Consensus-Based Acne Classification System and Treatment Algorithm for Spain. / Consenso español para establecer una clasificación y un algoritmo de tratamiento del acné.

Acne is a chronic inflammatory disease whose psychosocial effects can greatly impair quality of life. Various scales are used to classify the severity of acne, and several treatment algorithms are currently applied: no consensus on a common scale or treatment guidelines has been reached. A group of Spanish experts therefore met to identify a scale the majority could accept as the most appropriate for classifying severity and treating accordingly. The group chose the following classifications: comedonal acne, mild or moderate papulopustular acne, severe papulopustular acne, moderate nodular acne, and nodular-cystic acne (or acne tending to leave scars). Consensus was reached on first- and second-choice treatments for each type and on maintenance treatment. The experts also issued specific recommendations on antibiotic use (starting with mild or moderate papulopustular acne), always in combination with retinoids and/or benzoyl peroxide. The use of isotretinoin (starting at severe papulopustular or moderate nodular acne) was also covered.

Assessment of the efficacy and safety of a combination of 2 topical retinoids (RetinSphere) in maintaining post-treatment response of acne to oral isotretinoin.

INTRODUCTION: The high rate of relapse of acne lesions following oral isotretinoin treatment is a common problem which remains unsolved. To avoid or minimize relapses, topical retinoids have been used for many years as maintenance treatment. However, adverse effects frequently occur. AIMS: To determine the efficacy and safety of a new retinoid combination (Retinsphere technology) in maintaining post-treatment response to oral isotretinoin. PATIENTS AND METHODS: Prospective, randomized, double-blind and vehicle-controlled study of 30 patients with acne previously treated with isotretinoin. Treatment with the retinoid combination was applied to one side of the face and vehicle was applied to the other, once daily, for 3 months. Standardized photographs were taken using RBX technology at baseline, 1.5 months and 3 months. The primary efficacy endpoint was the appearance of relapse on the treated side compared to the vehicle-treated side. Other endpoints included lesion count, investigator-reported improvement, patient-reported improvement, impact on quality-of-life, and side effects. RESULTS: Although the majority of patients did not reach the total target dose of oral isotretinoin, the relapse rate was significantly lower on the retinoid-treated side compared to the vehicle-treated side. Likewise, improved lesion count and excellent tolerance were observed. CONCLUSIONS: This new retinoid combination (Retinsphere technology) were effective and safe as maintenance therapy after post-treatment response to oral isotretinoin in patients with acne.

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.

Effects of oral isotretinoin therapy on the nasal cavities.

INTRODUCTION: Isotretinoin (13 cis-retinoic acid) is the most effective treatment for acne vulgaris and is the only treatment option that can provide either remission or a permanent cure. OBJECTIVE: The aim of this study was to use both subjective and objective methods to assess the nasal complaints of patients with severe acne who received oral isotretinoin therapy. METHODS: Fifty-four subjects were enrolled in the study. All the subjects were assessed with subjective (NOSE and VAS questionnaires) and objective (rhinomanometry and saccharine) tests to determine the severity of their nasal complaints. RESULTS: The mean severity scores (min: 0; max: 100) for nasal dryness/crusting and epistaxis were 0.47±1.48 (0-5); 0.35±1.30 (0-5) at admission, 3.57±4.45 (0-10); 2.26±4.71 (0-20) at the first month, and 4.28±6 (0-20); 2.26±4.71 (0-20) at the third month of the treatment respectively. Total nasal resistance of 0.195±0.079 (0.12-0.56)Pa/cm3/s at admission, 0.21±0.084 (0.12-0.54)Pa/cm3/s at the first month, and 0.216±0.081 (0.14-0.54)Pa/cm3/s at the third month. CONCLUSION: Oral isotretinoin therapy can cause the complaint of nasal obstruction. In addition, nasal complaints, such as dryness/crusting and epistaxis, significantly increase in patients during the therapy schedule.

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.

Acné fulminans en paciente de pueblo originario del Paraguay

Introducción: el acné vulgar es una enfermedad común de la piel con un gran impacto en la calidad de vida. El acné fulminans es una variante rara y severa de acné inflamatorio. Se describe en la literatura muy pocos casos de acné en pueblos étnicos. Se presenta el caso de una niña de 13 años, originaria de pueblo étnico del Paraguay, en que se observó una presentación severa de acné inflamatorio, acné fulminans. Se realiza tratamiento antibiótico asociado a prednisona, la paciente abandona el seguimiento por lo cual no se inicia el tratamiento aconsejado de Isotretinoína. Conclusiones: el caso presentado en particular corresponde a una forma severa de acné en una población con bajos reportes de esta enfermedad. Consideramos de importancia el estudio de los factores intervinientes para el desarrollo de la enfermedad.

Introduction: acne vulgaris is a common skin disease with a great impact on quality of life. Acne fulminans is a rare and severe variant of inflammatory acne. Very few cases of acne in ethnic people are described in the literature. We present the case of a 13-year-old girl, originally from an ethnic town in Paraguay, in whom a severe presentation of inflammatory acne, acne fulminans, was observed. Antibiotic treatment associated with prednisone was carried out, the patient abandoned follow-up and therefore the recommended treatment of Isotretinoin was not started. Conclusions: the case presented in particular corresponds to a severe form of acne in a population with low reports of this disease. We consider the study of the factors involved in the development of the disease to be important.

