Retinoids are derivatives of vitamin

Retinoids are derivatives of vitamin A that have been shown to normalize keratinocyte differentiation and proliferation. Acitretin is an aromatic form of tretinoin, and is useful for controlling extensive or severe Darier disease. A wide range of adverse effects may occur with its use, including cheilitis, xerosis, retinoid dermatitis, dyslipidemia, desquamation, photosensitivity, paronychia, pyogenic granuloma, and onycholysis, which usually disappears when acitretin is used at lower doses or when the medicine is withdrawn. Rare serious adverse effects, including pancreatitis, seizures, and cerebral pseudotumor, have also been noted. Mood changes, depression, suicide risk, and inflammatory bowel disease are also controversial outcomes. 13-cis-Retinoic acid, also known as isotretinoin is a second-generation retinoid order Nutlin 3 that is particularly useful in severe cases of acne such as severe cystic acne. It shows beneficial activity in pityriasis rubra pilaris, Darier disease, and keratosis palmosis. Although data are currently limited, it is probable that isotretinoin can cause intestinal inflammation. A small number of case reports have reported the development of ischemic bowel disease (IBD) while receiving isotretinoin therapy. Reddy et al reviewed 85 cases of IBD associated with isotretinoin reported to the US Food and Drug Administration (FDA) between 1997 and 2002, and found that the causal association with isotretinoin was considered probable or highly probable in 75% of the cases. According to the summary of previous case reports, the period between isotretinoin initiation and IBD onset is most commonly in months, although it can range between days to a year. Retinoic acid can interfere with epithelial integrity and this may predispose a patient to intestinal inflammation. Proposed mechanisms include the following: (1) isotretinoin affects intestinal epithelial growth and is involved in cell repair and apoptosis; (2) isotretinoin increases T lymphocyte proliferation and gut homing as well as altering T lymphocyte subsets predisposed to inflammation; (3) isotretinoin causes neutrophil dysfunction, inhibition of glycoprotein synthesis, dendritic cell activation and its effects on plasma cell may also predispose a patient to inflammation. It is reasonable that acitretin and isotretinoin share certain common adverse effects. However, there have been no reports on small bowel perforation associated with acitretin. Hyperlipidemia occurs in certain patients on acitretin therapy. It is regarded as a modifiable risk factor for cardiovascular disease due to its influence on atherosclerosis. In addition, some cases may predispose patients to acute pancreatitis. In our case, persistent elevation in triglyceride levels was noted.
Conclusion
Introduction Sarcoidosis is an idiopathic systemic granulomatous disease, in which noncaseating granulomatous inflammation can occur in any organ. The skin is affected in about 25% of cases, and the majority of cases occur in black women. The scalp is rarely involved, and the inflammation may lead to cicatricial alopecia as a result of the destruction of hair follicles by the granulomatous formation. Clinically, sarcoidosis may present as papules, nodules, or plaques, and in some cases may resemble discoid lupus erythematosus (DLE) or necrobiosis lipoidica.
Case report A 57-year-old Taiwanese female had been very healthy most of her life. However, over the past 4–5 years, she had developed painful ulcerative wounds with alopecia on her frontoparietal scalp (Figure 1). She had not been treated for the wounds or alopecia prior to visiting our hospital. On examination, we saw several bean- to coin-sized depressed ulcers surrounded by a violaceous to erythematous hue, and telangiectasia on the right frontoparietal scalp. No other skin lesions were noted. DLE was suspected, and an incisional biopsy was performed. The pathology report showed noncaseating granulomatous inflammation involving the superficial and deep dermis (Figure 2). The granulomas were composed of epithelioid cells and occasional giant cells, rich in asteroid bodies. Results of direct immunofluorescence tests for immunoglobulin A (IgA), IgG, IgM, complement component 3 (C3), fibrinogen, and complement C1q were all negative. Periodic acid Schiff, Fite, and acid-fast stains did not reveal any pathogens, and the Venereal Disease Research Laboratory (VDRL) test was negative. Therefore, the diagnosis of sarcoidal alopecia was confirmed.