.

Retinoid-associated myopia in dermatologic patients: a systematic review

Systemic retinoids are among the most prescribed drugs in dermatology, thanks to their activity as proliferation modulators and keratinization normalizers. Common side effects such as blood lipid disorders, xerosis and photosensitivity are well established and usually dose dependent. Conversely, retinoid-associated ocular disturbances have been reported, yet with differences in terms of frequency and manifestations. As data regarding a potential correlation with refractive errors are heterogenous and have not been previously thoroughly addressed, we performed a systematic review of the literature with the aim of comprehensively evaluating the current evidence regarding retinoid-associated myopia in dermatologic patients.

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.

Voriconazole is superior to combined itraconazole/isotretinoin therapy and itraconazole monotherapy in recalcitrant dermatophytosis

BACKGROUND

There has been an emergence of recalcitrant, recurrent, and difficult-to-treat tinea. Monotherapy with oral antifungals leads to partial clearance or high recurrence of lesions. Isotretinoin is a good adjuvant to systemic antifungals in chronic dermatophytosis. Voriconazole could be a future alternative due to its efficacy against dermatophytes and little resistance.

OBJECTIVE

To evaluate the efficacy and safety of oral itraconazole, combined itraconazole/isotretinoin therapy, and voriconazole for recalcitrant tinea.

PATIENTS AND METHODS

This study included 90 patients with chronic, recurrent, and/or recalcitrant tinea. They were equally divided into 3 groups: itraconazole monotherapy, combined itraconazole/isotretinoin therapy, and voriconazole monotherapy. All patients received treatments for 6 weeks. The clinical response was classified as either a complete or incomplete clinical cure. Potassium hydroxide microscopy and culture were performed to identify mycological cure. Patients with complete cure were followed up for another 6 months to detect any recurrence.

RESULTS

Complete clinical cure was observed in 53.3% of the itraconazole group, 70% of the itraconazole/isotretinoin group, and 83.3% of the voriconazole group. Mycological cure was detected in 56.7% of the itraconazole group, 83.3% of the itraconazole/isotretinoin group, and 86.7% of the voriconazole group. There was a statistically significant difference between the three groups in favor of voriconazole, then the combined group. No significant adverse effects were observed. The recurrence rate was significantly lower in the voriconazole group compared to the other two groups.

CONCLUSIONS

Voriconazole could be a future alternative for the treatment of recalcitrant dermatophytosis.

A practical method for oral administration of isotretinoin in pediatric oncology patient: A case study of neuroblastoma

INTRODUCTION

Isotretinoin is a synthetic vitamin A derivative, administered off-label as maintenance therapy for neuroblastoma. This report addresses the challenge of administering isotretinoin to children, given its availability as soft gelatin capsules only.

CASE REPORT

A 3-year-old boy diagnosed with stage IV neuroblastoma has undergone multimodal therapy, including six cycles of chemotherapy, followed by tumor resection and radiotherapy. Later, he was initiated on immunotherapy and prescribed isotretinoin 50 mg orally twice daily for two weeks, before each immunotherapy cycle. Isotretinoin is not available in liquid formulation and the patient could not swallow isotretinoin capsules. Therefore, pharmacist counseling was required to ensure appropriate administration of the drug.

MANAGEMENT AND OUTCOMES

The patient's parents were instructed to pierce prescribed capsules, and empty and dilute their contents into a small glass containing olive oil after taking safety measures. Isotretinoin's stability in olive oil for 72 h was compared using high-performance liquid chromatography to its stability in soybean oil. The recovery rates were 98.62% and 98.3%, respectively. Drug miscibility was not an issue as isotretinoin is lipophilic. Therefore, it could be administered easily without considerable remaining on the interior wall of the glass.

DISCUSSION

To the best of our knowledge, this is the first report that suggests a practical method for administering isotretinoin in liquid form, particularly in pediatric oncology patients. Isotretinoin was noted to be stable in olive oil and its exposure to light and oxygen would not be an issue given the short time from preparation to administration and the low emphasis on exposure by the manufacturer when such a method is recommended.

