Continuing medical education
Oral retinoid therapy for dermatologic conditions in children and adolescents

This work was presented in part at the annual meeting of the Society for Pediatric Dermatology, Annapolis, Md, on July 20, 2002.
https://doi.org/10.1067/S0190-9622(03)01564-0Get rights and content

Abstract

The efficacy of systemic retinoid therapy in a number of dermatologic diseases is well established; however, concerns about potential side effects limit their use, especially in children. We review the efficacy and toxicity of oral retinoids in the pediatric population. The acute mucocutaneous toxicities commonly observed are typically well tolerated, readily treatable, and reversible. Systemic toxicities include teratogenicity and effects on the musculoskeletal, neurologic, and gastrointestinal systems. Children, like adults, generally tolerate short-term retinoid therapy without major complications. Concerns regarding serious systemic side effects are greater for those on high doses of oral synthetic retinoids for longer periods of time. Close patient monitoring and patient education can minimize the occurrence of complications.

Learning objective

At the conclusion of this learning activity, participants should be familiar with use of oral retinoids for childhood dermatologic conditions such as psoriasis, acne, and ichthyoses as well as safety and risks associated with oral retinoid use in children and adolescents.

Section snippets

Background

The term “retinoids” includes all compounds, synthetic and natural, that possess vitamin-A activity. Vitamin A cannot be synthesized in vivo by the human body and must, therefore, be acquired through diet. In mammals, vitamin A exists in interconvertible forms as retinol (vitamin-A alcohol), which is the main storage form; retinal (vitamin-A aldehyde), which is necessary in its 11-cis-isomer form for visual function; and retinoic acid (vitamin-A acid). Early evidence that retinoids play a role

Acne

Of all the currently available systemic retinoids, first-generation isotretinoin is the most effective against acne vulgaris. Although the exact mechanism of action is unknown, retinoids are thought to normalize follicular keratinization, reduce sebum production, and decrease 5α-dihydrotestosterone formation and androgen receptor-binding capacity.10, 11, 12 Isotretinoin is indicated for nodular acne that is refractory to traditional management, including topical medications and systemic

Mucocutaneous

Mucocutaneous toxicities are the most commonly observed side effects of oral retinoid use and are generally treatable, dose-dependent, and reversible. Cheilitis is the most common manifestation and occurs in virtually all patients on isotretinoin. In fact, absence of cheilitis in a patient apparently unresponsive to isotretinoin should raise suspicion of noncompliance. This cheilitis generally responds to continual application of topical emollients. Lubrication to the anterior nares is also

Monitoring guidelines

In healthy children taking systemic retinoids for acne or DOKs, laboratory tests of liver function and serum lipids should be performed before treatment, 1 month after initiation of treatment, and every 3 months thereafter. Pregnancy prevention program guidelines should be followed before treatment and on a monthly basis thereafter. For those requiring prolonged treatment with retinoids, baseline and yearly bone studies should be considered; however, the optimal bone study to perform remains

Conclusions

The use of oral retinoids for dermatologic conditions in children and adolescents should be considered in the framework of short-term versus long-term therapy. Numerous studies have shown that a standard 20-week course of isotretinoin for nodulocystic acne is generally well tolerated and safe. Acute mucocutaneous toxicities and mild laboratory abnormalities are common and reversible, and rarely a cause for cessation of therapy. Bony side effects from short-term retinoid therapy are rare; the

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    Funding sources: None.

    Disclosures: Dr Orlow served as a consultant to Hoffman-LaRoche from 2000 to 2001.

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