Spanish Consensus Document on the Treatment Algorithm for Rosacea. / Documento de consenso español para el algoritmo de tratamiento de la rosácea.

Recent scientific evidence and the incorporation of new drugs into the therapeutic arsenal against rosacea have made it necessary to review and update treatment criteria and strategies. To this end, a panel of 15 dermatologists, all experts in rosacea, was formed to share experiences and discuss treatment options, response criteria, and changes to treatment. Based on a critical review of the literature and a discussion of the routine practices of Spanish dermatologists, the panel proposed and debated different options, with consideration of the experience of professionals and the preferences of patients or equality criteria. Following validation of the proposals, the final recommendations were formulated and, together with the evidence from the main international guidelines and studies, used to produce this consensus document. The goal of this consensus document is to provide dermatologists with practical recommendations for the management of rosacea.

Acné conglobata familiar

El acné conglobata es una forma severa de acné que produce muchas lesiones inflamatorias y cicatrices, marcando la vida del paciente de manera negativa. Presentamos el caso de 2 hermanos con acné conglobata, ambos con lesiones en piel de 2 años de evolución con aparición de nódulos, quistes y fístulas en territorio corporal extenso. El primero con diagnóstico reciente de leucemia promielocítica aguda en planes de iniciar quimioterapia y, el segundo, sin patologías de base. El primer caso recibió tratamiento antibiótico sistémico por complicaciones infecciosas propias de la inmunodepresión, además recibió dexametasona y ácido transretinoico como quimioterapia, y es dado de alta con dichos medicamentos y antibiótico profiláctico. El segundo caso recibió tratamiento con antibiótico sistémico y dapsona. Ambos acuden a control a los 2 meses y se observó mejoría importante de las lesiones en piel. El primer paciente falleció por complicaciones inherentes a su patología de base y el segundo paciente abandonó el tratamiento.

Acne conglobata is a severe form of acne that produces many inflammatory lesions and scars, marking the patient's life in a negative way. We present the case of two brothers with acne conglobata, both with 2-year-old skin lesions with the appearance of nodules, cysts, and fistulas in extensive body territory. The first with a recent diagnosis of acute promyelocytic leukemia with plans to start chemotherapy and the second with no underlying pathologies. The first case received systemic antibiotic treatment due to infectious complications typical of immunosuppression, he also received dexamethasone and transretinoic acid as chemotherapy, and was discharged with the mentioned drugs and prophylactic antibiotic. The second case received treatment with systemic antibiotic and dapsone. Both cases returned for control at 2 months and significant improvement in skin lesions was observed. The first patient died due to complications inherent to his underlying pathology and the second patient abandoned treatment.

Assessments of the ocular surface and meibomian gland morphology in patients with treatment-naive acne vulgaris / Avaliação da superfície ocular e da morfologia das glândulas meibomianas em pacientes com acne vulgar virgens de tratamento

ABSTRACT Purpose: To investigate ocular surface and meibomian glands in patients with treatment-naive acne vulgaris. Methods: The Ocular Surface Disease Index (OSDI) questionnaire, invasive tear film breakup time, fluorescein staining of the ocular surface, and Schirmer II test were performed for all subjects. Total eyelid and meibomian gland secretion scores were assessed. Non-contact meibography was performed with the Sirius corneal topographic device. Results: The right eyes of 35 patients with acne vulgaris and 35 healthy volunteers were included the study. While the OSDI and staining scores were significantly higher in the acne group than in the control group (p=0.01 and p=0.003, respectively), the invasive tear film breakup time and Schirmer measurements were significantly lower in the acne group (p=0.000 and p=0.003, respectively). The total eyelid and meibomian gland secretion scores were also higher in the acne group than in the control group (p=0.003 and p=0.000, respectively). On the morphological evaluation of the meibomian glands, the thickening, thinning, tortuosity, and presence of ghost areas were statistically significantly more common in the acne vulgaris group than in the control group (p=0.000, p=0.001, p=0.05, and p=0.006, respectively). The percentage of the meibomian gland loss area was significantly high in the acne vulgaris group on both upper and lower meibography. The meibomian gland loss area positively correlated with total eyelid and meibomian gland secretion scores. Conclusion: Acne vulgaris may have a predisposition to meibomian gland dysfunction and ocular surface damage. Early recognition of meibomian gland and ocular surface alterations seems important, especially in acne vulgaris cases for which oral isotretinoin treatment is planned.

