Safe Use of Therapeutic-Dose Oral Isotretinoin in Patients With a History of Pseudotumor Cerebri.

Report of Cases | Case 1. A female patient in her teens presentedwith a 2-year history of severe, nodular, cystic acne of her face (Figure 1A), chest, and backwith significant scarring. Herhormonalworkupwasunrevealing. Twoyears earlier, she had receivedminocycline for acne and had developed an unusually severe headache; lumbar puncture confirmed PTC. Promptdiscontinuationofminocycline treatment led to longterm PTC symptom resolution. However, her acne was recalcitrant to treatment for several months with oral contraceptives, spironolactone (200 mg/d), topical antibiotics, and topical retinoids; she also required frequent intralesional triamcinolone for persistent painful cysts. Isotretinoin therapywas initiatedat 10mg/d for7days, and the dosewas increased slowly over 4months to 40mg/d; the patient noted skin dryness and facial erythema but developednosignsor symptomsconcerning forPTC.After9months of isotretinoin therapy (cumulativedose, 120mg/kg), her acne had markedly improved (Figure 1B). Case 2. Awomaninher late20spresentedwithpolycysticovariansyndrome, severe inflammatorynodular acnewithscarring (Figure2A), andahistoryofminocycline-associatedPTC (diagnosedatage16yearsvia lumbarpuncture).Heracnehadnot responded adequately to several topical retinoids at maximum concentrations, concomitantbenzoylperoxide, topical andoral antibiotics,spironolactone,andoralcontraceptives.Multipleclinicians had avoided isotretinoin use given her history of PTC. Owingtotherecalcitranceofheracnetocombinationtherapy withseveralagents, low-doseisotretinointherapywasbegun(initiatedat10mg/d),andthedosegradually increasedtotherapeutic levels (cumulative dose, 140mg/kg over 7 months of treatment). Sheexperienceddramatic acne improvementwithonly mildresidual scarring (Figure2B).Theonlyadverseeffectswere skindryness andhypertriglyceridemia, bothofwhich resolved after isotretinoin therapywas completed.