Use of oral isotretinoin to treat acne in the public system
a hospital-based retrospective cohort
Keywords:
Acne vulgaris, Isotretinoin, DermatologyAbstract
BACKGROUND: Acne needs to be treated early to prevent negative psychosocial impacts. In severe or moderate forms, which tend to leave scars, oral isotretinoin is the first-line therapy. However, concern about its adverse events, especially in developed countries, delays effective treatment. In contrast, isotreti-noin is widely prescribed in Brazilian private clinics. OBJECTIVES: To describe the use of isotretinoin for treating acne in a Brazilian public hospital, and to analyze whether its prescription is effective or belated. DESIGN AND SETTING: Retrospective cohort study in a public hospital. METHODS: Clinical and therapeutic data were obtained from the medical records of patients who were undergoing or had undergone acne treatment with isotretinoin in this hospital’s general dermatology outpatient clinic over the last seven years, up to April 2018. RESULTS: 1526 medical records from patients with acne were analyzed. Isotretinoin was prescribed for 279 patients (18.28%) with mild (1.19%), moderate (57.37%), severe (35.85%) or conglobata (5.57%) forms of acne vulgaris. Sequelae of acne were present at the start of most of these patients’ treatment. An initial daily dose of 20 mg was usually prescribed. The average initial dose/weight ratio was 0.33 mg/kg/day. The av-erage total dose/weight ratio was 127.61 mg/kg. There were only a few cases of laboratory abnormalities. CONCLUSION: Sequelae of acne at the onset of treatment reveal delayed indication of isotretinoin, which can have negative psychosocial impacts on quality of life. Isotretinoin should be indicated early to prevent this. Its use is supported by its lack of laboratory alterations and controllable adverse events.
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Das S, Reynolds RV. Recent advances in acne pathogenesis: implications for therapy. Am J Clin Dermatol. 2014;15(6):479-88. PMID: 25388823; doi: 10.1007/s40257-014-0099-z.
White GM. Recent finding in the epidemiologic evidence, classification, and subtypes of acne vulgaris. J Am Acad Dermatol. 1998;39(2 Pt 3):S34‑7. PMID: 9703121; doi: 10.1016/S0190-9622(98)70442-6.
Bagatin E, Timpano DL, Guadanhim LR, et al. Acne vulgaris: prevalence and clinical forms in adolescents from São Paulo, Brazil. An Bras Dermatol. 2014;89(3):428-35. PMID: 24937816; doi: 10.1590/abd1806-4841.20142100.
Thiboutot DM, Dréno B, Abanmi A, et al. Practical management of acne for clinicians: An international consensus from the Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol. 2018;78(2 Suppl 1):S11-S23.e1. PMID: 29127053; doi: 10.1016/j.jaad.2017.09.078.
Rigopoulos D, Larios G, Katsambas AD. The role of isotretinoin in acne therapy: why not as first-line therapy? facts and controversies. Clin Dermatol. 2010;28(1):24–30. PMID: 20082946; doi: 10.1016/j. clindermatol.2009.03.005.
Rademaker M. Isotretinoin: dose, duration and relapse. What does 30 years of usage tell us? Australas J Dermatol. 2013;54(3):157–62. PMID: 23013115; doi: 10.1111/j.1440-0960.2012.00947.x.
Costa CS, Bagatin E, Martimbianco ALC, et al. Oral isotretinoin for acne. Cochrane Database of Systematic Reviews 2018, Issue 11. Art. No.: CD009435. doi: 10.1002/14651858.CD009435.pub2.
Brzezinski P, Borowska K, Chiriac A, Smigielski J. Adverse effects of isotretinoin: A large, retrospective review. Dermatol Ther. 2017;30(4). PMID: 28295859; doi: 10.1111/dth.12483.
Strahan JE, Raimer S. Isotretinoin and the controversy of psychiatric adverse effects. Int J Dermatol. 2006;45(7):789-99. PMID: 16863513; doi: 10.1111/j.1365-4632.2006.02660.x.
Lee SY, Jamal MM, Nguyen ET, Bechtold ML, Nguyen DL. Does exposure to isotretinoin increase the risk for the development of inflammatory bowel disease? A meta-analysis. Eur J Gastroenterol Hepatol. 2016;28(2):210-6. PMID: 26545085; doi: 10.1097/MEG.0000000000000496.
Collins MK, Moreau JF, Opel D, et al. Compliance with pregnancy prevention measures during isotretinoin therapy. J Am Acad Dermatol. 2014;70(1):55-9. PMID: 24157382; doi: 10.1016/j.jaad.2013.08.034.
Dalgard F, Gieler U, Holm JØ, Bjertness E, Hauser S. Self-esteem and body satisfaction among late adolescents with acne: results from a population survey. J Am Acad Dermatol. 2008 Nov;59(5):746-51. PMID: 19119094; doi: 10.1016/j.jaad.2008.07.013.
Kellett SC, Gawkrodger DJ. The psychological and emotional impact of acne and the effect of treatment with isotretinoin. Br J Dermatol. 1999 Feb;140(2):273-82. PMID: 10233222; doi: 10.1046/j.1365-2133.1999.02662.x.
Brown BC, McKenna SP, Siddhi K, McGrouther DA, Bayat A. The hidden cost of skin scars: quality of life after skin scarring. J Plast Reconstr Aesthet Surg. 2008;61(9):1049-58. PMID: 18617450; doi: 10.1016/j. bjps.2008.03.020.