RESUMO Objetivo: Todos os indivíduos responderam ao questionário Ocular Surface Disease Index (OSDI) e tiveram avaliados o tempo de ruptura do filme lacrimal pelo método invasivo, a coloração da superfície ocular com fluoresceína e o teste de Schirmer II. Foram ainda avaliados o escore palpebral total e o de secreção das glândulas meibomianas. Foi realizada meibografia sem contato com um dispositivo topográfico corneano Sirius. Métodos: Todos os indivíduos responderam ao questionário Ocular Surface Disease Index (OSDI) e tiveram avaliados o tempo de ruptura do filme lacrimal pelo método invasivo, a coloração da superfície ocular com fluoresceína e o teste de Schirmer II. Foram ainda avaliados o escore palpebral total e o de secreção das glândulas meibomianas. Foi realizada meibografia sem contato com um dispositivo topográfico corneano Sirius. Resultados: Foram incluídos no estudo os olhos direitos de 35 voluntários com acne vulgar e 35 saudáveis. Os escores do Ocular Surface Disease Index e da coloração foram significativamente maiores no grupo com acne em comparação com o grupo controle (p=0,01 e p=0,003, respectivamente), mas o tempo de ruptura do filme lacrimal pelo método invasivo e as medidas do teste de Schirmer II foram significativamente menores (p=0,000 e p=0,003, respectivamente). O escore palpebral total e o escore de secreção das glândulas meibomianas também foram maiores no grupo com acne que no grupo controle (p=0,003 e p=0,000). Na avaliação morfológica das glândulas meibomianas, o espessamento, o afinamento, a tortuosidade e a presença de áreas fantasmas nas glândulas foram mais comuns no grupo acne vulgar que no grupo controle, com significância estatística (p=0,000, p=0,001, p=0,05 e p=0,006 respectivamente). A porcentagem da área de perdas das glândulas meibomianas foi significativamente mais alta no grupo com acne vulgar, tanto na meibografia superior quanto na inferior. A área de perda das glândulas meibomianas demonstrou uma correlação positiva com o escore palpebral total e com o escore de secreção das glândulas meibomianas. Conclusão: A acne vulgar pode levar a uma predisposição para a disfunção das glândulas meibomianas e para danos na superfície ocular. Parece ser importante reconhecer precocemente as alterações das glândulas meibomianas e da superfície ocular, especialmente nos casos de acne vulgar para os quais se planeja o tratamento oral com isotretinoína.

Reação adversa à isotretinoína: alteração do formato capilar / Adverse reaction to isotretinoin: alteration of the hair shaft structure

Embora pouco frequente na prática clínica, o uso de retinoides sistêmicos pode provocar alterações no formato, na coloração e textura das hastes capilares. Relatamos o caso de um paciente tratado com isotretinoína para acne vulgar que experimentou mudança do tipo capilar, de liso para encaracolado. Tais modificações são possíveis ao longo da terapia com retinoides orais; entretanto, a mudança do formato dos fios induzida pela isotretinoína é um fenômeno extremamente raro na literatura

Although little reported in daily practice, the use of systemic retinoids can cause changes in the shape, color, and texture of hair shafts. We report a case of a patient treated with isotretinoin for acne vulgaris who experienced new growing curly hair. Such hair changes are recognized during therapy with oral retinoids; however, isotretinoin-induced modifications on the hair fiber curvature are extremely rare.

Isotretinoin-induced arthritis: A rare but feasible diagnosis. Case report

Many medications and vaccines have had implications in the development of musculoskeletal and joint symptoms, and among them the use of retinoids has been associated with the development of musculoskeletal symptoms, as well as axial symptoms suggestive of spondyloarthritis, with sacroiliitis, and to a lesser extent the development of peripheral symptoms. We describe the debut of peripheral inflammatory symptoms with the use of isotretinoin, in a previously healthy patient.

Muchos medicamentos y vacunas han tenido implicaciones en el desarrollo de síntomas osteomusculares y articulares. Entre ellos, el uso de retinoides se ha asociado con el desarrollo de síntomas musculoesqueléticos, así como síntomas axiales sugestivos de espondiloartritis con sacroileítis, y en menor proporción el desarrollo de síntomas periféricos. Describimos el inicio de síntomas inflamatorios periféricos con el uso de isotretinoína en una paciente previamente sana.

Folliculitis decalvans: a case report of satisfactory recovery after implementing

ABSTRACT Introduction: Folliculitis decalvans is a rare skin disease characterized by the presence of painful papules and pustules with an underlying neutrophilic infiltrate, usually on the scalp. Its treatment is lengthy and challenging, and recurrence is relatively common. Although its etiology is unknown, several theories explaining its development have been proposed, including colonization by Staphylococcus aureus. Case description: This is the case of a 26-year-old male healthcare worker who visited the outpatient service after experiencing a 4-year history of painful pustules on the scalp; initially these lesions were located in the occipital region, but then also started to appear in the temporal and parietal regions. After being treated for bacterial folliculitis and having several recurrences, a skin biopsy was performed, which allowed diagnosing him with folliculitis decalvans. Once the diagnosis was made, isotretinoin (20mg) treatment was implemented for a year and a half, achieving complete remission of the lesions. Conclusion: Although this case has some limitations, such as the lack of histopathology images and some control laboratory tests, it clearly shows the difficulties faced when treating this type of skin disorders and presents an overview of the use of isotretinoin, evidencing that although this drug is well tolerated, possible adverse reactions from drug interactions with trimethoprim/sulfamethoxazole may arise. In addition, this case is of great importance since the possible presence of a familial cluster of folliculitis decalvans could be confirmed, if further genetic testing is performed.

