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Drug reaction with eosinophilia and systemic symptoms in metastatic basal cell carcinoma treated with vismodegib

We previously published the results of a study of very lowdose isotretinoin (5 mg/day) in the treatment of 60 adults with persistent low-grade acne. This showed that isotretinoin 5 mg/day was very effective in reducing the number of acne lesion and improving patients’ dermatological quality of life, with minimal adverse effects. However, concern was expressed that patients might relapse quickly. We therefore performed a follow-up study, 30–36 months later, to determine the rate of relapse. Three-quarters of patients who completed the 5-mg/day isotretinoin study were assessed. Their mean (SD) age was 38.3 7.1 years and 88% were women, which matched the original study population. In 40% of patients there was no recurrence of acne. In the remainder, mild acne recurred a mean 6.6 7.7 months after stopping treatment (range 0–24 months). This relapse rate is not dissimilar to longer term follow-up studies of standard dose isotretinoin (48% at 5 years). Although the acne that relapsed was minimal, almost half (48%) the patients elected, at some stage, to restart low-dose isotretinoin, 6% doxycycline and 6% topical retinoid. The mean duration ( SD) of any further treatment with isotretinoin was 12.4 8.5 months; treatment was often taken intermittently (5–10 mg twice/week). As part of the original protocol, patients received either 5-mg/day isotretinoin for 16 weeks or 32 weeks. The patients’ age, duration of treatment (16 vs 32 weeks) and severity of acne (at baseline or at the end of treatment) did not significantly affect whether patients acne relapsed or not, although there was a trend for patients who had received 32 weeks to do better. Cumulative dose was also not a factor in relapse. Very low-dose isotretinoin (5-mg/ day) controls acne quickly and effectively, and is very well tolerated. Altogether 40% of patients achieved long-term remission. The remainder maintained excellent control with intermittent very low-dose isotretinoin. It is time to revise the treatment protocols and guidelines of persistent adult acne, and consider very low-dose isotretinoin as a first line therapy. Concerns over pregnancy risks do however, remain.