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Isotretinoin-Induced Skin Fragility in an Aerialist
Author(s)
Helana Ghali, BS
Sharon E. Albers, MD

Isotretinoin was introduced more than 3 decades ago and marked a major advancement in the treatment of severe refractory cystic acne. The most common adverse effects linked to isotretinoin usage are mucocutaneous in nature, manifesting as xerosis and cheilitis.1 Skin fragility and poor wound healing also have been reported.2-6 Current recommendations for avoiding these adverse effects include refraining from waxing, laser procedures, and other elective cutaneous procedures for at least 6 months.7 We present a case of isotretinoin-induced cutaneous fragility resulting in blistering and erosions on the palms of a competitive aerial trapeze artist.

Case Report

A 25-year-old woman presented for follow-up during week 12 of isotretinoin therapy (40 mg twice daily) prescribed for acne. She reported peeling of the skin on the palms following intense aerial acrobatic workouts. She had been a performing aerialist for many years and had never sustained a similar injury. The wounds were painful and led to decreased activity. She had no notable medical history. Physical examination of the palms revealed erosions in a distribution that corresponded to horizontal bar contact and friction (Figure). The patient was advised on proper wound care, application of emollients, and minimizing friction. She completed the course of isotretinoin and has continued aerialist activity without recurrence of skin fragility.

Comment

Skin fragility is a well-known adverse effect of isotretinoin therapy.8 Pavlis and Lieblich9 reported skin fragility in a young wrestler who experienced similar skin erosions due to isotretinoin therapy. The proposed mechanism of isotretinoin-induced skin fragility is multifactorial. It involves an apoptotic effect on sebocytes,5 which results in reduced stratum corneum hydration and an associated increase in transepidermal water loss.6,10,11 Retinoids also are known to cause thinning of the skin, likely due to the disadhesion of both the epidermis and the stratum corneum, which was demonstrated by the easy removal of cornified cells through tape stripping in hairless mice treated with isotretinoin.12 In further investigations, human patients and hairless mice treated with isotretinoin readily developed friction blisters through pencil eraser abrasion.13 Examination of the friction blisters using light and electron microscopy revealed fraying or loss of the stratum corneum and viable epidermis as well as loss of desmosomes and tonofilaments. Additionally, intracellular and intercellular deposits of an unidentified amorphous material were noted.13

A and B, Erosions on the palms due to isotretinoin induced skin fragility.

Overall, the origin of skin fragility induced by isotretinoin is supported by its effect on sebocytes, increased transepidermal water loss, and profound disruption of the integrity of the epidermis, resulting in an elevated risk for inadvertent skin damage. Patients were encouraged to avoid cosmetic procedures in prior case reports,14-16 and because our case demonstrates the risk for cutaneous injury in athletes due to isotretinoin-induced skin fragility, we propose an extension of these warnings to encompass athletes receiving isotretinoin treatment. Offering early guidance on wound prevention is of paramount importance in maintaining athletic performance and minimizing painful injuries.

