Assessment of the In Vivo Reprotoxicity of Isotretinoin in Sprague-Dawley Male Rat.

BACKGROUND: Isotretinoin (ISO) belongs to a family of drugs called retinoids. It is the most effective drug prescribed by dermatologists for the treatment of the inflammatory disease, acne vulgaris. A significant barrier to the use of ISO has worries regarding its adverse effect profile. Despite the well-recognized reproductive toxicity and teratogenicity in females, there is no warning related to the use by male patients in the medication prospectus. Current data on the effects on human male fertility is contradictory and inconclusive. OBJECTIVES: This study was undertaken to investigate the potential effects of ISO oral doses in the Sprague-Dawley male rat germ cells using the sperm morphology assay. Also, the serum levels of the follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone were measured. METHODS: The rat groups were given varying ISO doses via gastric gavage for seven consecutive days. The epididymis sperm specimens were microscopically examined for the following reproductive toxicity parameters: sperm concentration, examined viability, motility, and morphology. The serum FSH, LH, and testosterone levels were measured by using the corresponding enzyme-linked immunosorbent assay (ELISA) kit. The data were analyzed statistically by one-way analysis of variance (ANOVA) followed by the Tukey test at P ≤ 0.05 significance level. RESULTS: The results indicated that the drug did not significantly increase the sex hormone levels but notably affected both the sperm quantity and quality. CONCLUSION: These observations suggest that ISO was reprotoxic, and future therapies should be further reassessed.

Evaluation of the protective effects of curcumin-rich turmeric (Curcuma longa) extract against isotretinoin-induced liver damage in rats.

AIM: The aim of this study was to evaluate the protective effect of curcumin-rich turmeric (CRT) extract against isotretinoin (ISO)-induced liver damage through routine biochemical parameters and oxidative stress parameters that indicate liver damage. MATERIAL AND METHOD: 42 albino Wistar rats of 200 g were randomly grouped as Group I: Healthy control, Group II: Sunflower oil, Group III: Curcumin 200 mg/kg, Group IV: ISO control groups (7.5 mg/kg), Group V: Curcumin 50 mg/kg + ISO 7.5 mg/kg, Group VI: Curcumin 100 mg/kg + ISO 7.5 mg/kg, Group VII: Curcumin 200 mg/kg + ISO 7.5 mg/kg. At the end, after the rats were killed, their blood and liver tissues were collected. ALT and AST levels in serum; superoxide dismutase activity (SOD), GSH, and MDA levels in liver tissue were determined. RESULTS: Our results showed that ALT, AST, and MDA levels increased, and SOD and GSH levels decreased in the ISO-administered group compared to the healthy control group. CRT 50, 100, and 200 mg/kg groups were compared to ISO group. A dose-dependent increase in protective effect was observed. A decrease in ALT, AST, and MDA levels, and an increase in SOD and GSH levels were determined. A protective effect was found at all doses. The best protective effect was in the CRT 200 mg/kg group. CONCLUSION: CRT extract can be considered a candidate herbal medicine for the elimination of liver damage in individuals using ISO. However, further experimental and clinical validation should be studied.

Toxicity, Genotoxicity, and Carcinogenicity of Isotretinoin.

BACKGROUND: Acne is a chronic inflammatory disease mainly observed in adolescence, but it can also be seen during the neonatal, infantile, pre-pubertal, and adult periods. Isotretinoin (13-cis-retinoic acid) is a first-generation retinoid and is the most effective treatment for acne vulgaris. OBJECTIVE: The present study has been systematically designed to figure out the toxic, genotoxic, and carcinogenic activities of isotretinoin. METHODS: In this study, a systematic approach was followed by focusing on the possible links between these topics. The search of the databases was carried out author in accordance with the guidelines of the Centre for Reviews and Dissemination (2009) developed by York University National Institute of Health Research. The search was concentrated on the Web of Science, PubMed, Science Direct, Scopus, EBSCO Host, and Google Scholar databases. RESULTS: Isotretinoin was found as a toxic agent in all studies. All researchers proposed that apoptosis is the only pathway of adverse effects of isotretinoin. However, genotoxicity, teratogenicity, and carcinogenicity information of isotretinoin is very limited and controversial. CONCLUSION: More detailed studies need to clarify the genotoxic and carcinogenic potential of isotretinoin. Patients should be informed correctly, the risks of treatment should be explained, and awareness should be raised.