RESUMEN Introducción. La folliculitis decalvans es una enfermedad dermatológica rara caracterizada por la presencia de pápulas y pústulas dolorosas que están acompañadas de un infiltrado de neutrófilos subyacente. Esta condición suele aparecer en el cuero cabelludo, su recurrencia es relativamente común y su tratamiento, largo y difícil. Aunque su etiología es desconocida, se han propuesto muchas teorías que intentan explicar su aparición, siendo la colonización por Staphylococcus aureus una de ellas. Presentación del caso. Hombre de 26 años que se desempeñaba como trabajador de la salud y consultó por un cuadro clínico de 4 años de evolución caracterizado por la aparición de pústulas dolorosas en la región occipital, las cuales posteriormente se extendieron a la región temporal y parietal. Después de tratarlo como una foliculitis infecciosa y tras múltiples recurrencias, se realizó una biopsia de las lesiones que permitió diagnosticarlo con folliculitis decalvans. Se instauró un tratamiento consistente de 20mg de isotretinoina al día por un año y medio, con el cual se logró la resolución de la folicutis. Sin embargo, dos años después tuvo un relapso, pero, según el paciente, esto pudo ocurrir por el consumo de derivados lácteos, ya que, según indicó, cuando suspende el consumo de esta clase de productos no aparecen más lesiones luego de 2-3 semanas. Conclusión. Aunque este caso tiene algunas limitaciones como la ausencia de imágenes histopatológicas y algunos laboratorios de control, muestra las dificultades para tratar este tipo de condiciones dermatológicas y presenta un panorama del uso de la isotretinoina, ya que evidencia que este medicamento tiene una buena tolerancia, pero presenta interacciones medicamentosas adversas con la trimetoprima/sulfametoxazol. Además, este caso es de gran importancia, ya que, si se realizan más pruebas genéticas, podría confirmarse la posible presencia de un grupo familiar de foliculitis decalvante.

Lacrimal gland atrophy and dry eye related to isotretinoin, androgen, and prolactin: differential diagnosis for Sjögren's syndrome / Atrofia das glândulas lacrimais e olho seco relacionados aisotretinoína, androgênio e prolactina: diagnóstico diferencial com a síndrome de Sjögren

ABSTRACT This report is of three cases of sicca syndrome, initially suspected to be Sjögren's syndrome, which was ruled out by clinical and laboratory investigations. The patients were a 24-year-old woman, a 32-year-old man, and a 77-year-old woman with chronic symptoms of sicca syndrome, including dry eye syndrome. The first case was associated with the use of isotretinoin, a retinoic acid. The second was associated with the use of anabolic androgenic steroids, and the third was related to a prolactin- secreting pituitary adenoma. All cases manifested sicca, including dry eye syndrome, after those events, and the manifestations persisted. Magnetic resonance imaging revealed bilateral atrophy of the lacrimal gland. The medical history, ocular examinations, laboratory exams, and magnetic resonance images confirmed dry eye syndrome; however, the exams were all negative for Sjögren's syndrome. The lacrimal gland was absent on magnetic resonance imaging in all three cases. The clinical history revealed that the signs and symptoms appeared after chronic exposure to retinoic acid, anabolic androgenic steroids, and a prolactin-secreting pituitary adenoma, respectively. Chronic isotretinoin, anabolic androgenic steroids, and prolactin-secreting pituitary adenoma or, in this last case, its inhibitory treatment, can cause lacrimal gland atrophy, sicca syndrome, and dry eye syndrome, and a differential diagnosis of Sjögren's syndrome. Further studies on doses, time, and other susceptibilities to the long-lasting adverse effects of retinoic acid, anabolic androgenic steroids, and the repercussions of prolactin-secreting pituitary adenoma are necessary to confirm and expand upon these associations.

RESUMO O relato descreve três casos de síndrome de sicca, inicialmente suspeitos de serem a síndrome de Sjögren, que fo­ram negados pela investigação clínica e laboratorial. O primeiro associado ao uso de isotretinoína, um ácido retinóico, o segundo ao uso de esteroides androgênicos anabolizantes e o terceiro relacionado ao adenoma da hipófise secretora da prolactina, todos manifestaram sicca, incluindo a síndrome do olho seco após esses eventos e as manifestações persistem. A ressonância magnética revelou atrofia bilateral da glândula lacrimal. Eles eram uma mulher de 24 anos, um homem de 32 anos e uma mulher de 77 anos com sintomas crônicos da síndrome de sicca, incluindo a síndrome do olho seco. A história médica, o exame ocular, os exames laboratoriais e a ressonância magnética foram confirmados como síndrome do olho seco, no entanto, todos os exames foram negativos para a síndrome de Sjögren. A glândula lacrimal estava ausente na ressonância magnética nos três casos. A história clínica revelou que sinais e sintomas se manifestaram após exposição crônica ao ácido retinóico, esteróides anabolizantes androgênicos e adenoma secretivo da prolactina hipofisária, respectivamente. Isotretinoína crônica, esteroides anabólicos androgênicos e adenoma hipofisário secretor de prolactina ou, neste último caso, seu tratamento inibitório pode ser a causa da atrofia da glândula lacrimal, síndrome da sicca e síndrome do olho seco e diagnóstico diferencial da síndrome de Sjögren. Estudos adicionais sobre doses, duração e outras suscetibilidades aos efeitos adversos duradouros do ácido retinóico, esteroides androgênicos anabólicos e repercussões do adenoma da hipófise secretora da prolactina são necessários para confirmar e detalhar essas associações.

