Clinical and Experimental Dermatology 1992; 17: 250-251,
Acute Achilles tendonitis following oral isotretinoin therapy for acne vulgaris W.W.BOTTOMLEY AND W.J.CUNLIFFE Leeds Foundation for Dermatological Research, Leeds General Infirmary, Great George Street, Leeds LS 1 3EX Accepted for publication 1 October 1991 Summary We report three cases of acute Achilles tendonitis following administration of isotretinoin for acne vulgaris. In this rarely documented side-effect, the symptoms were intimately related to the isotretinoin therapy. Modification of dose regimes permitted control of the tendonitis and an eventual successful response to isotretinoin therapy. Oral isotretinoin has been in use for more than 10 years and is known to cause a wide variety of predictable sideeffects' the most common of which are cutaneous and dose related. Musculoskeletal problems are also well known to occur and these include myalgia, arthralgia and less commonly arthritis^ and muscle damage,^ however, isolated Achilles tendonitis has been reported on a rare and sporadic basis. We wish to report a series of three patients who developed acute Achilles tendonitis during administration of isotretinoin for acne.
and became asymptomatic 2 weeks after finishing the isotretinoin. Case 2
A 32-year-old female was started on isotretinoin in a dosage of 0-5 mg/kg and developed an acute Achilles tendonitis with swelling, tenderness and erythema over both Achilles tendons causing some difficulty in walking. She was treated with ibruprofen 400 mg t.d.s. with reasonable improvement but her symptoms persisted. After 2 weeks the dosage of isotretinoin was reduced to alternate day therapy with a further improvement in the symptoms. The isotretinoin was continued for a total of 18 weeks and all symptoms had cleared completely 3 weeks after discontinuation of the isotretinoin. Case 3
A 33-year-old man developed extreme difficulty in walking 6 weeks after commencing a course of isotretinoin. He experienced pain and tenderness in both All three patients had acne of more than 10 years and had Achilles tendons, the left being considerably worse than failed to respond to adequate courses of several anti- the right. Indomethacin in a dosage of 50 mg three times biotics. daily was given and the dosage of the isotretinoin was reduced to 0-25 mg/kg. However, his tendonitis persisted and the isotretinoin was therefore discontinued and his Case 1 symptoms resolved after 2 weeks. He was recommenced a A 23-year-old male presented with acute pain and small dose of isotretinoin 10 mg daily, which was then tenderness over both Achilles tendons which worsened increased to 20 mg daily after 2 weeks without a return of on waking such that he had great difficulty in weight the tendonitis; he remained on the same dose for 20 bearing. This started 6 weeks after commencing isotreti- weeks. noin in a dosage of 1 mg/kg. Examination revealed mild In all three cases, a small wedge was given to elevate the bilateral swelling erythema and tenderness over both heel with some additional improvement to their sympAchilles tendons. An initial attempt to control the toms. All three patients had X-rays of their Achilles tendonitis with ibruprofen in a dosage of 400 mg three tendons that were normal, as was a D.I.S.H. screen. In all times daily was unsuccessful and the isotretinoin had to three patients, the acne had resolved at the end of their be discontinued. Two weeks after stopping the isotreti- isotretinoin therapy. noin his symptoms had almost completely resolved. The isotretinoin was restarted at a dosage of 0-5 mg/kg and his tendonitis recurred but to a lesser extent and his Discussion symptoms were controlled on the original dosage of Myalgia and arthralgia occur in about 15% of patients ibruprofen. He received in total 20 weeks of isotretinoin taking isotretinoin, these symptoms are usually mild and Case reports