Efficacy and safety of low-level light therapy by delicate pulsed light combined with low-dose oral isotretinoin for the treatment of acne vulgaris: a randomized split-face study

Acne vulgaris (AV) is a common dermatosis that causes psychological problems. Isotretinoin is the first-line treatment for moderate-to-severe AV, but its onset of effect is delayed. Although light-based therapy is widely used in the treatment of AV, there is a lack of reports on delicate pulsed light (DPL) which has a narrow therapeutic spectrum (500-600 nm). Low-level light therapy (LLLT) has shown an emerging role in anti-inflammatory effects and skin repair. This study investigates the efficacy and safety of low-dose oral isotretinoin combined with LLLT using DPL in patients with moderate-to-severe AV. Thirty-six patients with moderate-to-severe AV were enrolled and received low-dose oral isotretinoin (10-20 mg/day). The two sides of the face were randomly assigned to receive DPL (6-9 J/cm²) or not at an interval of 2 weeks for 4 treatment sessions (weeks 0, 2, 4, 6). Photos, GAGS score, counts of papules, pustules, comedones, TEWL, melanin and erythema index, side effects, efficacy, and satisfactory score were recorded at each visit and at 4 weeks after the final treatment (week 10). Thirty-three patients completed the study. DPL and oral isotretinoin combined therapy exhibited significantly improved GAGS score as well as the number of the lesions from week 2 and maintained until week 10. At the end of the observation, the improvement of GAGS was 70.88% on the DPL and isotretinoin combined side versus 62.12% on the side with isotretinoin monotherapy (p = 0.0009). The improvement for papule number was 61.58% on the DPL combined side versus 43.33% on the control side (p < 0.0001), for comedone was 63.15% versus 43.30% (p = 0.0008). TEWL and indexes of melanin and erythema also had better outcomes with DPL combined therapy at week 10. All the side effects were temporary and tolerable; no adverse effects were observed. Oral low-dose isotretinoin combined with LLLT by DPL offers a combination with reduced side effects and better outcomes within a limited treatment duration, which advances the onset of effect of isotretinoin monotherapy and improves lesion clearance.

Development, optimization, and validation of Inflammatory Bowel Disease rat model using isotretinoin

BACKGROUND

and Purpose: Inflammatory Bowel Disease (IBD) is a persistent bio-psychological disorder with the absence of actual pathological reason. Association between IBD and isotretinoin has been reported by many human and in vitro studies. However, in this study, our focus is on finding the causal relationship between IBD and isotretinoin for the development of a new animal model.

METHODS

Twenty-eight Sprague Dawley rats were taken for this study and divided into five groups (i.e. Group 1: Normal control, Group 2: Standard IBD Model Group (Indomethacin treated), Group 3: Isotretinoin low dose (7 mg/kg), Group 4: Isotretinoin medium dose (35 mg/kg), Group 5: Isotretinoin high dose (70 mg/kg). The rats were treated according to assigned treatment and observed on different days to evaluate the severity of IBD with the help of symptomatical (nausea, diarrhea, stool consistency, etc.) activity, biochemical parameters, macroscopy, and histological analyses.

KEY RESULTS

During the entire study period, body weight, stool consistency and frequency of the animals had been observed daily. No significant reduction in body weight was observed between the disease induced and normal control animals; however, it was observed that the stool consistency of the animals became less (mucus in stool) day by day and stool frequency increased (frequent defecation) in the different isotretinoin groups compared to the control group. There was statistically significant increase in TBARS levels of isotretinoin low (p < 0.05), medium (p < 0.001) and high dose (p < 0.01) treated group was observed, as compared to control group. Similarly, statistically significant effects of isotretinoin on GSH level (p < 0.01), CAT activity (p < 0.01), and SOD (p < 0.01) were also observed. Increase in TNF-α levels found significantly higher in isotretinoin medium dose (35 mg/kg) treated group (p < 0.001) as compared with control group as well as standard IBD model group. All the three-isotretinoin treated groups (Isotretinoin low dose: p < 0.001; Isotretinoin medium dose: p < 0.001; Isotretinoin high dose: p < 0.001) depicted significant difference in macroscopic scores as compared with control group; these results are comparable with standard IBD model group. Histological analyses revealed that, among three-dose groups of isotretinoin, there was excessive amount of crypt abscesses, infiltration of inflammatory cells, and formation of ulceration observed in isotretinoin medium dose treated group.

CONCLUSION

As standard indomethacin treated group, isotretinoin also caused significant damage to intestinal mucosa, and form ulceration in gastrointestinal tract. Compared to control group, isotretinoin significantly worsens the disease condition, which were comparable to the indomethacin-treated group; however, isotretinoin at the dose of 35 mg/kg caused maximum severe damage to the intestinal mucosa.