References
  1. Rajput I, Anjankar VP. Side effects of treating acne vulgaris with isotretinoin: a systematic review. Cureus. 2024;16:E55946. doi:10.7759/cureus.55946
  2. Hatami P, Balighi K, Asl HN, et al. Isotretinoin and timing of procedural interventions: clinical implications and practical points. J Cosmet Dermatol. 2023;22:2146-2149. doi:10.1111/jocd.15874
  3. McDonald KA, Shelley AJ, Alavi A. A systematic review on oral isotretinoin therapy and clinically observable wound healing in acne patients. J Cutan Med Surg. 2017;21:325-333. doi:10.1177/1203475417701419
  4. Layton A. The use of isotretinoin in acne. Dermatoendocrinol. 2009;1:162-169. doi:10.4161/derm.1.3.9364
  5. Zouboulis CC. Isotretinoin revisited: pluripotent effects on human sebaceous gland cells. J Invest Dermatol. 2006;126:2154-2156. doi:10.1038/sj.jid.5700418
  6. Kmiec´ ML, Pajor A, Broniarczyk-Dyła G. Evaluation of biophysical skin parameters and assessment of hair growth in patients with acne treated with isotretinoin. Postepy Dermatol Alergol. 2013;30:343-349. doi:10.5114/pdia.2013.39432
  7. Waldman A, Bolotin D, Arndt KA, et al. ASDS Guidelines Task Force: Consensus recommendations regarding the safety of lasers, dermabrasion, chemical peels, energy devices, and skin surgery during and after isotretinoin use. Dermatolog Surg. 2017;43:1249-1262. doi:10.1097/DSS.0000000000001166
  8. Aksoy H, Aksoy B, Calikoglu E. Systemic retinoids and scar dehiscence. Indian J Dermatol. 2019;64:68. doi:10.4103/ijd.IJD_148_18
  9. Pavlis MB, Lieblich L. Isotretinoin-induced skin fragility in a teenaged athlete: a case report. Cutis. 2013;92:33-34.
  10. Herane MI, Fuenzalida H, Zegpi E, et al. Specific gel-cream as adjuvant to oral isotretinoin improved hydration and prevented TEWL increase—a double-blind, randomized, placebo-controlled study. J Cosmet Dermatol. 2009;8:181-185. doi:10.1111/j.1473-2165.2009.00455.x
  11. Park KY, Ko EJ, Kim IS, et al. The effect of evening primrose oil for the prevention of xerotic cheilitis in acne patients being treated with isotretinoin: a pilot study. Ann Dermatol. 2014;26:706-712. doi:10.5021/ad.2014.26.6.706
  12. Elias PM, Fritsch PO, Lampe M, et al. Retinoid effects on epidermal structure, differentiation, and permeability. Lab Invest. 1981;44:531-540.
  13. Williams ML, Elias PM. Nature of skin fragility in patients receiving retinoids for systemic effect. Arch Dermatol. 1981;117:611-619.
  14. Rubenstein R, Roenigk HH, Stegman SJ, et al. Atypical keloids after dermabrasion of patients taking isotretinoin. J Am Acad Dermatol. 1986;15:280-285. doi:10.1016/S0190-9622(86)70167-9
  15. Zachariae H. Delayed wound healing and keloid formation following argon laser treatment or dermabrasion during isotretinoin treatment. Br J Dermatol. 1988;118:703-706. doi:10.1111/j.1365-2133.1988.tb02574.x
  16. Katz BE, Mac Farlane DF. Atypical facial scarring after isotretinoin therapy in a patient with previous dermabrasion. J Am Acad Dermatol. 1994;30:852-853. doi:10.1016/S0190-9622(94)70096-6
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From the University of South Florida, Tampa. Helana Ghali is from the Morsani College of Medicine, and Dr. Albers is from the Department of Dermatology and Cutaneous Surgery.

The authors report no conflict of interest.

Correspondence: Helana Ghali, BS, 560 Channelside Dr, Tampa, FL 33602 (ghali2@usf.edu).

Cutis. 2024 July;114(1):32-33. doi:10.12788/cutis.1042

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Cutis
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Case Reports
Author(s)
Helana Ghali, BS
Sharon E. Albers, MD
Author(s)
Helana Ghali, BS
Sharon E. Albers, MD
Author and Disclosure Information

 

From the University of South Florida, Tampa. Helana Ghali is from the Morsani College of Medicine, and Dr. Albers is from the Department of Dermatology and Cutaneous Surgery.

The authors report no conflict of interest.

Correspondence: Helana Ghali, BS, 560 Channelside Dr, Tampa, FL 33602 (ghali2@usf.edu).

Cutis. 2024 July;114(1):32-33. doi:10.12788/cutis.1042

Author and Disclosure Information

 

From the University of South Florida, Tampa. Helana Ghali is from the Morsani College of Medicine, and Dr. Albers is from the Department of Dermatology and Cutaneous Surgery.

The authors report no conflict of interest.

Correspondence: Helana Ghali, BS, 560 Channelside Dr, Tampa, FL 33602 (ghali2@usf.edu).

Cutis. 2024 July;114(1):32-33. doi:10.12788/cutis.1042

Article PDF
CT114001032.pdf
Article PDF
CT114001032.pdf

Isotretinoin was introduced more than 3 decades ago and marked a major advancement in the treatment of severe refractory cystic acne. The most common adverse effects linked to isotretinoin usage are mucocutaneous in nature, manifesting as xerosis and cheilitis.1 Skin fragility and poor wound healing also have been reported.2-6 Current recommendations for avoiding these adverse effects include refraining from waxing, laser procedures, and other elective cutaneous procedures for at least 6 months.7 We present a case of isotretinoin-induced cutaneous fragility resulting in blistering and erosions on the palms of a competitive aerial trapeze artist.

