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- Presentation
Rare Complications During Isotretinoin Therapy: Rhabdomyolysis and Herpes Labialis
Description
The talk reviewed two rare but important complications seen during isotretinoin therapy. In the first case, a healthy teenage male on isotretinoin for nodulocystic acne developed worsening myalgias while continuing regular exercise. His creatine kinase (CK) gradually rose from a mild elevation to 7,500, with elevated AST, prompting discontinuation of isotretinoin and emergency evaluation. He was diagnosed with rhabdomyolysis and acute kidney injury, improved with IV fluids, and recovered fully. The speaker emphasized that CK can be elevated by exercise, especially in young athletic males, so routine CK monitoring is not recommended in asymptomatic patients, but it is appropriate when myalgias occur. Risk factors for rhabdomyolysis include intense exercise, dehydration, infections, and other medications or drugs, and suspected cases should be evaluated with CK, metabolic panel, urinalysis, and renal function tests. The second case involved a patient who developed severe lip inflammation initially mistaken for sunburn/cheilitis after sun exposure while on isotretinoin. The lesion was later recognized as herpes labialis, likely triggered by the combination of photosensitivity and mucosal barrier disruption from isotretinoin. Treatment was switched to antiviral therapy and prednisone was stopped. Key teaching points were to consider herpes simplex in severe or rapidly worsening cheilitis, especially when there is burning out of proportion, vesicles, punched-out lesions, or scalloped borders, and to obtain follow-up photos when the diagnosis is unclear. Overall, the presentation stressed careful counseling, attention to exercise habits, and a low threshold to investigate unusual symptoms during isotretinoin treatment.
View moreConclusions
- Isotretinoin can rarely be associated with clinically significant rhabdomyolysis, especially in patients who exercise vigorously, become dehydrated, or use other myotoxic substances or medications.
- Worsening myalgias during isotretinoin therapy should prompt CK testing, and suspected rhabdomyolysis should be evaluated with CMP, urinalysis, and prompt hydration management.
- Routine CK monitoring is generally not recommended for asymptomatic isotretinoin patients because baseline exercise-related CK elevations are common and can lead to false positives.
- Patients on isotretinoin, particularly teenage athletes, need explicit counseling to avoid unusually intense training while otherwise maintaining reasonable activity.
- The relationship between isotretinoin and muscle injury may involve oxidative stress in muscle that synergizes with exercise-induced damage.
- L-carnitine supplementation may improve isotretinoin-associated myalgias and lab abnormalities in some patients, although the evidence is limited.
- Severe cheilitis in a patient taking isotretinoin is not always simple drug-induced irritation and may represent herpes labialis.
- Photosensitivity plus barrier disruption from isotretinoin can create a setting in which HSV is triggered or reactivated after sun exposure.
- When cheilitis looks unusually severe, painful, vesicular, punched-out, or rapidly progressive, clinicians should consider HSV and obtain follow-up photos if needed.
- Careful history-taking about exercise intensity, hydration, and other drugs or supplements is essential for interpreting CK elevations and stratifying rhabdomyolysis risk.
- Marson and Baldwin. The creatine kinase conundrum: a reappraisal of the association of isotretinoin, creatine kinase, and rhabdomyolysis. Int J Dermatol. 2020.#10.1111/ijd.14758
- Georgala et al. Journal of the European Academy of Dermatology and Venereology, 1999.
- Yarizadh et al. Journal of the American College of Nutrition, 2020.