Low-Dose versus Conventional-Dose Oral Isotretinoin Regimens: A Systematic Review on Randomized Controlled Comparative Studies of Different Regimens

BACKGROUND

The effectiveness of Isotretinoin is superior compared to other acne therapies, particularly in reducing acne lesion counts. Concerns, however, arise relating the most optimal dosage regimen with the best efficacy and lesser side effect Objective: We intend to review existing randomized controlled comparative studies of isotretinoin in different regimens Methods: PubMed, Cochrane, Scopus, and ScienceDirect were searched. The inclusion criteria is RCT article. Full-text reading excluded articles that did not use GAGS as the method of measurement. The Out of 921 articles electronically searched, 6 RCTs were extracted and summarized descriptively. After full-text reading, 4 RCTs were included. We then conducted risk of bias assessments for the selected studies using The Cochrane Risk of Bias Tool.

RESULTS

Across all trials, low-dose regimens were preferable in all types of acne-owing to its similar efficacy to conventional dose but with fewer occurrence of side effects as well as better patients' satisfaction and compliance. Furthermore, a continuous low-dose regimen had the best efficacy in comparison to other regimens of low-dose treatment.

DISCUSSION

The limitations of our study include a slight difference of dosage between selected studies. Another limitations are that some studies did not explain the side effects and relapse rate thoroughly and did not state the compliance scoring method used.

CONCLUSION

This review recommends continuous low-dose treatment as the chosen regimen for acne vulgaris. However, further evaluation regarding relapse rate compared to the conventional dose is needed.

Oral isotretinoin (Roaccutane) use during incisional surgery: safe or risky?

Two cases are presented that demonstrate normal wound healing following bilateral reduction mammoplasty, in young female patients taking therapeutic doses of Isotretinoin (Roaccutane). Review of the literature does not provide evidence that Isotretinoin impairs would healing, nor that it promotes hypertrophic or keloid scarring in surgical patients.

A randomized prospective study of low-dose isotretinoin alone and combination with salicylic acid and mandelic peel against acne tarda

BACKGROUND

Acne tarda (AT) is typically known as adult acne and most preferably affected 25-45 age groups. Used isotretinoid mono-therapy is not effective and also produces side effects from long treatment.

AIM

The present study assesses the effectiveness of combined treatment of oral isotretinoid with topical chemical peeling (20% salicylic and 10% mandelic acid known as SM peeling) by a comparative double-blind randomized single-center interventional open-label study.

MATERIALS AND METHODS

A total fifty-eight participants AT outpatients (25-45 age-groups) attending for diagnosis in two groups and effectiveness of proposed combined treatments were determined at baseline and follow-up within 4weeks interval. Briefly group A (n=28) received 0.5 mg/kg of oral isotretinoin once daily for sixteen weeks and group B (n=30) received the same oral dose, addition with SM peeling every four weeks interval for sixteen weeks. After four weeks, treatment efficacy was assessed based on Michelson's acne severity index (MASI) and visual analog scale (VAS), further validated using statistical tools.

RESULTS

Based on MASI and VAS scores, combined treatment was significantly effective than the monotherapy. The pre- and post-treatment analyses of response to scarring, inflammatory components at baseline and at the end of treatment were also statistically significant with p>0.008.

CONCLUSION

The above investigation revealed that the combination of oral isotretinoin with SM peeling was highly effective and could be used as newer therapy against AT without any serious side effects.

Comparative efficacy of using a combination of intralesional purified protein derivative with low dose isotretinoin in the treatment of recalcitrant common warts

BACKGROUND

Intralesional immunotherapy with PPD is an effective and tolerable therapeutic modality for the treatment of common warts. However, the complete clearance rates are still unsatisfactory.

OBJECTIVES

We thought to evaluate the efficacy and safety of adding low dose isotretinoin to intralesional PPD versus PPD monotherapy for viral warts.

METHODS AND MATERIALS

The study included two groups: Group (A) was treated by intralesional PPD at 2-week intervals until complete clearance or for a maximum of 6 sessions in addition to an oral placebo. Group (B): was treated with both intralesional PPD and low dose isotretinoin for a 3-month course.

RESULTS

There was no statistically significant difference between both groups regarding the therapeutic response.

CONCLUSIONS

In common warts, the low dose of isotretinoin did not add a true therapeutic value in the studied groups. Perhaps higher doses of isotretinoin could provide a better response, which warrants further investigation. This article is protected by copyright. All rights reserved.

