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    Lip Abscess Associated With Isotretinoin Treatment of Acne Vulgaris

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    Sulistya Ningsih
    A 15-year-old boy developed a severe lip abscess requiring incision and drainage while taking isotretinoin for acne vulgaris. Isotretinoin is known to cause cheilitis and dry mucous membranes, weakening barriers and increasing bacterial colonization. This case report discusses how the combination of isotretinoin-induced cheilitis, decreased barriers, and Staphylococcus aureus colonization likely caused the patient's abscess, which was initially misdiagnosed due to its rarity. The abscess resolved with appropriate antibiotic treatment but emphasizes the need to consider infectious etiologies in severe lip swelling in those taking isotretinoin.

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    Lip Abscess Associated With Isotretinoin Treatment of Acne Vulgaris

    Uploaded by

    Sulistya Ningsih
    19 views2 pages
    A 15-year-old boy developed a severe lip abscess requiring incision and drainage while taking isotretinoin for acne vulgaris. Isotretinoin is known to cause cheilitis and dry mucous membranes, weakening barriers and increasing bacterial colonization. This case report discusses how the combination of isotretinoin-induced cheilitis, decreased barriers, and Staphylococcus aureus colonization likely caused the patient's abscess, which was initially misdiagnosed due to its rarity. The abscess resolved with appropriate antibiotic treatment but emphasizes the need to consider infectious etiologies in severe lip swelling in those taking isotretinoin.

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    A 15-year-old boy developed a severe lip abscess requiring incision and drainage while taking isotretinoin for acne vulgaris. Isotretinoin is known to cause cheilitis and dry mucous membranes, weakening barriers and increasing bacterial colonization. This case report discusses how the combination of isotretinoin-induced cheilitis, decreased barriers, and Staphylococcus aureus colonization likely caused the patient's abscess, which was initially misdiagnosed due to its rarity. The abscess resolved with appropriate antibiotic treatment but emphasizes the need to consider infectious etiologies in severe lip swelling in those taking isotretinoin.

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    © All Rights Reserved
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    19 views2 pages

    Lip Abscess Associated With Isotretinoin Treatment of Acne Vulgaris

    Uploaded by

    Sulistya Ningsih
    A 15-year-old boy developed a severe lip abscess requiring incision and drainage while taking isotretinoin for acne vulgaris. Isotretinoin is known to cause cheilitis and dry mucous membranes, weakening barriers and increasing bacterial colonization. This case report discusses how the combination of isotretinoin-induced cheilitis, decreased barriers, and Staphylococcus aureus colonization likely caused the patient's abscess, which was initially misdiagnosed due to its rarity. The abscess resolved with appropriate antibiotic treatment but emphasizes the need to consider infectious etiologies in severe lip swelling in those taking isotretinoin.

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    © All Rights Reserved
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    of 2

    Research

    Case Report/Case Series

    Lip Abscess Associated With Isotretinoin Treatment


    of Acne Vulgaris
    Kevin C. Huoh, MD; Kay W. Chang, MD

    IMPORTANCE Isotretinoin is frequently prescribed for the treatment of acne vulgaris. Among

    the numerous documented adverse effects, most common are xerostomia and cheilitis. Lip
    abscesses as a consequence of cheilitis present dramatically and may pose a diagnostic
    challenge.
    OBSERVATIONS We present a case of a 15-year-old boy with a severe lip abscess requiring
    incision and drainage and hospital admission for intravenous antibiotic treatment of
    methicillin-resistant Staphylococcus aureus. We discuss the pathophysiologic characteristics
    of isotretinoin therapy and the likely causative role that the medication played in the
    development of the lip abscess.
    CONCLUSIONS AND RELEVANCE Although rare, lip abscesses related to isotretinoin therapy
    present with substantial morbidity and should be promptly recognized. Misdiagnosis of
    mucositis and angioedema may delay appropriate therapy.
    JAMA Dermatol. 2013;149(8):960-961. doi:10.1001/jamadermatol.2013.4066
    Published online June 12, 2013.

    sotretinoin is commonly prescribed to adolescents for the


    treatment of acne vulgaris.1 Numerous adverse effects are
    well documented and include xerostomia and cheilitis.2
    However, perioral abscesses as a complication of isotretinoinassociated cheilitis are not commonly reported but represent
    substantial morbidity to patients. The rarity of such occurrences can lead to misdiagnosis or delayed diagnosis.3
    The overall incidence of perioral abscesses, including lip
    abscesses, is not reported in the pediatric literature to our
    knowledge, but the condition can be regarded as an unusual
    entity. We present the dramatic case of a severe lip abscess in
    a 15-year-old boy likely related to concurrent use of isotretinoin. Although uncommon, this entity should be recognized
    as a potential complication of isotretinoin therapy and differentiated from angioedema or severe mucositis in order for appropriate therapy to be started promptly.