Isotretinoin Impairs the Secretory Function of Meibomian Gland Via the PPARγ Signaling Pathway.

Purpose: To investigate the effects of isotretinoin on the ocular surface and to explore the possible mechanisms. Methods: Rats were treated with isotretinoin 20 mg/kg/d for five months and tested monthly for tear secretion, fluorescein staining, and infrared photography. After five months of treatment, tissues were harvested for routine staining to evaluate the morphological changes; and real-time polymerase chain reaction, Western blot, and immunohistochemistry to study the expression of associated genes and their products such as forkhead box protein O1 (FoxO1), forkhead box protein O3, peroxisome proliferator-activated receptor γ (PPARγ), adipose differentiation-related protein, elongation of very long chain fatty acids protein 4, fatty acid binding protein 4, matrix metalloproteinase-9, and interleukin-6. Results: Systemically, isotretinoin-treated rats have a significantly lower body weight that controls and apparent skin damage. Locally, although there was no alteration in tear secretion, a significant corneal involvement indicated by increased fluorescein staining scores, and also the contrast of meibomian gland was significantly reduced but no significant atrophy of the acinus was found. In addition, isotretinoin causes a decrease in conjunctival goblet cells. Furthermore, isotretinoin treatment did not cause the upregulation of FoxO1 and inflammation related genes but significantly suppressed the expression of PPARγ pathway. Conclusions: Isotretinoin does not cause a significant atrophy of the acinus and a significant change of FoxO1 expression in the meibomian gland. Isotretinoin causes meibomian gland dysfunction, affecting meibocyte differentiation and qualitative and quantitative changes in the meibum, through PPARγ pathway.

The impact of isotretinoin on the pituitary-ovarian axis: An interpretative review of the literature.

Isotretinoin (13-cis-retinoic acid), a derivative of vitamin A, is used in the treatment of severe acne resulting in sebum suppression induced by sebocyte apoptosis. Isotretinoin treatment is associated with several adverse effects including teratogenicity, hepatotoxicity, and dyslipidemia. Isotretinoin's effects on endocrine systems and its potential role as an endocrine disruptor are not yet adequately investigated. This review presents clinical, endocrine, and molecular evidence showing that isotretinoin treatment adversely affects the pituitary-ovarian axis and enhances the risk of granulosa cell apoptosis reducing follicular reserve. Isotretinoin is associated with pro-apoptotic signaling in sebaceous glands through upregulated expression of p53, forkhead box O transcription factors (FOXO1, FOXO3), and tumor necrosis factor-related apoptosis inducing ligand (TRAIL). Two literature searches including clinical and experimental studies respectively support the hypothesis that isotretinoin's toxicological mode of action on the pituitary-ovarian axis might be caused by over-expressed p53/FOXO1 signaling resulting in gonadotropin suppression and granulosa cell apoptosis. The reduction of follicular reserve by isotretinoin treatment should be especially considered when this drug will be administered for the treatment of acne in post-adolescent women, in whom fertility may be adversely affected. In contrast, isotretinoin treatment may exert beneficial effects in states of hyperandrogenism, especially in patients with polycystic ovary syndrome.

Effect of isotretinoin on induced tooth movement in rats.

INTRODUCTION: This study was performed to evaluate the effect of isotretinoin on tooth displacement and tissues related to induced tooth movement (ITM) in rats. METHODS: Wistar rats were randomly divided into 4 groups: vegetable oil (O; n = 40), 7.5 mg/kg isotretinoin (I; n = 40), vegetable oil + ITM (OM; n = 44), and 7.5 mg/kg isotretinoin and ITM (IM; n = 39). After the daily application of the solutions for 30 days, an orthodontic appliance was installed to mesially displace the maxillary first right molar (30 cN) of rats in the OM and IM groups. The animals were killed 2, 7, 14, or 21 days after placement of the devices. The animals in the O and I groups did not undergo ITM but were killed simultaneously. The animals were examined for tooth displacement, the neoformation of mature collagen, bone and root resorption, the presence of hyalinized areas, and trabecular bone modeling by microcomputed tomography. RESULTS: There was no difference in tooth displacement, the number of osteoclasts, the presence of hyalinized areas, or trabecular bone among the O, I, OM, and IM groups across the periods tested (P >0.05). A lower percentage of mature collagen was found in the IM group than in the OM group on day 7 (P <0.05). A lower frequency of root resorption was found in the IM group than in the OM group on days 2 and 21 (P <0.05). CONCLUSIONS: Isotretinoin at 7.5 mg/kg decreased root resorption in rats subjected to ITM.