Effects of oral isotretinoin therapy on the nasal cavities / Efeitos nasais da terapia com isotretinoína oral

Abstract Introduction Isotretinoin (13 cis-retinoic acid) is the most effective treatment for acne vulgaris and is the only treatment option that can provide either remission or a permanent cure. Objective The aim of this study was to use both subjective and objective methods to assess the nasal complaints of patients with severe acne who received oral isotretinoin therapy. Methods Fifty-four subjects were enrolled in the study. All the subjects were assessed with subjective (NOSE and VAS questionnaires) and objective (rhinomanometry and saccharine) tests to determine the severity of their nasal complaints. Results The mean severity scores (min: 0; max: 100) for nasal dryness/crusting and epistaxis were 0.47 ± 1.48 (0-5); 0.35 ± 1.30 (0-5) at admission, 3.57 ± 4.45 (0-10); 2.26 ± 4.71 (0-20) at the first month, and 4.28 ± 6 (0-20); 2.26 ± 4.71 (0-20) at the third month of the treatment respectively. Total nasal resistance of 0.195 ± 0.079 (0.12-0.56) Pa/cm3/s at admission, 0.21 ± 0.084 (0.12-0.54) Pa/cm3/s at the first month, and 0.216 ± 0.081 (0.14-0.54) Pa/cm3/s at the third month. Conclusion Oral isotretinoin therapy can cause the complaint of nasal obstruction. In addition, nasal complaints, such as dryness/crusting and epistaxis, significantly increase in patients during the therapy schedule.

Resumo Introdução A isotretinoína (ácido-13 cis-retinóico) é o tratamento por via oral mais eficaz para acne vulgar e é a única opção de tratamento que pode produzir remissão ou cura permanente. Objetivo Usar métodos subjetivos e objetivos para avaliar as queixas nasais de pacientes com acne grave que receberam terapia com isotretinoína oral. Método Foram incluídos no estudo 54 indivíduos. Todos os indivíduos foram avaliados por meio de testes subjetivos (questionários NOSE e escala EVA) e objetivos (rinomanometria e teste de sacarina) para determinar a gravidade de suas queixas nasais. Resultados Os escores médios de gravidade (min: 0; max: 100) para ressecamento/crostas e epistaxe nasal foram de 0,47 ± 1,48 (0-5); 0,35 ± 1,30 (0-5) no início, 3,57 ± 4,45 (0-10); 2,26 ± 4,71 (0-20) no primeiro mês e 4,28 ± 6 (0-20); 2,26 ± 4,71 (0-20) no terceiro mês do tratamento, respectivamente. A resistência nasal total foi de 0,195 ± 0,079 (0,12 a 0,56) Pa/cm3/s no início, 0,21 ± 0,084 (0,12 a 0,54) Pa/cm3/s no primeiro mês e 0,216 ± 0,081 (0,14 a 0,54) Pa/cm3/s no terceiro mês. Conclusão A terapia com isotretinoína por via oral pode resultar em queixa de obstrução nasal. Além disso, queixas nasais, tais como ressecamento/formação de crostas e epistaxe, aumentam significativamente nos pacientes durante o esquema terapêutico.

Ocular surface changes in the treatment of rosacea: comparison between low-dose oral isotretinoin and doxycycline / Alterações da superfície ocular no tratamento da Rosácea: comparação entre isotretinoína oral em baixa dosagem e doxiciclina

ABSTRACT Purpose: To compare the impact of ocular changes between systemic treatment with doxycycline and low-dose oral isotretinoin in patients with moderate-to-severe papulopustular rosacea. Methods: Patients were randomized to receive either isotretinoin 0.3-0.4 mg/kg (group A) or doxycycline 100 mg/day (group B) for 16 weeks. Ocular symptoms were searched and evaluated, including best-corrected visual acuity (BCVA), Schirmer test, breakup time, rose bengal staining score, and meibomian gland dysfunction grading. The patients were retested at the end of treatment. Results: The present study included 39 patients (30 females and 9 males). Best-corrected visual acuity was > 20/30 in >90% of patients in both groups and did not change after treatment. After treatment, improvement in ocular symptoms and meibomian gland dysfunction was more pronounced in group B (p<0.05); the other parameters did not reach statistical significance. Conclusion: Doxycycline improved meibomian gland dysfunction, ocular symptoms, and ocular surface in patients with rosacea. Even though some patients experienced worsening meibomian gland dysfunction and symptoms, no subject experienced any serious complications after administration of low-dose isotretinoin.

RESUMO Objetivos: Comparar o impacto das alterações oculares entre o tratamento sistêmico de doxiciclina e isotretinoína em baixa dosagem em pacientes com rosácea papulopustulosa moderada a grave. Métodos: Os pacientes form randomizados para receber isotretinoína 0,3 a 0,4 mg/kg (grupo A) ou doxiciclina 100mg/dia (grupo B) por 16 semanas. Os sintomas oculares foram pesquisados e avaliados, incluindo melhor acuidade visual corrigida, teste de Schirmer, tempo de ruptura do filme lacrimal, coloração de rosa bengala e graduação da disfunção de glândula de Meibomius. Os pacientes foram novamente testados no final do tratamento. Resultados: O presente estudo incluiu 39 pacientes (30 mulheres e 9 homens). A melhor acuidade visual corrigida foi >20/30 em >90% dos pacientes em ambos os grupos e não se alterou após o tratamento. A melhora dos sintomas oculares e da disfunção de glândula de Meibomius foi mais pronunciada no grupo B (p<0,05) após o tratamento; as demais variáveis não atingiram significância estatística. Conclusão: A doxiciclina melhorou a disfunção de glândula de Meibomius, os sintomas oculares e a superfície ocular de pa cientes com rosácea. Mesmo que alguns pacientes tenham piorado a disfunção e os sintomas da glândula de Meibomius, nenhum indivíduo apresentou complicações graves após a admi nistração de baixas doses de isotretinoína.