Seite S, Caixeta C, Towersey L. Large-scale survey to describe acne management in Brazilian clinical practice. Clin Cosmet Investig Dermatol. 2015;8:571-7. PMID: 26609243; doi: 10.2147/CCID.S94315.
Leyden JJ. Antibiotic resistance in topical treatment of acne vulgaris. Cutis. 2004; 73(6 suppl.):6-10. PMID: 15228128.
Margolis DJ. Antibiotics, acne, and upper respiratory tract infections. LDI Issue Brief. 2006;11(4):1-4. PMID: 16708431.
Zaghloul SS, Cunliffe WJ, Goodfield MJ. Objective assessment of compliance with treatments in acne. Br J Dermatol. 2005;152(5):1015‑21. PMID: 15888162; doi: 10.1111/j.1365-2133.2005.06357.x.
Ballanger F, Baudry P, N’Guyen JM, Khammari A, Dréno B. Heredity: a prognostic factor for acne. Dermatology. 2006;212(2):145-9. PMID: 16484821; doi: 10.1159/000090655.
Tan J, Knezevic S, Boyal S, Waterman B, Janik T. Evaluation evidence for acne remission with oral isotretinoin cumulative dosing of 120‑150 mg/kg. J Cutan Med Surg. 2016;20(1):13-20. PMID: 26187395; doi: 10.1177/1203475415595776.
Kaminsky A. Less common methods to treat acne. Dermatology. 2003;206(1):68-73. PMID: 12566807; doi: 10.1159/000067824.
Agarwal US, Besarwal RK, Bhola K. Oral isotretinoin in different dose regimens for acne vulgaris: a randomized comparative trial. Indian J Dermatol Venereol Leprol. 2011;77(6):688-94. PMID: 22016276; doi: 10.4103/0378-6323.86482.
Lee JW, Yoo KH, Park KY, et al. Effectiveness of conventional, low-dose and intermittent oral isotretinoin in the treatment of acne: a randomized, controlled comparative study. Br J Dermatol. 2011;164(6):1369-75. PMID: 21114478; doi: 10.1111/j.1365-2133.2010.10152.x.
Rademaker M, Wishart JM, Birchall NM. Isotretinoin 5 mg daily for low-grade adult acne vulgaris – a placebo-controlled, randomized double-blind study. J Eur Acad Dermatol Venereol. 2014;28(6):747-54. PMID: 23617693; doi: 10.1111/jdv.12170.
Cunliffe WJ, van de Kerkhof PC, Caputo R, et al. Roaccutane treatment guidelines: results of an international survey. Dermatology. 1997;194(4):351-7. PMID: 9252756; doi: 10.1159/000246134.
Rademaker M. Making sense of the effects of the cumulative dose of isotretinoin in acne vulgaris. Int J Dermatol. 2016;55(5):518-23. PMID: 26471145; doi: 10.1111/ijd.12942.
Alirezai M, George SA, Coutts I, et al. Daily treatment with adapalene gel 0.1% maintains initial improvement of acne vulgaris previously treated with oral lymecycline. Eur J Dermatol. 2007;17(1):45-51. PMID: 17324827; doi: 10.1684/ejd.2007.0188.
Poulin Y, Sanchez NP, Bucko A, et al. A 6-month maintenance therapy with adapalene-benzoyl peroxide gel prevents relapse and continuously improves efficacy among patients with severe acne vulgaris: results of a randomized controlled trial. Br J Dermatol. 2011;164(6):1376-82. PMID: 21457209; doi: 10.1111/j.1365-2133.2011.10344.x.
McLane J. Analysis of common side effects of isotretinoin. J Am Acad Dermatol. 2001,45(5):S188-94. PMID: 11606952; doi: 10.1067/ mjd.2001.113719.
Altman RS, Altman LJ, Altman JS. A proposed set of new guidelines for routine blood tests during isotretinoin therapy for acne vulgaris. Dermatology. 2002;204(3):232-5. PMID: 12037453; doi: 10.1159/000057887.
Lee YH, Scharnitz TP, Muscat J, et al. Laboratory monitoring during isotretinoin therapy for acne: a systematic review and meta-analysis. JAMA Dermatol. 2016;152(1):35-44. PMID: 26630323; doi: 10.1001/ jamadermatol.2015.3091.
Shinkai K, McMichael A, Linos E. Isotretinoin laboratory test monitoring—a call to decrease testing in an era of high-value, cost-conscious care. JAMA Dermatol. 2016;152(1):17-9. PMID: 26629966; doi: 10.1001/jamadermatol.2015.3128.
Hobson JG, Cunningham MJ, Lesiak K, et al. Isotretinoin monitoring trends: a national survey of dermatologists. J Drugs Dermatol. 2017;16(6):557-64. PMID: 28686773.
Halvorsen JA, Stern RS, Dalgard F, et al. Suicidal ideation, mental health problems and social impairment are increased in adolescents with acne: a population-based study. J Invest Dermatol. 2011;131(2):363-70. PMID: 20844551; doi: 10.1038/jid.2010.264.
Margolis DJ, Fanelli M, Hoffstad O, Lewis JD. Potential association between the oral tetracycline class of antimicrobials used to treat acne and inflammatory bowel disease. Am J Gastroenterol. 2010,105(12):2610‑6. PMID: 20700115; doi: 10.1038/ajg.2010.303.