Optimizing Isotretinoin Treatment of Acne: Update on Current Recommendations for Monitoring, Dosing, Safety, Adverse Effects, Compliance, and Outcomes.

Acne vulgaris is the most common skin disease treated by dermatologists. It can be severe and result in permanent scars. Isotretinoin is the most effective treatment for acne and has the potential for long-term clearance. Prescribing and monitoring protocols can vary widely among prescribers. Recent studies, reports, and consensus statements help shed light on optimizing the use of isotretinoin for acne. A recent literature review is summarized in this article to help the practitioner optimize isotretinoin use for acne. The article outlines the advantages and disadvantages of standard, high-dose, and low-dose isotretinoin regimens; discusses the current status of controversies surrounding isotretinoin (including depression/suicide, pregnancy, and inflammatory bowel disease); reviews monitoring recommendations and treatment for hypertriglyceridemia and elevated transaminase levels; and discusses common adverse effects seen with isotretinoin, along with their treatment and prevention.

Phase I trial of belinostat in combination with 13-cis-retinoic acid in advanced solid tumor malignancies: a California Cancer Consortium NCI/CTEP sponsored trial.

PURPOSE: The reported maximum tolerated dose (MTD) of single-agent belinostat is 1000 mg/m2 given days 1-5, every 21 days. Pre-clinical evidence suggests histone deacetylase inhibitors enhance retinoic acid signaling in a variety of solid tumors. We conducted a phase I study of belinostat combined with 50-100 mg/m2/day 13-cis-retinoic acid (13-cRA) in patients with advanced solid tumors. METHODS: Belinostat was administered days 1-5 and 13-cRA days 1-14, every 21 days. Dose-limiting toxicity (DLT) was defined as cycle 1 hematologic toxicity grade ≥ 3 not resolving to grade ≤ 1 within 1 week or non-hematologic toxicity grade ≥ 3 (except controlled nausea and vomiting and transient liver function abnormalities) attributable to belinostat. RESULTS: Among 51 patients, two DLTs were observed: grade 3 hypersensitivity with dizziness and hypoxia at 1700 mg/m2/day belinostat with 100 mg/m2/day 13-cRA, and grade 3 allergic reaction at 2000 mg/m2/day belinostat with 100 mg/m2/day 13-cRA. The MTD was not reached. Pharmacokinetics of belinostat may be non-linear at high doses. Ten patients had stable disease, including one with neuroendocrine pancreatic cancer for 56 cycles, one with breast cancer for 12 cycles, and one with lung cancer for 8 cycles. Partial responses included a patient with keratinizing squamous cell carcinoma of the tonsils, and a patient with lung cancer. CONCLUSIONS: The combination of belinostat 2000 mg/m2 days 1-5 and 13-cRA 100 mg/m2 days 1-14, every 21 days, was well-tolerated and an MTD was not reached despite doubling the established single-agent MTD of belinostat.

Safety of isotretinoin treatment as measured by liver parameters.

Isotretinoin is an analogue of vitamin A and by suppressing the sebaceous glands it is often prescribed in cases of severe acne treatment. The treatment for the average patient is carried out during two to ten months. This study was designed to investigate liver structure, hepatic enzyme levels and the stress oxidative parameter after isotretinoin treatment during a similar period and using the dosages of 1 mg/kg and another one of 10 mg/kg in young male Wistar rats. We have analyzed the blood serum biochemical levels to determine hepatic function and lipid peroxidation, hepatic tissue levels of hepatic enzymes, histology and ultrastructure. The groups receiving 1 mg/kg were not altered after treatment. Their ultrastructure showed a metabolically more active organ after treatment with 10 mg/kg, in which there was an increase in the area occupied by mitochondria and rough reticulum in electron transmission images. The group that received 10 mg/kg also showed increased alkaline phosphatase, decreased high density lipoprotein and low density lipoprotein. The changes observed with the 10 mg/kg dose were not conclusive for liver damage, because of the lack of histological structural modifications and the few biochemical alterations. The 1 mg/kg dose showed a liver responding to some stimuli but without profound alterations. So, we confirm that the proposed protocol with 1mg/kg or 10 mg/kg isotretinoin did not cause important biochemical and histological disfunctions for male Wistar rat livers.