Isotretinoína durante a gestação e malformações fetais associadas / Isotretinoin during pregnancy and associated fetal malformations / Isotretinoína durante el embarazo y malformaciones fetales asociadas

Introdução: A isotretinoína (13-cis-ácido retinóico) é a substância ativa do medicamento Roacutan®, retinoide de ação antisseborreica específico para tratamento oral de acne grave. Contudo, o uso indiscriminado deste medicamento para tratamento de acne, sem o conhecimento dos efeitos causados ao feto, contribui para ocorrência de malformações irreversíveis na criança. Objetivo: Relatar os impactos induzidos pelo uso da isotretinoína (Roacutan®) na gestação. Método: Os dados foram coletados, após aprovação pelo CEP/UNIFIPA, por meio de questionários distribuídos on-line para mulheres previamente contatadas via internet em sites sobre o tema gestação e Roacutan® e convidadas a participar do estudo por meio de plataforma específica. Doze mulheres com idades entre 27 e 37 anos responderam o questionário, residentes nos estados de São Paulo, Minas Gerais, Bahia, Rio de Janeiro, Paraná e Rio Grande do Sul, sendo três profissionais da área de saúde, três das áreas de humanas e exatas e seis de outras áreas. Resultados: As participantes relataram o uso do medicamento entre os anos de 2012 e 2018, por questões estéticas, quando estavam com idade entre 22 e 35 anos, por períodos menores que 20 dias (20%), de um mês a três meses (50%), seis meses (20%) e dez meses (10%), na dosagem de 20 mg, com ingestão de um (80%) a dois comprimidos por dia. Todas usaram o medicamento após prescrição médica e foram alertadas para fazerem uso de anticoncepcional. Contudo, duas mulheres engravidaram antes do início do tratamento (20%), oito durante o uso do medicamento (80%), sendo que maioria das mulheres usou o medicamento durante o primeiro mês de gestação (70%), uma até o segundo mês (10%) e duas até o terceiro mês (20%). A maioria informou que foi a primeira gestação (67%) e nenhuma delas teve outro filho depois. Ao saberem da gravidez com o uso concomitante do medicamento todas as mães relataram receio de malformações, especialmente relacionadas a defeitos neurológicos e cardíacos. Após o nascimento, oito bebês (80%) ficaram internados na UTI por períodos de dois a 25 dias e um deles veio a óbito. Com exceção de uma criança que não apresentou malformação, todas as outras apresentaram malformações como microtia e anotia uni ou bilateral, fenda palatina, paralisia facial uni ou bilateral e cardiopatia, na maioria dos casos em associação. Duas das crianças afetadas (20%) passaram por procedimentos cirúrgicos. Atualmente, todas as crianças estão bem de saúde, de forma geral. Nenhuma das participantes fez novo uso da isotretinoína e a maioria (90%) alerta outras mulheres sobre os riscos do medicamento em uma possível gestação. Uma das participantes alerta também os homens que fazem uso de isotretinoína. A única mulher que não informa sobre os efeitos teratogênicos do medicamento, coincidentemente, é de quem a criança não apresentou malformações congênitas. Conclusão: Embora esteja bem estabelecido o caráter teratogênico da isotretinoína na gestação e o medicamento seja usado mediante prescrição médica e com indicação de não engravidar, ainda os casos de gestação durante o tratamento são comuns. Dessa forma, é importante que campanhas de conscientização sobre esse assunto sejam realizadas de maneira continuada.(AU)

Introduction: Isotretinoin (13-cis retinoic acid) is the active substance in Roacutan®, a specific anti-seborrhoic retinoid for oral severe acne treatment. However, the indiscriminate use of this medicine for acne treatment, without knowledge of the effects caused to the fetus, contributes to the occurrence of irreversible malformations in children. Objectives: Report the impacts induced by the use of isotretinoin (Roacutan®) during pregnancy. Method: Data were collected, after approval by CEP/UNIFIPA, through questionnaires distributed online to women previously contacted via the Internet on pregnancy and Roacutan® websites and invited to participate to the study through a specific platform. Twelve women aged between 27 and 37 years old answered the questionnaire, they live in São Paulo, Minas Gerais, Bahia, Rio de Janeiro, Paraná and Rio Grande do Sul states. Three of them are health professionals, three are from the humanities and six from other fields. Results: Participants reported the use of the drug between 2012 and 2018, for aesthetic reasons, when they were aged 22 to 35 years old. The reported periods were shorter than 20 days (20%), from one month to three months (50%), six months (20%) and ten months (10%), at a dosage of 20mg, with the ingestion of one (80%) to two tablets per day. All used the drug after prescription and were warned to use contraceptive. However, two women became pregnant before treatment (20%) and eight during medication use (80%). Most women used the drug during the first month of pregnancy (70%), one until the second month. (10%) and two until the third month (20%). Most reported that it was their first pregnancy (67%) and none of them had another child afterwards. Upon knowing about pregnancy with concomitant use of the drug all mothers reported fear of malformations, especially related to neurological and cardiac defects. After birth, eight babies (80%) were admitted to the ICU (Intensive Care Unit) for periods of two to 25 days and one of them died. Except for one child who had no malformation, all the others presented malformations such as unilateral and bilateral microtia and anotia, cleft palate, unilateral or bilateral facial paralysis and heart disease, in most cases in association. Two of the affected children (20%) underwent surgical procedures. Today all children are in good health overall. None of the participants made new use of isotretinoin and most of them (90%) warn other women about the risks of the drug in a possible pregnancy. One of the participants also warns men who use isotretinoin. Conclusion: The only woman who does not report about the teratogenic effects of the drug, coincidentally, is whose child did not have congenital malformations. Although the teratogenic character of isotretinoin in pregnancy is well established and the drug is used under medical prescription and doctors indicate contraceptive use, pregnancy is still common during treatment. Therefore, it is important that awareness campaigns on this subject be carried out on a continuous basis.(AU)