Diffuse idiopathic skeletal hyperostosis in a young woman treated with isotretinoin

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

Pregnancy and neonatal outcomes after periconceptional exposure to isotretinoin in Koreans

OBJECTIVE

Isotretinoin should not be used during pregnancy because of the risk of birth defects. Most pregnant women exposed to isotretinoin choose voluntary pregnancy termination due to concerns about birth defects. However, birth outcome data supporting the termination of pregnancy are lacking. This study aimed to evaluate pregnancy and neonatal outcomes after periconception exposure to isotretinoin.

METHODS

This was a prospective cohort study. We evaluated pregnancy and neonatal outcomes after exposure to isotretinoin in 151 pregnant women. Among 1,026 callers at the Korean Teratology Information Service from 2001 to 2017 exposed to isotretinoin during the periconception period, 151 pregnant women who received counseling on teratogenic risk after visiting the clinic were included.

RESULTS

Among the 151 participants who visited the clinic, only 42 were evaluated using ultrasonography until approximately 20 weeks of gestation. Ultimately, 23 patients were included in the study. The average gestation period during the last exposure to the drug was 2 weeks, and the average daily exposure dose was 12 mg. There were two cases of major birth defects in the exposure group. Spontaneous abortion rates were 17.7% and 8.7% in the exposure and nonexposure groups, respectively (P=0.035). There was no significant difference between the exposure and non-exposure groups in terms of pregnancy and neonatal outcomes.

CONCLUSION

There was no significant difference in pregnancy and neonatal outcomes, including birth defects, between the exposure and non-exposure groups. Further studies with larger sample sizes are required to validate our findings.

Cross-sectional assessment of the ellipsoid zone and the retinal pigment epithelium-Bruch membrane complex after systemic isotretinotin use

PURPOSE

To evaluate the cross-sectional areas of the retinal pigment epithelium-Bruch membrane complex (RPE-B) and ellipsoid zon (EZ) and the thickness of the macula, retinal nerve fibre layer (RNFL), and ganglion cell-inner plexiform layer (GC-IPL) in patients using short-term systemic isotretinoin.

METHOD

A total of 43 right eyes of 43 patients treated with systemic isotretinoin for acne vulgaris were included in this prospective study. Macula, GC-IPL, RNFL thicknesses and central cross-sectional EZ and RPE-B areas were evaluated with optical coherence tomography (Zeiss, Cirrus HD OCT 5000) prior to treatment and in first, second and third months after the onset of isotretinoin treatment. For the measurement of EZ and RPE-B area, foveal EDI-OCT scans were binarized by using the public domain software ImageJ 1.51 s.

RESULTS

Mean duration of isotretinoin treatment was 77 ± 15 days and mean dose was 2228 ± 574 milligrams. There was a statistically significant increment in central cross-sectional EZ and RPE-B areas in each follow-up examination, when analysed by repeated measurement analysis (p:0.002 and p:0.006, respectively). There was no correlation between total isotretinoin dose and the difference between final and basal EZ and RPE-B areas (p > 0.05, for both). When repeated measurements in follow-up examinations were compared, GC-IPL thicknesses except the superotemporal region (p:0.040) and RNFL thicknesses did not show a significant difference (p > 0.05). There was not any significant relation between total isotretinoin dose and 3rd month and basal measurement differences in macula, GC-IPL and RNFL thicknesses in any area (p > 0.05, for all).

CONCLUSION

There has been an increase in the area of RPE-B and EZ with short-term use of isotretinoin therapy. Future studies examining the relationship between functional tests and the RPE-B and EZ areas may provide more in-depth information on the effects of isotretinoin in the eye.

Risk of psychiatric disorders in patients taking isotretinoin: A nationwide, population-based, cohort study in Taiwan

BACKGROUND

After isotretinoin's approval to treat patients with recalcitrant acne, there have been continued debates around its psychiatric safety profile. This study aimed to assess the risk of psychiatric disorders in patients with acne who are taking isotretinoin.

METHODS

We used de-identified information from Taiwan's National Health Insurance Research Database from 2000 to 2015 to examine the risk for psychiatric disorders among patients with acne who were taking isotretinoin. We performed subgroup analyses based on the dosage and duration of isotretinoin administration.

