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Acne is a persistent inflammatory condition that is common among teenagers and may affect women of all age-groups. Common predisposing factors in females are hormonal changes and hyperandrogenism disorders. Oral isotretinoin has been widely used and has been found to be efficacious in treating moderate-to-severe acne. This drug is a vitamin A derivative which can be safely used in patients who do not respond to appropriate antimicrobial therapies. This agent acts by reducing the sebum excretion rate and the sebaceous gland size, unlike antibiotics—which target pathogens.
This article reports on moderate acne of a 29-year-old female, which was unresponsive to conventional antibiotic therapy. The patient was found to have nodular lesions and comedones on her facial skin. She was given isotretinoin, 0.5 mg/kg/day for the first month, and then, for the first 10 days of every month for the subsequent 5 months. Besides, standard moisturizing and washing procedures were to be followed.
At the end of 6 months, here acne-severity reduced and the initial redness of the skin—during the first month of therapy—also attenuated. Intermittent therapy helped in preventing side effects and the relapse of lesions.
The patient did not have any systemic disease and was not on any regular medication. She had been prescribed conventional antibiotic therapy for acne, earlier, with no benefits. Thus, isotretinoin successfully ameliorated acne in this patient with minimal side effects.
Acne is a persistent inflammatory disease that affect more than 80% of teenagers, and may persist through adulthood. Facial skin is the most common site for acne appearance, while these lesions may also affect the back and chest in some individuals. Severe acne is can cause scarring and is associated with low self-esteem and psychological morbidity, especially in young adults.
The key pathogenetic mechanisms involved in acne development include – alteration of follicular keratinization that leads to comedones; increased and altered sebum production under androgen control; follicular colonization by Propionibacterium acnes; and complex inflammatory mechanisms that involve innate and acquired immunity. Contributing factors that influence the etiology are genetics; diet – like regulate intake of chocolates and dairy products; smoking; and the use of occlusive cosmetics. In adult women, androgens play a major role, particularly, in those undergoing hormonal treatments – for hyperandrogenism disorders, such as polycystic ovary syndrome (PCOS); using hormone-based therapies, such as oral contraceptive; and on anti-androgen medications.
Acne can occur in women of all ages – for example, at premenarchal stage, during puberty, adolescence, adulthood and post menopause. The level of severity may vary among women—who usually develop lesions on the lower third of the face, especially, on the chin and jawline.
Acne lesions may present as comedones, papules, pustules, nodules and/or cysts. Persistent acne is that which persists beyond adolescence into adulthood while late-onset acne is that which begins after the age of 25 years.1
This is a case of a 29-year-old lady who presented with long-standing moderate acne.
The patient did not have any systemic disease and was not on any regular medication. She had been prescribed conventional antibiotic therapy for acne, earlier, with no benefits.
On examination, non-inflammatory lesions – comedones as well as inflammatory nodules were identified on the facial skin.
The patient was prescribed isotretinoin, 0.5 mg/kg/day for the first month, and then, the same dose for the first 10 days of each month for the upcoming 5 months. In addition, standard moisturizing and washing procedures were advised.
Intermittent isotretinoin therapy led to a decrease in the FDA global grade by the end of 6 months. The only side effect reported was dry skin. Intermittent therapy helped in controlling the facial rash or redness. Furthermore, this treatment prevented relapse of lesions, 12 months post treatment.
Isotretinoin – 13‐cis‐retinoic acid, is derived from vitamin A and is available as topical and oral formulations. Oral isotretinoin was approved by the US Food and Drug Administration (US FDA) for treating nodulocystic acne in the year 1982, and is deemed as one of the most clinically effective anti‐acne therapies. In the recent past, oral isotretinoin has also shown efficacy in the treatment of acne that tend to cause scarring and those which show no improvement with appropriate topical antimicrobial and/or long‐term oral antibiotics.
The usual daily dose of oral isotretinoin varies from 0.5-1.0 mg/kg body weight—which demonstrates benefits in about 85% of individuals who receive it, within 16 weeks of therapy. Some patients with recalcitrant lesions may require five or six months to achieve a complete response.
Isotretinoin targets all the primary causal factors involved in acne. This agent does not act directly on microbial cells, but markedly reduces the sebum excretion rate and the sebaceous gland size. Reduced sebum secretion leads to decreased follicular hyperkeratinisation and the alteration of the microenvironment within the sebaceous duct, providing greater Propionibacterium acnes (P. acnes) suppression – which is the common causative organism.
Oral isotretinoin also modifies inflammatory activity at the cellular level and normalises exaggerated toll‐like receptor‐mediated innate immune responses in acne. Furthermore, this drug activates tumor suppressor genes in the skin – inducing apoptosis and cell cycle arrest within sebaceous glands.2
This case study describes the efficacy of intermittent isotretinoin therapy on long-standing moderate acne in adults. Here, a 29-year-old female without a systemic condition or any relevant drug history who did not benefit from conventional antibiotic therapy for acne was given intermittent isotretinoin. After using isotretinoin, 0.5 mg/kg/day for the first month, and then, for the first 10 days of every month for the subsequent 5 months, along with standard moisturizing and washing procedures, the severity of her nodular lesions and comedones ameliorated. At the end of 6 months of this treatment, the FDA global grade of her acne was decreased and the lesions did not recur even after 12 months, post treatment. Furthermore, intermittent therapy with isotretinoin had minimal side effects and less complaint of redness of the facial skin – only during the first month.
- Tan AU, Schlosser BJ, Paller AS. A review of diagnosis and treatment of acne in adult female patients. Int J WomensDermatol. 2017;4(2):56-71. Published 2017 Dec 23. doi:10.1016/j.ijwd.2017.10.006
- Costa CS, Bagatin E, Martimbianco ALC, et al. Oral isotretinoin for acne. Cochrane Database Syst Rev. 2018;11(11):CD009435. Published 2018 Nov 24. doi:10.1002/14651858.CD009435.pub2