Introducción: La isotretinoína (ácido 13-cis retinoico) es el principio activo de Roacutan®, un retinoide antiseborreico específico para el tratamiento oral del acné severo. Sin embargo, el uso indiscriminado de este medicamento para el tratamiento del acné, sin conocer los efectos causados al feto, contribuye a la aparición de malformaciones irreversibles en los niños. Objetivo: Informar los impactos inducidos por el uso de isotretinoína (Roacutan®) durante el embarazo. Método: Los datos se recopilaron, después de la aprobación del CEP/UNIFIPA, a través de cuestionarios distribuidos en línea a mujeres previamente contactadas a través de Internet sobre sitios de embarazo y Roacutan® e invitadas a participar en el estudio a través de una plataforma específica. Doce mujeres de 27 a 37 años respondieron el cuestionario, que residen en los estados de São Paulo, Minas Gerais, Bahía, Río de Janeiro, Paraná y Rio Grande do Sul, siendo tres profesionales de la salud, tres de los humanos y y seis de otras áreas. Resultado: Los participantes informaron el uso de la droga entre 2012 y 2018, por razones estéticas, cuando tenían entre 22 y 35 años, por períodos de menos de 20 días (20%), de un mes a tres meses (50%) , seis meses (20%) y diez meses (10%), a una dosis de 20 mg, con la ingestión de una (80%) a dos tabletas por día. Todos usaron el medicamento después de la prescripción y se les advirtió que usaran anticonceptivos. Sin embargo, dos mujeres quedaron embarazadas antes del inicio del tratamiento (20%), ocho durante el uso de medicamentos (80%), y la mayoría de las mujeres usaron el medicamento durante el primer mes de embarazo (70%), una hasta el segundo mes. (10%) y dos hasta el tercer mes (20%). La mayoría informó que era su primer embarazo (67%) y ninguno de ellos tuvo otro hijo después. Al enterarse del embarazo con el uso concomitante de la droga, todas las madres informaron temor a malformaciones, especialmente relacionadas con defectos neurológicos y cardíacos. Después del nacimiento, ocho bebés (80%) fueron ingresados en la UCI por períodos de dos a 25 días y uno de ellos murió. A excepción de un niño que no tenía malformación, todos los demás tenían malformaciones como microthay y anotación unilateral y bilateral, paladar hendido, parálisis facial unilateral o bilateral y enfermedad cardíaca, en la mayoría de los casos en combinación. Dos de los niños afectados (20%) se sometieron a procedimientos quirúrgicos. Hoy todos los niños gozan de buena salud en general. Ninguno de los participantes hizo un nuevo uso de isotretinoína y la mayoría (90%) advierte a otras mujeres sobre los riesgos del medicamento en un posible embarazo. Uno de los participantes también advierte a los hombres que usan isotretinoína. La única mujer que no informa sobre los efectos teratogénicos de la droga, casualmente, es cuyo hijo no tuvo malformaciones congénitas. Conclusión: Aunque el carácter teratogénico de la isotretinoína en el embarazo está bien establecido y el medicamento se usa con receta médica y con una indicación de no quedar embarazada, el embarazo sigue siendo común durante el tratamiento. Por lo tanto, es importante que las campañas de sensibilización sobre este tema se lleven a cabo de manera continua.(AU)

Embriopatía por isotretinoína: Una entidad que puede evitarse / Isotretinoin embryopathy: An entity that can be avoided

La isotretinoína es el medicamento más efectivo en el tratamiento del acné noduloquístico recalcitrante grave. Sin embargo, el tratamiento con este fármaco se encuentra asociado con efectos adversos, y el más grave es la teratogénesis. Se ha estimado que 40% de los embarazos expuestos a isotretinoína presenta un aborto espontáneo y 35% desarrolla embriopatía. Se presenta el caso de un recién nacido con antecedente de exposición prenatal a isotretinoína, una entidad clínica que puede evitarse, con graves defectos congénitos en el sistema nervioso central e importantes dismorfias faciales, con evolución clínica desfavorable.

Isotretinoin is the most effective drug in the treatment of severe recalcitrant nodulocystic acne. However, treatment with this drug is associated with adverse effects, the most severe being teratogenesis. It has been estimated that 40% of pregnancies exposed to isotretinoin present spontaneous abortion and 35% develop embryopathy. We present the case of a newborn with a history of prenatal exposure to isotretinoin, a clinical entity that can be avoided, with severe congenital defects in the central nervous system and important facial dysmorphisms, with unfavorable clinical course.