RESULTS

This study included 29,943 participants during a 16-year follow-up period. We found no significantly increased risk for psychiatric disorders among patients taking isotretinoin compared with patients who did not receive isotretinoin treatment (adjusted hazard ratio [aHR]: 1.009, 95% confidence interval [CI]: 0.422-1.696). Subgroup analyses showed no significantly increased risk for psychiatric disorders in patients taking different doses of isotretinoin (≤ 20 mg per day, aHR: 0.892, 95% CI: 0.371-1.501; > 20 mg per day, aHR: 1.068, 95% CI: 0.446-1.798). There was also no significant increase in risk for patients undergoing isotretinoin treatment over different periods (≤ 6 months, aHR: 0.924, 95% CI: 0.392-1.612; > 6 months, aHR: 1.196, 95% CI: 0.488-2.004).

LIMITATIONS

We did not analyze the risk of suicidal ideation, and it could be underestimated in medical claims databases.

CONCLUSIONS

We found no increased risk of psychiatric disorders among Taiwanese patients with acne who were taking isotretinoin. Higher dosage or longer duration of isotretinoin treatment did not increase the risk for developing a psychiatric disorder.

Isotretinoin-Delonix polymeric nanoparticles: Potentials for skin follicular targeting in acne treatment

In acne management, oral isotretinoin (IST) is associated with various untoward systemic effects, while its topical formulation has irritation side effects. Delonix (DLX) is a natural galactomannan derived from Delonix regia seed that can fabricate nanoparticles for topical skin delivery. This study aims to develop IST-DLX nanoparticles and assess their prospects for acne treatment. Fluorescent-DLX nanoparticles (made with a lipophilic BODIPY dye) or IST-DLX nanoparticles were prepared and characterized. BODIPY-DLX nanoparticles' skin distribution and IST-DLX nanoparticles' in-vitro targeting were assessed in pig ear skin, inflammatory modulation was assessed in AMJ-2 macrophage cells, while skin penetration and irritation were assessed in Wistar rats. IST-DLX nanoparticles had ≈230 nm, negative zeta potential, and ≈30% encapsulation efficiency. Confocal showed BODIPY in DLX nanoparticles accumulated in hair follicles as compared to BODIPY solution. IST-DLX nanoparticles released ≈37% IST over 48 h and increased IST 3-fold in hair follicles compared to IST solution. IST-DLX nanoparticles suppressed IL-6 expression in cells and reduced photo-irritation in Wistar rats compared to IST solution. In conclusion, IST-DLX nanoparticles may target and deliver adequate IST to skin layers associated with acne, avoid systemic penetration, modulate inflammatory pathogenic acne stage and prevent IST topical photo-irritation.

The Impact of Isotretinoin Therapy on the Nasal Skin Thickness and Elasticity: An Ultrasonography and Elastography Based Assessment in Relation to Dose and Duration of Therapy

BACKGROUND

This study aimed to evaluate the impact of isotretinoin therapy on the nasal skin thickness and elasticity with regard to implications for rhinoplasty METHODS: A total of 40 acne vulgaris patients (mean±SD age: 20.9 ± 3.0 years, 65.0% were females) initiating oral isotretinoin treatment (0.25 mg/kg/day, n = 16 or 0.5 mg/kg/day, n = 24) were included in this prospective 4-month isotretinoin follow-up study. Ultrasonography assessments regarding nasal skin thickness (dermis and soft tissue) and elastography were repeated at second and fourth months of treatment.

RESULTS

No significant difference was noted between isotretinoin dose groups in terms of second month and fourth month nasal skin thickness (dermis and soft tissue) values measured at any region. Each dose revealed significant decrease in dermis and soft tissue thickness from baseline at any region (p ranged  < 0.001 to  < 0.001), while only fourth month values at nasal tip and second month values at rhinion for dermis and only fourth month values at rhinion and glabella for subcutaneous tissue significantly differed from baseline (p < 0.01 for each) in the 0.25 mg and 0.50 mg dose groups, respectively. Elastography values at fourth month of isotretinoin treatment were significantly higher than pre-treatment and second month values in both 0.25 mg (90.4 ± 20.6 vs. 59.5 ± 21.8 and 76.4 ± 22.9, p < 0.01 for each) and 0.5 mg (86.7 ± 20.6 vs. 61.8 ± 23.2 and 76.9±24, p < 0.01 for each) dose groups.

CONCLUSIONS

In conclusion, our findings revealed the association of isotretinoin treatment with a significant decrease in dermis and subcutaneous soft tissue thickness measured at each anatomical landmark, regardless of the treatment dose.

LEVEL OF EVIDENCE IV

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