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ACUTE ACHILLES T E N D O N I T I S resolve once treatment is stopped.'' Other musculoskeletal side-effects are known to occur, however, the mechanism of production of these phenomena is poorly understood. To date there are four reported cases of Achilles tendonitis associated with isotretinoin, in the case described by McGuire et al.^ the patient was physically active and showed evidence of calcification within the Achilles tendon and the spinal column. In a similar case to ours,' a 17-year-old man developed acute Achilles tendonitis shortly after starting isotretinoin which improved on withdrawal and deteriorated on reintroduction of isotretinoin. He was able to tolerate isotretinoin at a reduced dosage. In neither case were details concerning additional treatment required or final outcome available and details ofthe other patients are sparse—simply being recorded as having Achilles tendonitis. None of our patients were particularly physically active or had evidence of calcification. In all three cases the symptoms correlated very closely with the administration and withdrawal of isotretinoin. Our management shows that for Achilles tendonitis induced by isotretinoin, the drug may be continued at an appropriately reduced dosage with or without a short interuption depending on the severity ofthe symptoms. A
251
dose reduction with an appropriate increase in the duration of the therapy should produce the same clinical response in a patient's acne as the cumulative dose is probably as relevant to the successful outcome ofthe acne as is the daily dosage;* our patients all showing a satisfactory resolution of their acne after the end of isotretinoin therapy. References 1, Bigby M, Stern RS, Adverse reactions to isotretinoin, A report from the Adverse Drug Reporting Systtm. Journal of the American Academy of Dermatology 1988; 18: S43-S52, 2, Camisa C, Acute arthritis during isotretinoin therapy for acne. Journal of the American Academy of Dermatology 1986; 15: 10611062, 3, Hodak E, Gadoth N, David M, Sandbank M, Muscle damage induced by isotretinoin, British Medical Journal 1986; 293: 425426, 4, Windhorst DB, Nigra T, General clinical toxicology of oral retinoids. Journal of the American Academy of Dermatology 1982; 6: 675-682, 5, McGuire J, Milstone L, Lawson J, Isotretinoin administration alters juvenile and adult bone, Retinoids: New Trends in Research and Therapy, Retinoid Symposium 1984; 419-439, 6, Chivot M, Midoun H, Isotretinoin and acne—a study of relapses, Dermatologica 1990; 180: 240-243,
Acute Achilles tendonitis following oral isotretinoin therapy for acne vulgaris W.W.BOTTOMLEY AND W.J.CUNLIFFE Leeds Foundation for Dermatological Research, Leeds General Infirmary, Great George Street, Leeds LS 1 3EX Accepted for publication 1 October 1991 Summary We report three cases of acute Achilles tendonitis following administration of isotretinoin for acne vulgaris. In this rarely documented side-effect, the symptoms were intimately related to the isotretinoin therapy. Modification of dose regimes permitted control of the tendonitis and an eventual successful response to isotretinoin therapy. Oral isotretinoin has been in use for more than 10 years and is known to cause a wide variety of predictable sideeffects' the most common of which are cutaneous and dose related. Musculoskeletal problems are also well known to occur and these include myalgia, arthralgia and less commonly arthritis^ and muscle damage,^ however, isolated Achilles tendonitis has been reported on a rare and sporadic basis. We wish to report a series of three patients who developed acute Achilles tendonitis during administration of isotretinoin for acne.