Extirpación quirúrgica con cierre primario y uso de Isotretinoína en acné queloídeo de la nuca: serie de 6 casos clínicos / Acne keloidalis nuchae

El Acné queloídeo de la nuca se presenta principalmente en hombres jóvenes de raza negra; su etiología es desconocida, pero se piensa que sería multifactorial. El cuadro clínico corresponde a pápulas y pústulas que tienden a confluir en placas de aspecto queloídeo y que se observan como alopecia cicatricial, produciendo gran repercusión tanto física como psicológica en el paciente. Histológicamente se distingue una etapa temprana y una avanzada. No existe tratamiento curativo para este cuadro, pero se ha experimentado con múltiples opciones de tratamiento. En este trabajo se exponen los resultados de nuestra experiencia terapéutica con cirugía excisional asociada a cierre primario y posterior uso de Isotretinoína oral.

The Acne keloidalis nuchae occurs mainly in young black men; its etiology is unknown but is thought to be multifactorial. Clinically it presents as papules and pustules which tend to coalesce in keloid-like plaques and they are observed as scarring alopecia, producing great impact both physically and psychologically in the patient. An early and an advanced stage can be distinguished with histological techniques. There is no cure for this pathology, even though multiple treatments have been tried. In this paper, we expose the results of our therapeutic experience with excisional surgery associated with primary closure and subsequent use of oral Isotretinoin.

Efeito da Isotretinoína na Xerostomia, pH e Fluxo Salivar / The Effect of Isotretinoin on Xerostomia, pH and Flow Salivary

A isotretinoína é um derivado sintético da vitamina A empregada no tratamento da acne. As reações adversas na cavidade bucal são poucorelatadas na literatura. Esta pesquisa consiste em um estudo transversal que teve como objetivo avaliar a influência da isotretinoína no grau de xerostomia, pH e fluxo salivar. Após aprovação pelo CEP do Hospital Infantil Nossa Senhora da Glória - SESA, e consentimento e/ou assentimento dos participantes, foi aplicado um questionário, o Xerostomia Inventory Dutch version, para avaliar o grau de xerostomia e coletada a saliva total para análise do fluxo e pH. A amostra foi constituída por 87 indivíduos, divididos em quatro grupos: G1 ? controle, indivíduos não acneicos saudáveis (n=16); G2? indivíduos acneicos que nunca fizeram uso de isotretinoína (n=16); G3? indivíduos acneicos em uso de isotretinoína (n=45); G4? indivíduos acneicos que haviam concluído o tratamento com isotretinoína (n=10). Os indivíduos deste último grupo haviam concluído o tratamento em um intervalo de 30 a 60 dias. Com base nos dados obtidos foram calculados média, mediana,desvio padrão e aplicado o teste estatístico de Kruskal Wallis. Os resultados dos parâmetros estudados para os grupos G1, G2, G3 e G4 foram, respectivamente: grau de xerostomia ? 16,44±3,16, 17,62±2,68,21,55±3,45, 18,00±2,71 (p<0,0001); fluxo salivar ? 1,08±0,40, 0,89±0,37,0,90±0,58 e 1,22±0,55 mL/min (p=0,139); pH da saliva ? 7,05±0,37, 7,05±0,32, 6,89±0,24, 6,91±0,24 (p=0,104). Concluiu-se que o fluxo salivar foi menor nos indivíduos acneicos que não usam e os que usam a isotretinoína (G2 e G3) em relação aos grupos G1 e G4, porém esta diferença não foi estatisticamente significante. A xerostomia nos indivíduos acneicos que usam a isotretinoína (G3) foi maior em relação aos grupos G1, G2 e G4 e esta diferença foi estatisticamente significante.

Isotretinoin is a synthetic derivative of vitamin A, used in the treatment of acne. The adverse reactions in the oral cavity are scarcely reported in the literature. This research consists of a cross-sectional study in healthy and aims to evaluate the influence of isotretinoin in the degree of xerostomia, salivary flow and pH. After approval by the IRB at Children?s Hospital Nossa Senhora da Glória-SESA, individuals have signed the informed consent form, and the search was performed by applying a questionnaire, Xerostomia Inventory Dutch version (XID), to assess the degree of xerostomia and collecting overall saliva for flow analysis and pH. The sample consisted of 87 subjects, divided into four groups: G1 Control ? no acneicos, healthy individuals (n = 16); G2 acneicos individuals who have never made use of isotretinoin (n = 16); G3 acneicos individuals using isotretinoin (n = 45); G4 acneicos individuals who had completed treatment with isotretinoin (n = 10). Individuals of this latter group had completed treatment in a range of 30 to 60 days. From the obtained values were calculated the average,standard deviation and applied a statistical test of Kruskal Wallis. The results of the parameters studied for G1, G2, G3 and G4 were: degree of xerostomia- 16.44±3.16, 17.62±2.68, 21.55±3.45, 18.00±2.71 (p<0.0001); salivary flow ? 1.08±0.40, 0.89±0.37, 0.90±0.58, and 1.22±0.55mL/min (p=0.139); saliva pH ? 7.05 ± 0.37, 7.05 ± 0.32, 6.89 ± 0.24, 6.91 ± 0.24 (p=0.104). It was found that the salivary flow was higher in acneicos individuals who do not use and those who use isotretinoin (G2 and G3) in relation to the groups G1 and G4, but this difference was not statistically significant. Xerostomia in acneicos individuals who use isotretinoin (G3) was higher compared to the G1, G2 and G4 and this difference was statistically significant.