    Report of a Case
    A 15-year-old boy presented urgently to the pediatric otolaryngology clinic with a 2-day history of lower lip swelling. He
    and his mother described rapid onset of edema, erythema, and
    pain of the lower lip. Because his symptoms were initially
    thought to be caused by allergic angioedema, corticosteroid
    therapy was initiated by a pediatrician. This did not lead to resolution of the edema. The patient was then prescribed cephalexin antibiotic therapy for presumed infection. Despite 3 doses
    of the medication, the lip swelling had progressed substan960

    Author Affiliations: Division of


    Otolaryngology, Department of
    OtolaryngologyHead and Neck
    Surgery, Stanford University School
    of Medicine, Palo Alto, California
    (Huoh, Chang).
    Corresponding Author: Kevin C.
    Huoh, MD, Department of
    OtolaryngologyHead and Neck
    Surgery, Stanford University, 801
    Welch Rd, Palo Alto, CA 94304
    (khuoh@ohns.stanford.edu).

    tially. He otherwise felt well and did not have fevers or chills.
    His medical history was notable only for acne vulgaris, for
    which he was taking systemic isotretinoin. Both parents were
    health care providers.
    On examination, the patient was afebrile and normotensive. The lip was extremely edematous and erythematous
    (Figure). Both sides of the lower lip were exquisitely tender to
    palpation and indurated. Facial strength and sensation were
    intact. The remainder of his physical examination was unremarkable.
    Given the suspicion of abscess formation, needle aspiration of the lip was performed with return of frank purulence.
    The lip was then incised and drained under local anesthesia
    with release of a copious amount of purulence. The abscess
    pocket extended the full length of the lip. Samples were obtained for culture. The patient was admitted for empirical intravenous ampicillin-sulbactam and vancomycin therapy.
    He remained afebrile throughout the hospitalization, with
    substantial improvement in lower lip edema, erythema, and
    pain. The cultures grew methicillin-resistant Staphylococcus
    aureus (MRSA) that was also resistant to clindamycin. The patient was discharged with a prescription for trimethoprimsulfamethoxazole oral therapy.

    Discussion
    Since its approval by the Food and Drug Administration in 1982,
    isotretinoin has been frequently prescribed for a variety of cu-

    JAMA Dermatology August 2013 Volume 149, Number 8

    Downloaded From: http://archderm.jamanetwork.com/ by Sulistya ningsih on 02/09/2015

    jamadermatology.com

    Lip Abscess Associated With Isotretinoin Treatment

    Case Report/Case Series Research

    Figure. Severe Edema and Erythema of Lower Lip Caused by Lip Abscess

    taneous conditions, most commonly cystic nodular acne vulgaris. It is estimated that more than 20 million people worldwide have taken isotretinoin.4
    The exact mechanism of isotretinoin in its function in the
    treatment of acne is not well understood. Isotretinoin (13-cisretinoic acid), a vitamin A derivative, regulates transcription in
    order to decrease proliferation, differentiation, and activity of
    basal sebocytes. In addition, isotretinoin induces apoptosis of
    sebocytes, thereby reducing the overall sebum excretion rate.
    By altering the microfollicular environment, isotretinoin also
    decreases the total number of Propionibacterium acnes, which
    are follicle-dwelling bacteria often implicated in acne vulgaris.5
    Despite its elusive mechanism of action, much has been
    published regarding the adverse effects of isotretinoin. Most
    notable and controversial are the teratogenic effects of the
    medication that are so severe that dual methods of contraception are required for young women taking the drug.

