DermHelpCentral

Isotretinoin and Inflammatory Bowel Disease

This is a recent article which addresses this area.  Many of the other references are to a small number of patients only.

Bernstein CN, Nugent Z, Longobardi T, Blanchard JF.  Isotretinoin is not associated with inflammatory bowel disease: a population-based case-control study.  Am J Gastroenterol. 2009 Nov;104:2774-8.  University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada

Abstract:
OBJECTIVES: There is anecdotal evidence that isotretinoin use is associated with development of colitis. We aimed at determining whether there is an association between isotretinoin use and development of inflammatory bowel disease (IBD).

METHODS: The population-based University of Manitoba IBD Epidemiology Database and a control group matched by age, sex, and geographical residence were linked to the provincial prescription drug registry, a registry that was initiated in 1995. The number of users and duration of isotretinoin use were identified in both IBD cases and controls.

RESULTS: We found that 1.2% of IBD cases used isotretinoin before IBD diagnosis, which was statistically similar to controls (1.1% users). This was also similar to the number of IBD patients who used isotretinoin after a diagnosis of IBD (1.1%). There was no difference between isotretinoin use before Crohn's disease compared with its use before ulcerative colitis.

CONCLUSIONS: Patients with IBD were no more likely to have used isotretinoin before diagnosis than were sex-, age-, and geography-matched controls. Although there may be anecdotes of isotretinoin causing acute colitis, our data suggest that isotretinoin is not likely to cause chronic IBD.

Isotretinoin and Psychiatric Symptoms

For a good review of "Isotretinoin, Depression and Suicide" see this full text adticle.

Conclusions of this article

"Consideration of the limited data available would suggest that the incidence of depression and suicide during isotretinoin therapy may be no greater than the background incidence. A causal relationship has not been demonstrated. The occurrence of an idiosyncratic reaction to isotretinoin producing major depression and suicidal ideation, as suggested by case studies, remains a possibility — although, if so, this would seem to be a relatively rare occurrence. Given the evidence suggesting that isotretinoin treatment may attenuate psychiatric associations of acne, and given the evidence that acne is often not a trivial complaint, withholding therapy because of concerns regarding depression or potential for suicide is not justified. Nevertheless, there are grounds for carefully monitoring patients undergoing treatment with isotretinoin for the emergence of depressive and suicidal ideation. Ideally, the patient's GP, as well as their dermatologist, should be involved in this surveillance."

On Itch (Mark Twain)

Huckleberry Finn, Chapter 2

There was a place on my ankle that got to itching, but I dasn't scratch it; and then my ear begun to itch; and next my back, right between my shoulders. Seemed like I'd die if I couldn't scratch. Well, I've noticed that thing plenty times since. If you are with the quality, or at a funeral, or trying to go to sleep when you ain't sleepy--if you are anywheres where it won't do for you to scratch, why you will itch all over in upwards of a thousand places.

Pretty soon Jim says: "Say, who is you? Whar is you? Dog my cats ef I didn' hear sumf'n. Well, I know what I's gwyne to do: I's gwyne to set down here and listen tell I hears it agin." So he set down on the ground betwixt me and Tom. He leaned his back up against a tree, and stretched his legs out till one of them most touched one of mine.

My nose begun to itch. It itched till the tears come into my eyes. But I dasn't scratch. Then it begun to itch on the inside. Next I got to itching underneath. I didn't know how I was going to set still. This miserableness went on as much as six or seven minutes; but it seemed a sight longer than that. I was itching in eleven different places now. I reckoned I couldn't stand it more'n a minute longer, but I set my teeth hard and got ready to try.

Isotretinoin and Inflammatory Bowel Disease

There have been a few articles on a possible association between inflammatory bowel disease (IBS) and isotretinoin (Accutane).  As with many of these relationships, there is no hard and fast evidence.  Here is a commentary from "Journal Watch" by a respected dermatologist, Dr. Jeffrey Callen.  If you are a patient or the parent of a patient who is (or is contemplating) taking isotretinoin, this is something to consider and study.  You may want to discuss this with your dermatologist:

from Journal Watch, November 2009.  Isotretinoin and IBS

"Isotretinoin use was no more common in patients with IBD than in the general population.

Recently, questions about a link between isotretinoin treatment of acne vulgaris and development or exacerbation of inflammatory bowel disease (IBD) have been debated in the medical literature (and in the lay press). Several lawsuits have been filed against pharmaceutical companies and individual prescribers. Gastroenterologists with whom I have discussed this issue have given mixed answers as to whether they think the association is real or a coincidental observation. IBD is believed to result from a genetic susceptibility awakened by an environmental trigger; peak onset occurs in the third decade of life, with steady increases through the second decade.

Investigators at the University of Manitoba performed a province-wide case-control study to look for an IBD–isotretinoin association. They identified 2008 patients younger than 40 with physician and hospital claims coded for Crohn disease or ulcerative colitis, a method previously verified as highly sensitive and specific for identifying IBD. The investigators matched each case by age, sex, and geographic residence with 10 controls from the general population and then checked a pharmaceutical database for prescriptions to all study participants.

Twenty-five of the patients (1.2%) had been prescribed isotretinoin before receiving an IBD diagnosis, and 23 started isotretinoin after such diagnosis; the rate of isotretinoin use in patients who developed IBD did not differ from the rate of use among controls. The researchers found that isotretinoin use was rare in young IBD patients before IBD diagnosis and that isotretinoin use was neither more nor less prevalent in IBD patients than in the general population.

Comment: This well-designed and well-performed study used data that were easily obtained in a population covered by a single payer and whose drug use was recorded in a large database. The power of such a study to answer this and other questions is immense. This study did not address whether isotretinoin has an adverse effect on gastrointestinal mucosa, but the findings clearly demonstrate a lack of association between isotretinoin use and the development of IBD in the general population.

Unfortunately, some gastroenterologists, influenced by individual case observations, strongly believe in this association (as in the editorial by Shale and colleagues.), and some, perhaps, are willing to aid plaintiffs in complaints against pharmaceutical companies and prescribing physicians.

Jeffrey P. Callen, M.D.

Melanoma In-Situ

Melanoma In Situ is being diagnosed with increasing frequency.  Skill with dermoscopy is one reason, increaing awareness of the dangers of atypical dark lesions another, trends in dermatopathology a third.  There are a number of other theories.

Simply MIS is a Stage 0 lesion.  The link above is accurate and helpful.  Strictly speaking MIS is not cancer -- yet.  And no one knows whether these really progress to Stage I -- but the risks of waiting (for most people) outweigh the benefits.  The cure rate for MIS is 100% at ten years.