Overexpression of p53 explains isotretinoin's teratogenicity.

The precise molecular basis of retinoid embryopathy is yet unknown. This hypothesis predicts that isotretinoin (13-cis retinoic acid), the prodrug of all-trans retinoic acid (ATRA), exaggerates neural crest cell (NCC) apoptosis via upregulation of the pro-apoptotic transcription factor p53, the guardian of the genome. Increased p53 signalling is associated with Treacher Collins-, CHARGE- and fetal alcohol syndrome, which exhibit dysmorphic craniofacial features resembling retinoid embryopathy. In addition, developmental studies of NCC homeostasis in the zebrafish support the pivotal role of p53. Translational evidence implies that isotretinoin-stimulated overactivation of p53 during embryogenesis represents the molecular basis of isotretinoin's teratogenicity.

The effects of microduplication 1q21.1 and in-utero isotretinoin exposure.

The impact of in-utero isotretinoin exposure has been widely reported, with many affected pregnancies failing to reach term.1 2 Due to the low numbers of in-utero isotretinoin exposed pregnancies, the interactions between this drug and rare genetic defects such as microduplication 1q21.1 are unclear, particularly how they might manifest phenotypically. We present this case of in-utero isotretinoin exposure occurring in a child with microduplication 1q21.1. The child was born with congenital abnormalities which did not fit into a single syndrome. Regrettably in-utero exposure to isotretinoin continues to occur. We hope this case will trigger further discussion on the dangers of dispensing Isotretinoin without ensuring stringent pregnancy testing and its potential interaction with genetic abnormalities, in particular with microduplication 1q21.1.

Developmental Neurotoxic Effects of Percutaneous Drug Delivery: Behavior and Neurochemical Studies in C57BL/6 Mice.

Dermatosis often as a chronic disease requires effective long-term treatment; a comprehensive evaluation of mental health of dermatology drug does not receive enough attention. An interaction between dermatology and psychiatry has been increasingly described. Substantial evidence has accumulated that psychological stress can be associated with pigmentation, endocrine and immune systems in skin to create the optimal responses against pathogens and other physicochemical stressors to maintain or restore internal homeostasis. Additionally, given the common ectodermal origin shared by the brain and skin, we are interested in assessing how disruption of skin systems (pigmentary, endocrine and immune systems) may play a key role in brain functions. Thus, we selected three drugs (hydroquinone, isotretinoin, tacrolimus) with percutaneous excessive delivery to respectively intervene in these systems and then evaluate the potential neurotoxic effects. Firstly, C57BL/6 mice were administrated a dermal dose of hydroquinone cream, isotretinoin gel or tacrolimus ointment (2%, 0.05%, 0.1%, respectively, 5 times of the clinical dose). Behavioral testing was performed and levels of proteins were measured in the hippocampus. It was found that mice treated with isotretinoin or tacrolimus, presented a lower activity in open-field test and obvious depressive-like behavior in tail suspension test. Besides, they damaged cytoarchitecture, reduced the level of 5-HT-5-HT1A/1B system and increased the expression of apoptosis-related proteins in the hippocampus. To enable sensitive monitoring the dose-response characteristics of the consecutive neurobehavioral disorders, mice received gradient concentrations of hydroquinone (2%, 4%, 6%). Subsequently, hydroquinone induced behavioral disorders and hippocampal dysfunction in a dose-dependent response. When doses were high as 6% which was 3 times higher than 2% dose, then 100% of mice exhibited depressive-like behavior. Certainly, 6% hydroquinone exposure elicited the most serious impairment of hippocampal structure and survival. The fact that higher doses of hydroquinone are associated with a greater risk of depression is further indication that hydroquinone is responsible for the development of depression. These above data demonstrated that chronic administration of different dermatology drugs contributed into common mental distress. This surprising discovery of chemical stressors stimulating the hippocampal dysfunction, paves the way for exciting areas of study on the cross-talk between the skin and the brain, as well as is suggesting how to develop effective and safe usage of dermatological drugs in daily practice.