Case Report

A 25-year-old woman presented for follow-up during week 12 of isotretinoin therapy (40 mg twice daily) prescribed for acne. She reported peeling of the skin on the palms following intense aerial acrobatic workouts. She had been a performing aerialist for many years and had never sustained a similar injury. The wounds were painful and led to decreased activity. She had no notable medical history. Physical examination of the palms revealed erosions in a distribution that corresponded to horizontal bar contact and friction (Figure). The patient was advised on proper wound care, application of emollients, and minimizing friction. She completed the course of isotretinoin and has continued aerialist activity without recurrence of skin fragility.

Comment

Skin fragility is a well-known adverse effect of isotretinoin therapy.8 Pavlis and Lieblich9 reported skin fragility in a young wrestler who experienced similar skin erosions due to isotretinoin therapy. The proposed mechanism of isotretinoin-induced skin fragility is multifactorial. It involves an apoptotic effect on sebocytes,5 which results in reduced stratum corneum hydration and an associated increase in transepidermal water loss.6,10,11 Retinoids also are known to cause thinning of the skin, likely due to the disadhesion of both the epidermis and the stratum corneum, which was demonstrated by the easy removal of cornified cells through tape stripping in hairless mice treated with isotretinoin.12 In further investigations, human patients and hairless mice treated with isotretinoin readily developed friction blisters through pencil eraser abrasion.13 Examination of the friction blisters using light and electron microscopy revealed fraying or loss of the stratum corneum and viable epidermis as well as loss of desmosomes and tonofilaments. Additionally, intracellular and intercellular deposits of an unidentified amorphous material were noted.13

A and B, Erosions on the palms due to isotretinoin induced skin fragility.

Overall, the origin of skin fragility induced by isotretinoin is supported by its effect on sebocytes, increased transepidermal water loss, and profound disruption of the integrity of the epidermis, resulting in an elevated risk for inadvertent skin damage. Patients were encouraged to avoid cosmetic procedures in prior case reports,14-16 and because our case demonstrates the risk for cutaneous injury in athletes due to isotretinoin-induced skin fragility, we propose an extension of these warnings to encompass athletes receiving isotretinoin treatment. Offering early guidance on wound prevention is of paramount importance in maintaining athletic performance and minimizing painful injuries.

Isotretinoin was introduced more than 3 decades ago and marked a major advancement in the treatment of severe refractory cystic acne. The most common adverse effects linked to isotretinoin usage are mucocutaneous in nature, manifesting as xerosis and cheilitis.1 Skin fragility and poor wound healing also have been reported.2-6 Current recommendations for avoiding these adverse effects include refraining from waxing, laser procedures, and other elective cutaneous procedures for at least 6 months.7 We present a case of isotretinoin-induced cutaneous fragility resulting in blistering and erosions on the palms of a competitive aerial trapeze artist.

Case Report

A 25-year-old woman presented for follow-up during week 12 of isotretinoin therapy (40 mg twice daily) prescribed for acne. She reported peeling of the skin on the palms following intense aerial acrobatic workouts. She had been a performing aerialist for many years and had never sustained a similar injury. The wounds were painful and led to decreased activity. She had no notable medical history. Physical examination of the palms revealed erosions in a distribution that corresponded to horizontal bar contact and friction (Figure). The patient was advised on proper wound care, application of emollients, and minimizing friction. She completed the course of isotretinoin and has continued aerialist activity without recurrence of skin fragility.

Comment

Skin fragility is a well-known adverse effect of isotretinoin therapy.8 Pavlis and Lieblich9 reported skin fragility in a young wrestler who experienced similar skin erosions due to isotretinoin therapy. The proposed mechanism of isotretinoin-induced skin fragility is multifactorial. It involves an apoptotic effect on sebocytes,5 which results in reduced stratum corneum hydration and an associated increase in transepidermal water loss.6,10,11 Retinoids also are known to cause thinning of the skin, likely due to the disadhesion of both the epidermis and the stratum corneum, which was demonstrated by the easy removal of cornified cells through tape stripping in hairless mice treated with isotretinoin.12 In further investigations, human patients and hairless mice treated with isotretinoin readily developed friction blisters through pencil eraser abrasion.13 Examination of the friction blisters using light and electron microscopy revealed fraying or loss of the stratum corneum and viable epidermis as well as loss of desmosomes and tonofilaments. Additionally, intracellular and intercellular deposits of an unidentified amorphous material were noted.13

A and B, Erosions on the palms due to isotretinoin induced skin fragility.

