A randomized open label comparative study to determine the various side effects and patient satisfaction of low dose continuous versus low dose intermittent oral isotretinoin therapy in moderate to severe acne vulgaris

Background: Acne Vulgaris is chronic inflammatory disease of pilosebaceous units. Oral isotretinoin is recommended for moderate to severe acne vulgaris who are not responding satisfactorily to conventional therapies. Recent reports indicate that acne patients have been benefiting from the low dose treatment protocols. However, long term daily use of this drug results in frequent side effects such mucocutaneous and systemic side effects. Our aim was to assess and compare the various side effects and patient satisfaction of oral isotretinoin in low dose continuous and intermittent treatment of moderate to severe acne vulgaris.Methods: This was a prospective randomized open labeled comparative study carried out at outpatient department in the Department of Dermatology in Mandya Institute of Medical sciences, Mandya. Patients with moderate to severe acne were assigned equally (50 subjects each) to one of the two treatment regimens by using block randomization technique, Group A was given low dose continuous regimen-20 mg oral isotretinoin once daily for 4 months and Group B was given low dose intermittent regimen-20 mg oral isotretinoin once daily for 1 week out of every 4 weeks. The patients were followed up every 4th week during the treatment period. The patients were examined and side effects were noted in each visit. A six month follow-up evaluation was done to analyze patient satisfaction.Results: Muco-cutaneous dryness was most common adverse effect noted in both the groups A and B. Itching (42%), Alopecia (44%), Myalgia (36%) were seen most commonly in group A and Acne flaring (47%) was most common with group B. With regard to patient satisfaction, in group A 42% were satisfied and 20% were very satisfied, in group B 36% were satisfied and 14% were very satisfied.Conclusions: Study suggests that, Muco-cutaneous dryness was most common side effect in both treatment regimens. Side effects were more frequent with low dose continuous than low dose intermittent isotretinoin regimen. Patient satisfaction was better in continuous regimen.

Modulation of biochemical activity of hepatocytes in culture by matrix substratum.

The influence of extra cellular matrix on the biochemical activity of hepatocytes was studied by maintaining rat hepatocytes in primary culture in a serum free medium on different matrix protein substrata or biomatrices prepared from liver, aorta or mammary gland. There was significant difference in the individual protein synthesis and distribution by cells maintained on different substrata. Comparison of the kinetics of synthesis and secretion of albumin by cells maintained on different tissue biomatrix showed that those maintained on hepatic biomatrix synthesized more albumin and retained more of albumin synthetic capacity, when compared to those maintained on aortic and mammary gland biomatrix. Similarly, hepatocytes maintained on hepatic biomatrix synthesized significantly more apo B, the major apo protein of VLDL, than those maintained on heterologous tissue matrix. Induction of tyrosine aminotransferase by dexamethasone and the uptake of [14C]-amino isobutyric acid were found to be maximum in cells maintained on liver biomatrix than the heterologous biomatrix. But cells maintained on hepatic biomatrix incorporated less amounts of radioactivity into total cytoskeletal proteins as well as the individual proteins such as actin and the cytokeratins C8 and C18 while that by cells maintained on aortic biomatrix was significantly high. Quantitative analysis of the relative incorporation of radioactivity into individual cytoskeletal proteins and albumin in pulse labelling studies with cells maintained in culture on different matrix for different lengths of time revealed a reciprocal relationship between these two activities. These results indicate that the substrata with which the cells are in contact influence on a selective basis, the biochemical activity of hepatocytes in primary culture.

Synthesis of NAD+ in erythrocytes incubated with nicotinic acid and the effect of di-(2-ethyl hexyl) phthalate (DEHP).

Synthesis of NAD+ from nicotinic acid by erythrocytes incubated in SAGM phosphate solution and effect of di-[2-ethyl hexyl] phthalate, a plasticizer commonly used in PVC blood/component storage bags, on this synthesis was studied. Erythrocytes are able to synthesise NAD+ in SAGM (sodium chloride, adenine, glucose, mannitol) phosphate solution and this synthesis was more in the presence of added nicotinic acid (optimum concentration 1 mM). The level of NAD+ decreased when the incubation period was increased from 24 to 48 hr. Glutamine had a deleterious effect on this synthesis, possibly due to the decrease in pH. Di-[2-ethyl hexyl] phthalate had an inhibitory effect on NAD+ synthesis when the cells were incubated in SAGM phosphate solution, either alone or in the presence of added nicotinic acid. There was significant decrease in the release of potassium and haemoglobin from the cells in the presence of nicotinic acid, indicating increased red cell stability.

Effect of DEHP [di-(2-ethyl hexyl) phthalate] on lipid peroxidation in liver in rats and in primary cultures of rat hepatocytes.

The effect of DEHP [di-(2-ethly hexyl) phthalate] on lipid peroxidation in the liver in rats and in primary cultures of rat hepatocytes incubated with it was studied. The doses of DEHP used in this study corresponded to the low levels of this substance leaching into blood stored in DEHP plasticised PVC bags. Increased activity of superoxide dismutase (SOD) and catalase, increased concentration of malondialdehyde (MDA) and conjugated dienes and decrease in the concentration of glutathione and vitamin E have been observed in the liver of rats administered DEHP. Primary cultures of rat hepatocytes incubated with DEHP also showed increase in the activity of these enzymes, increase in the concentration of MDA and decrease in vitamin E. These results indicate that DEHP promotes lipid peroxidation. Incorporation of vitamin E along with DEHP into the culture medium containing hepatocytes counteracted these effects.

Toxic effect of systemic administration of low doses of the plasticizer di-(2-ethyl hexyl) phthalate [DEHP] in rats.

DEHP [di-(2 ethyl hexyl) phthalate], a widely used plasticizer in blood storage bags, leaches out in appreciable amounts into blood (about 10 mg/100 ml) resulting in exposure of recipients of blood transfusion to this compound. Various reports indicate the toxicity of DEHP, particularly in liver and reproductive organs but all these studies used large doses (up to 2 g or more/Kg body weight) and oral route of administration which are not relevant to the intravenous administration during blood transfusion or the low amounts present in blood. We have studied changes in the activity of some important enzymes-gamma-GT, ALT, CPK, LDH, alkaline phosphatase, acid phosphatase, beta-glucuronidase and few other parameters like vitamin E, glutathione, serum albumin etc in rats administered low doses of DEHP (corresponding to transfusion of 2, 4, 6 and 10 units of blood). Histopathology of the organs has also been carried out. The results obtained indicate no serious toxic effects for DEHP at the level present in blood stored in DEHP plasticized blood bags as evidenced by the lack of any significant alteration in most of the biochemical parameters studied. Even in those cases where there was alteration (for e.g., decrease in the level of vitamin E) 24 hr after administration of DEHP, it returned to near normal level with in 72 hr to 7 days. No histopathological changes were observed in any of the organs at these levels of DEHP. It is concluded that DEHP did not cause any serious toxic effect even at doses corresponding to transfusion of several units of blood in a recipient.