and became asymptomatic 2 weeks after finishing the isotretinoin. Case 2
A 32-year-old female was started on isotretinoin in a dosage of 0-5 mg/kg and developed an acute Achilles tendonitis with swelling, tenderness and erythema over both Achilles tendons causing some difficulty in walking. She was treated with ibruprofen 400 mg t.d.s. with reasonable improvement but her symptoms persisted. After 2 weeks the dosage of isotretinoin was reduced to alternate day therapy with a further improvement in the symptoms. The isotretinoin was continued for a total of 18 weeks and all symptoms had cleared completely 3 weeks after discontinuation of the isotretinoin. Case 3
A 33-year-old man developed extreme difficulty in walking 6 weeks after commencing a course of isotretinoin. He experienced pain and tenderness in both All three patients had acne of more than 10 years and had Achilles tendons, the left being considerably worse than failed to respond to adequate courses of several anti- the right. Indomethacin in a dosage of 50 mg three times biotics. daily was given and the dosage of the isotretinoin was reduced to 0-25 mg/kg. However, his tendonitis persisted and the isotretinoin was therefore discontinued and his Case 1 symptoms resolved after 2 weeks. He was recommenced a A 23-year-old male presented with acute pain and small dose of isotretinoin 10 mg daily, which was then tenderness over both Achilles tendons which worsened increased to 20 mg daily after 2 weeks without a return of on waking such that he had great difficulty in weight the tendonitis; he remained on the same dose for 20 bearing. This started 6 weeks after commencing isotreti- weeks. noin in a dosage of 1 mg/kg. Examination revealed mild In all three cases, a small wedge was given to elevate the bilateral swelling erythema and tenderness over both heel with some additional improvement to their sympAchilles tendons. An initial attempt to control the toms. All three patients had X-rays of their Achilles tendonitis with ibruprofen in a dosage of 400 mg three tendons that were normal, as was a D.I.S.H. screen. In all times daily was unsuccessful and the isotretinoin had to three patients, the acne had resolved at the end of their be discontinued. Two weeks after stopping the isotreti- isotretinoin therapy. noin his symptoms had almost completely resolved. The isotretinoin was restarted at a dosage of 0-5 mg/kg and his tendonitis recurred but to a lesser extent and his Discussion symptoms were controlled on the original dosage of Myalgia and arthralgia occur in about 15% of patients ibruprofen. He received in total 20 weeks of isotretinoin taking isotretinoin, these symptoms are usually mild and Case reports
250
ACUTE ACHILLES T E N D O N I T I S resolve once treatment is stopped.'' Other musculoskeletal side-effects are known to occur, however, the mechanism of production of these phenomena is poorly understood. To date there are four reported cases of Achilles tendonitis associated with isotretinoin, in the case described by McGuire et al.^ the patient was physically active and showed evidence of calcification within the Achilles tendon and the spinal column. In a similar case to ours,' a 17-year-old man developed acute Achilles tendonitis shortly after starting isotretinoin which improved on withdrawal and deteriorated on reintroduction of isotretinoin. He was able to tolerate isotretinoin at a reduced dosage. In neither case were details concerning additional treatment required or final outcome available and details ofthe other patients are sparse—simply being recorded as having Achilles tendonitis. None of our patients were particularly physically active or had evidence of calcification. In all three cases the symptoms correlated very closely with the administration and withdrawal of isotretinoin. Our management shows that for Achilles tendonitis induced by isotretinoin, the drug may be continued at an appropriately reduced dosage with or without a short interuption depending on the severity ofthe symptoms. A
251
dose reduction with an appropriate increase in the duration of the therapy should produce the same clinical response in a patient's acne as the cumulative dose is probably as relevant to the successful outcome ofthe acne as is the daily dosage;* our patients all showing a satisfactory resolution of their acne after the end of isotretinoin therapy. References 1, Bigby M, Stern RS, Adverse reactions to isotretinoin, A report from the Adverse Drug Reporting Systtm. Journal of the American Academy of Dermatology 1988; 18: S43-S52, 2, Camisa C, Acute arthritis during isotretinoin therapy for acne. Journal of the American Academy of Dermatology 1986; 15: 10611062, 3, Hodak E, Gadoth N, David M, Sandbank M, Muscle damage induced by isotretinoin, British Medical Journal 1986; 293: 425426, 4, Windhorst DB, Nigra T, General clinical toxicology of oral retinoids. Journal of the American Academy of Dermatology 1982; 6: 675-682, 5, McGuire J, Milstone L, Lawson J, Isotretinoin administration alters juvenile and adult bone, Retinoids: New Trends in Research and Therapy, Retinoid Symposium 1984; 419-439, 6, Chivot M, Midoun H, Isotretinoin and acne—a study of relapses, Dermatologica 1990; 180: 240-243,