Overall, the origin of skin fragility induced by isotretinoin is supported by its effect on sebocytes, increased transepidermal water loss, and profound disruption of the integrity of the epidermis, resulting in an elevated risk for inadvertent skin damage. Patients were encouraged to avoid cosmetic procedures in prior case reports,14-16 and because our case demonstrates the risk for cutaneous injury in athletes due to isotretinoin-induced skin fragility, we propose an extension of these warnings to encompass athletes receiving isotretinoin treatment. Offering early guidance on wound prevention is of paramount importance in maintaining athletic performance and minimizing painful injuries.

References
  1. Rajput I, Anjankar VP. Side effects of treating acne vulgaris with isotretinoin: a systematic review. Cureus. 2024;16:E55946. doi:10.7759/cureus.55946
  2. Hatami P, Balighi K, Asl HN, et al. Isotretinoin and timing of procedural interventions: clinical implications and practical points. J Cosmet Dermatol. 2023;22:2146-2149. doi:10.1111/jocd.15874
  3. McDonald KA, Shelley AJ, Alavi A. A systematic review on oral isotretinoin therapy and clinically observable wound healing in acne patients. J Cutan Med Surg. 2017;21:325-333. doi:10.1177/1203475417701419
  4. Layton A. The use of isotretinoin in acne. Dermatoendocrinol. 2009;1:162-169. doi:10.4161/derm.1.3.9364
  5. Zouboulis CC. Isotretinoin revisited: pluripotent effects on human sebaceous gland cells. J Invest Dermatol. 2006;126:2154-2156. doi:10.1038/sj.jid.5700418
  6. Kmiec´ ML, Pajor A, Broniarczyk-Dyła G. Evaluation of biophysical skin parameters and assessment of hair growth in patients with acne treated with isotretinoin. Postepy Dermatol Alergol. 2013;30:343-349. doi:10.5114/pdia.2013.39432
  7. Waldman A, Bolotin D, Arndt KA, et al. ASDS Guidelines Task Force: Consensus recommendations regarding the safety of lasers, dermabrasion, chemical peels, energy devices, and skin surgery during and after isotretinoin use. Dermatolog Surg. 2017;43:1249-1262. doi:10.1097/DSS.0000000000001166
  8. Aksoy H, Aksoy B, Calikoglu E. Systemic retinoids and scar dehiscence. Indian J Dermatol. 2019;64:68. doi:10.4103/ijd.IJD_148_18
  9. Pavlis MB, Lieblich L. Isotretinoin-induced skin fragility in a teenaged athlete: a case report. Cutis. 2013;92:33-34.
  10. Herane MI, Fuenzalida H, Zegpi E, et al. Specific gel-cream as adjuvant to oral isotretinoin improved hydration and prevented TEWL increase—a double-blind, randomized, placebo-controlled study. J Cosmet Dermatol. 2009;8:181-185. doi:10.1111/j.1473-2165.2009.00455.x
  11. Park KY, Ko EJ, Kim IS, et al. The effect of evening primrose oil for the prevention of xerotic cheilitis in acne patients being treated with isotretinoin: a pilot study. Ann Dermatol. 2014;26:706-712. doi:10.5021/ad.2014.26.6.706
  12. Elias PM, Fritsch PO, Lampe M, et al. Retinoid effects on epidermal structure, differentiation, and permeability. Lab Invest. 1981;44:531-540.
  13. Williams ML, Elias PM. Nature of skin fragility in patients receiving retinoids for systemic effect. Arch Dermatol. 1981;117:611-619.
  14. Rubenstein R, Roenigk HH, Stegman SJ, et al. Atypical keloids after dermabrasion of patients taking isotretinoin. J Am Acad Dermatol. 1986;15:280-285. doi:10.1016/S0190-9622(86)70167-9
  15. Zachariae H. Delayed wound healing and keloid formation following argon laser treatment or dermabrasion during isotretinoin treatment. Br J Dermatol. 1988;118:703-706. doi:10.1111/j.1365-2133.1988.tb02574.x
  16. Katz BE, Mac Farlane DF. Atypical facial scarring after isotretinoin therapy in a patient with previous dermabrasion. J Am Acad Dermatol. 1994;30:852-853. doi:10.1016/S0190-9622(94)70096-6