    ARTICLE INFORMATION
    Accepted for Publication: February 6, 2013.
    Published Online: June 12, 2013.
    doi:10.1001/jamadermatol.2013.4066.
    Author Contributions: Both authors had full access
    to all of the data in the study and take responsibility
    for the integrity of the data and the accuracy of the
    data analysis.
    Study concept and design: Both authors.
    Acquisition of data: Both authors.
    Analysis and interpretation of data: Both authors.
    Drafting of the manuscript: Huoh.
    Critical revision of the manuscript for important
    intellectual content: Chang.
    Administrative, technical, and material support:
    Both authors.
    Study supervision: Chang.

    However, a plethora of other adverse effects are also well


    described, including xerostomia, cheilitis, depression and
    suicidal ideation, acral desquamation, alopecia, ocular
    abnormalities, and hypertriglyceridemia.2 The mucocutaneous effects of isotretinoin are so common that the absence
    of these symptoms implies medication nonadherence. 4
    More than 90% of patients taking isotretinoin report dry
    mucous membranes and cheilitis. This is usually treated
    with topical emollients and steroids.2
    The fissuring and cracking of the lips associated with cheilitis lead to the breakdown of an important mucocutaneous barrier, which can predispose patients to bacterial or viral infection. Dramatic presentations of complete mucosal denuding
    of the lip have been described.6 In addition to causing breakdown of the mucosal membrane barriers, isotretinoin also leads
    to increased colonization with S aureus, which increases the
    incidence of folliculitis and furunculosis.7
    This perfect storm of isotretinoin leading to cheilitis, decreased mucocutaneous barriers, and staphylococcal colonization likely caused the severe lip abscess in our patient that
    was initially misdiagnosed as allergic angioedema. In addition, both of the patients parents were health care providers
    and presumably exposed the patient to carriage of MRSA.8
    Prompt recognition of a lip abscess led to successful and rapid
    treatment and resolution of the problem.
    Our case is strikingly similar to one previously reported by
    Beer et al.3 In the previous report, the authors present a case
    of a MRSA lip abscess thought to be related to concurrent
    isotretinoin use. To our knowledge, no other cases have been
    reported in the literature. By presenting our case, we hope to
    raise awareness of the development of severe lip abscesses related to isotretinoin use and prevent delayed diagnosis or misdiagnosis of this serious complication of a commonly used acne
    treatment. Pediatricians of patients receiving isotretinoin
    should suspect infectious etiology in the presence of rapid and
    dramatic lip swelling.

    Conflict of Interest Disclosures: None reported.


    REFERENCES
    1. Wysowski DK, Swann J, Vega A. Use of
    isotretinoin (Accutane) in the United States: rapid
    increase from 1992 through 2000. J Am Acad
    Dermatol. 2002;46(4):505-509.

    3. Beer K, Oakley H, Waibel J. Perioral abscess


    associated with isotretinoin. J Drugs Dermatol.
    2009;8(11):1034-1036.
    4. Lowenstein EB, Lowenstein EJ. Isotretinoin
    systemic therapy and the shadow cast upon
    dermatologys downtrodden hero. Clin Dermatol.
    2011;29(6):652-661.

    Downloaded From: http://archderm.jamanetwork.com/ by Sulistya ningsih on 02/09/2015

    6. Graham BS, Barrett TL. Mucosal denudation of


    the lips from isotretinoin therapy. Arch Dermatol.
    1999;135(3):349-350.
    7. Williams RE, Doherty VR, Perkins W, Aitchison
    TC, Mackie RM. Staphylococcus aureus and
    intra-nasal mupirocin in patients receiving
    isotretinoin for acne. Br J Dermatol.
    1992;126(4):362-366.

    2. Meigel WN. How safe is oral isotretinoin?


    Dermatology. 1997;195(suppl 1):22-28; 38-40.

    jamadermatology.com

    5. Rigopoulos D, Larios G, Katsambas AD. The role


    of isotretinoin in acne therapy: why not as first-line
    therapy? facts and controversies. Clin Dermatol.
    2010;28(1):24-30.

    8. Albrich WC, Harbarth S. Health-care workers:


    source, vector, or victim of MRSA? Lancet Infect Dis.
    2008;8(5):289-301.

    JAMA Dermatology August 2013 Volume 149, Number 8

    961

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