Colloidal carriers of isotretinoin for topical acne treatment: skin uptake, ATR-FTIR and in vitro cytotoxicity studies.

Acne vulgaris is the chronical, multifactorial and complex disease of the pilosebaceous unit in the skin. The main goal of the topical therapy in acne is to target the drug to epidermal and deep dermal regions by minimizing systemic absorption . Isotretinoin, a retinoic acid derivative, is the most effective drug in acne pathogenesis. Because systemic treatment may cause many side effects, topical isotretinoin treatment is an option in the management of acne. However, due to its high lipophilic character, isotretinoin tends to accumulate in the upper stratum corneum, thus its penetration into the lower layers is limited, which restricts the efficiency of topical treatment. Microemulsions are fluid, isotropic, colloidal drug carriers that have been widely studied as drug delivery systems. The percutaneous transport of active agents can be enhanced by microemulsions when compared with their conventional formulations. The purpose of this study was to evaluate microemulsions as alternative topical carriers for isotretinoin with an objective to improve its skin uptake. After in vitro permeation studies, the dermal penetration of isotretinoin from microemulsions was investigated by tape stripping procedure. Confocal laser scanning microscopy provided insight about the localization of the drug in the skin. The interaction between the microemulsion components and stratum corneum lipids is studied by ATR-FTIR spectroscopy. The relative safety of the microemulsions was assessed in mouse embryonic fibroblasts using MTT viability test. The results indicate that microemulsion-based novel colloidal carriers have a potential for enhanced skin delivery and localization of isotretinoin.

Congenital microtia in a neonate due to maternal isotretinoin exposure 1 month before pregnancy: Case Report.

Isotretinoin is a drug used for treating severe cystic/nodular acne. Severe malformations have been documented in neonates whose mothers had taken isotretinoin during pregnancy. Women who became pregnant one cycle after completing therapy are believed to be at teratogenic risk not higher than baseline. We describe the case of a newborn whose mother had taken the drug for 4 weeks. The woman then had contraception for 4 weeks (after the drug treatment had finished), and became pregnant after that period. The newborn had isolated bilateral microtia due to suspected isotretinoin exposure. His mother also had a history of urine tract infection in the second week of pregnancy that was treated with cephalexin. The parents were not from a consanguineous marriage and had no family history of congenital malformations. To reduce the risk, effective contraception should be continued in fertile women more than 1 month after completing therapy.

Selenium ameliorates isotretinoin-induced liver injury and dyslipidemia via antioxidant effect in rats.

Isotretinoin (Iso) is a widely used retinoid for the treatment of dermatologic conditions. Although it has broad side effects, there is no well-designed study about preventive effects against its hepatic toxicity. This study was undertaken to evaluate the protective effect of selenium (Se) against Iso-induced hepatotoxicity in Wistar rats. Animals were divided into four groups. The first group served as control. The second, third and fourth groups received Se, Iso and Se & Iso, respectively, for 28 days. Se was administered daily orally at a dose of 50 µg / 100 g body weight. Iso was given daily orally at a dose of 0.75 mg/ 100 g /day in olive oil. Iso caused significant increases in serum levels of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, cholesterol, triglycerides, and high-density lipids content. Animals also showed significant rise in thiobarbituric acid reacting substance and nitric oxide content with concomitant decrease in reduced glutathione content and the antioxidant enzyme activities of superoxide dismutase and catalase in liver tissue after Iso exposure. Se administration produced a significant protection against the hepatotoxic effects of Iso and markedly alleviated alterations in these parameters. The results obtained herein clearly indicate that Iso causes induction of oxidative stress and the co-administration of Iso and Se provides protection against Iso-induced liver injury.

[Exposure to isotretinoin during pregnancy in France: 25 years of follow-up]. / Isotrétinoïne et grossesse : bilan français de 25 années de suivi.

