Isotretinoin - Multiple nodular, cystic, pustular and comadonic lesions on face, upper back and shoulders for 2 years.

068. A 24-year-old unmarried woman has multiple nodular, cystic, pustular and comadonic lesions on face, upper back and shoulders for 2 years. The drug of choice for her treatment would be:

1. Acitretin

2. Isotretinoin

3. Doxycycline

4. Azithromycin

Answer

2. Isotretinoin

Reference

Harrison 16^th Edition Page 295

Katzung 9^th Edition Page 1024

Quality

Reader

Status

Repeat

Discussion

Treatment of acne vulgaris is directed toward elimination of comedones by normalization of follicular keratinization, decreasing sebaceous gland activity, decreasing the population of lipophilic bacteria and yeast, and decreasing inflammation. Acne vulgaris may be treated with either local or systemic medications. Minimal to moderate, pauci-inflammatory disease may respond adequately to local therapy alone. Although areas affected with acne should be kept clean, there is little evidence to suggest that removal of surface oils plays an important role in therapy. Overly vigorous scrubbing may aggravate acne due to mechanical rupture of comedones. Topical agents such as retinoic acid, benzoyl peroxide, or salicylic acid may alter the pattern of epidermal desquamation, preventing the formation of comedones and aiding in the resolution of preexisting cysts. Topical antibacterial agents such as benzoyl peroxide, azelaic acid, topical erythromycin (with or without zinc), clindamycin, or tetracycline are also useful adjuncts to therapy.

Patients with moderate to severe acne with a prominent inflammatory component will benefit from the addition of systemic therapy. Oral tetracyclines or erythromycin in doses of 250 to 1000 mg/d will decrease follicular colonization with some of the lipophilic organisms. They also appear to have an anti-inflammatory effect independent of their antibacterial effect. Female patients who do not respond to oral antibiotics may benefit from hormonal therapy. Women placed on oral contraceptives containing ethinyl estradiol and norgestimate have demonstrated improvement in their acne when compared to a placebo control.

Explanation

Severe nodulocystic acne not responsive to oral antibiotics, hormonal therapy, or topical therapy may be treated with the synthetic retinoid isotretinoin.

Comments

Isotretinoin is used at doses of 0.5 to 2.0 mg/kg as a single daily dose for 15 to 20 weeks.

Tips

The use of this drug is limited by its teratogenicity, and female patients must be screened for pregnancy prior to initiating therapy, maintain a method of birth control during therapy, and be screened for pregnancy during treatment. Patients receiving this medication develop extremely dry skin and cheilitis and must be followed for development of hypertriglyceridemia.