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A case of paraneoplastic pemphigus associated with Castleman disease reacting with multiple autoantigens, including the p200 protein

isotretinoin were used separately; however, to our knowledge, only a few published reports describe this adverse effect when these drugs were used in combination. We conducted an online survey where dermatologists in the west of Scotland were asked to provide information regarding their standard practice when suggesting treatment escalation from oral tetracycline antibiotics to isotretinoin in patients with acne vulgaris. Of the 46 respondents, four (9%) suggested a ‘washout’ period of 5 days, 14 (30%) suggested 7 days, 22 (48%) suggested 2 weeks and six (13%) did not routinely suggest one. Assuming standard acne antibiotic doses and normal liver and renal function, it takes approximately 5–7 half-lives, from steady state, for a drug to be eliminated. Basing our calculation on seven halflives to achieve a theoretical 99% drug clearance, doxycycline (half-life 12–24 h) takes between 84 and 168 h (3 5–7 0 days) to be cleared. Similarly, minocycline (half-life 11–26 h) requires 77–182 h (3 2–7 5 days) to be eliminated. Half-life data for other tetracycline antibiotics used in the treatment of acne are generally shorter. Under the assumption that pseudotumour cerebri is caused by the presence of both drugs in the body, and not by a long-lasting effect, a 7-day ‘washout’ period would therefore be adequate. This means that a shorter ‘washout’ period may expose patients to a serious adverse effect, while prolonging this period may unnecessarily delay required treatment. As the use of oral isotretinoin is increasing and its prescribing subject to intense scrutiny and strict guidelines, it is useful to incorporate scientific pharmacology in the prescribing of acne medications. We hope this will be useful in standardizing practice for other dermatologists.