Because of its teratogenicity, isotretinoin is contraindicated in pregnant women and also among women of childbearing age in the absence of effective contraception. The objective of this work is to summarize the results of studies assessing the effects of regulatory measures successively implemented in France since 1996 to prevent foetal exposure to isotretinoin. The five pharmacovigilance studies have shown persistence of pregnancies exposed to isotretinoin, with an estimated incidence in the latter study, between 0.32 and 0.95 per 1000 treated women of childbearing age. The strengthening of the prevention plan of pregnancies, established in France in March 2010, seems to have resulted in a decrease in the incidence of pregnancies exposed, but this trend needs to be confirmed. However, these pregnancies are almost preventable, because most of them are explained by the non-compliance with the conditions of prescribing and dispensing. Then it seems mandatory to not deliver oral isotretinoin if it is not prescribed in accordance with the prescription laid down by the authorities.

The in vitro and in vivo genotoxicity of isotretinoin assessed by cytokinesis blocked micronucleus assay and comet assay.

Isotretinoin is a retinoic acid frequently used in monotherapy or combined with narrow-band ultraviolet B (NBUVB) irradiation to treat patients with acne and psoriasis vulgaris. As both diseases need frequent and/or prolonged therapeutic interventions, the study of the genotoxicity of retinoids becomes important. Our aim was to study the genotoxic effects of isotretinoin alone or combined with NBUVB. In vitro studies were performed in the absence of S9 metabolic activation using blood from five healthy volunteers, incubated 72 h with isotretinoin (1.2-20 µM) (i.e., at concentrations usually achieved in blood with therapeutic doses as well as at higher concentrations). In vivo studies were also performed using blood from two patients with acne and three patients with psoriasis vulgaris treated with isotretinoin in monotherapy (8 or 20mg/day) or combined with NBUVB (20mg isotretinoin/day+NBUVB). The genotoxic effect was evaluated by the cytokinesis-blocked micronucleus and the comet assays. Our studies showed that isotretinoin alone was not genotoxic when tested in human lymphocytes in vitro and in vivo. There was no clear genotoxic effect in psoriatic patients treated with isotretinoin and NBUVB. The in vitro studies showed that isotretinoin induced apoptosis and necrosis in human lymphocytes at higher doses.

Severe generalised rhabdomyolysis with fatal outcome associated with isotretinoin.

Isotretinoin is considered to be a safe and effective therapy in otherwise therapy-resistant acne. Elevated serum creatine phosphokinase values with or without muscle-related symptoms in isotretinoin-treated patients have been reported and interpreted as benign phenomena, lethal cases have not been described yet. We present the case of a 20-year-old male who died from severe generalised rhabdomyolysis associated with isotretinoin treatment.

Isotretinoin treatment induces oxidative toxicity in blood of patients with acne vulgaris: a clinical pilot study.

Acne vulgaris is the one of the most common skin diseases. Although isotretinoin (13-cis-retinoic acid) is an effective and well-tolerated medication, it has a wide range of side effects. Because the effects of isotretinoin on oxidant and antioxidant systems have not yet been clarified, we investigated plasma and erythrocyte antioxidant vitamins, lipid peroxidation (LP), reduced glutathione (GSH) and glutathione peroxidase (GSH-Px) values in patients with acne vulgaris before and after isotretinoin treatment. The study was performed on the blood plasma and erythrocytes of 31 acne vulgaris patients. Blood samples were taken from the patients before treatment and after isotretinoin (oral and 0·5-0·7 mg·kg(-1)) treatment for 2 months. Plasma amtioxidant vitamins, erythrocyte malondialdehyde, GSH and GSH-Px levels were measured. Plasma vitamin E (p < 0·001), lipid peroxidation (LP) and serum high-density lipoprotein cholesterol (p < 0·001) values were significantly lower in the treatment group than in the pre-treatment group, although erythrocyte LP (p < 0·001), GSH (p < 0·01) and GSH-Px (p < 0·001), aspartate aminotransferase (p < 0·05), alanine aminotransferase (p < 0·05), density lipoprotein cholesterol (p < 0·001) and total cholesterol (p < 0·01) levels were significantly higher in the treatment group than in the pre-treatment group. Vitamins A, C and ß-carotene concentrations did not change significantly between the two groups. In conclusion, the results of the current study indicate that isotretinoin treatment induces oxidative stress and liver damage by decreasing plasma vitamin E and increasing erythrocytes GSH-Px, GSH and liver enzyme values.