References
  1. Rajput I, Anjankar VP. Side effects of treating acne vulgaris with isotretinoin: a systematic review. Cureus. 2024;16:E55946. doi:10.7759/cureus.55946
  2. Hatami P, Balighi K, Asl HN, et al. Isotretinoin and timing of procedural interventions: clinical implications and practical points. J Cosmet Dermatol. 2023;22:2146-2149. doi:10.1111/jocd.15874
  3. McDonald KA, Shelley AJ, Alavi A. A systematic review on oral isotretinoin therapy and clinically observable wound healing in acne patients. J Cutan Med Surg. 2017;21:325-333. doi:10.1177/1203475417701419
  4. Layton A. The use of isotretinoin in acne. Dermatoendocrinol. 2009;1:162-169. doi:10.4161/derm.1.3.9364
  5. Zouboulis CC. Isotretinoin revisited: pluripotent effects on human sebaceous gland cells. J Invest Dermatol. 2006;126:2154-2156. doi:10.1038/sj.jid.5700418
  6. Kmiec´ ML, Pajor A, Broniarczyk-Dyła G. Evaluation of biophysical skin parameters and assessment of hair growth in patients with acne treated with isotretinoin. Postepy Dermatol Alergol. 2013;30:343-349. doi:10.5114/pdia.2013.39432
  7. Waldman A, Bolotin D, Arndt KA, et al. ASDS Guidelines Task Force: Consensus recommendations regarding the safety of lasers, dermabrasion, chemical peels, energy devices, and skin surgery during and after isotretinoin use. Dermatolog Surg. 2017;43:1249-1262. doi:10.1097/DSS.0000000000001166
  8. Aksoy H, Aksoy B, Calikoglu E. Systemic retinoids and scar dehiscence. Indian J Dermatol. 2019;64:68. doi:10.4103/ijd.IJD_148_18
  9. Pavlis MB, Lieblich L. Isotretinoin-induced skin fragility in a teenaged athlete: a case report. Cutis. 2013;92:33-34.
  10. Herane MI, Fuenzalida H, Zegpi E, et al. Specific gel-cream as adjuvant to oral isotretinoin improved hydration and prevented TEWL increase—a double-blind, randomized, placebo-controlled study. J Cosmet Dermatol. 2009;8:181-185. doi:10.1111/j.1473-2165.2009.00455.x
  11. Park KY, Ko EJ, Kim IS, et al. The effect of evening primrose oil for the prevention of xerotic cheilitis in acne patients being treated with isotretinoin: a pilot study. Ann Dermatol. 2014;26:706-712. doi:10.5021/ad.2014.26.6.706
  12. Elias PM, Fritsch PO, Lampe M, et al. Retinoid effects on epidermal structure, differentiation, and permeability. Lab Invest. 1981;44:531-540.
  13. Williams ML, Elias PM. Nature of skin fragility in patients receiving retinoids for systemic effect. Arch Dermatol. 1981;117:611-619.
  14. Rubenstein R, Roenigk HH, Stegman SJ, et al. Atypical keloids after dermabrasion of patients taking isotretinoin. J Am Acad Dermatol. 1986;15:280-285. doi:10.1016/S0190-9622(86)70167-9
  15. Zachariae H. Delayed wound healing and keloid formation following argon laser treatment or dermabrasion during isotretinoin treatment. Br J Dermatol. 1988;118:703-706. doi:10.1111/j.1365-2133.1988.tb02574.x
  16. Katz BE, Mac Farlane DF. Atypical facial scarring after isotretinoin therapy in a patient with previous dermabrasion. J Am Acad Dermatol. 1994;30:852-853. doi:10.1016/S0190-9622(94)70096-6
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Isotretinoin-Induced Skin Fragility in an Aerialist
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Practice Points

  • Isotretinoin is used to treat severe nodulocystic acne but can cause adverse effects such as skin fragility, xerosis, and poor wound healing.
  • Dermatologists should inform athletes of heightened skin vulnerability while undergoing isotretinoin treatment.
  • Isotretinoin-induced skin fragility involves the effects of isotretinoin on sebocytes, transepidermal water loss, and disruption of the integrity of the epidermis.
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