Isotretinoin (Accutane), a vitamin A derivative, is a highly effective medication for treating severe acne. However, it is also known for its numerous side effects, including musculoskeletal pain[1]Alkan S, Kayiran N, Zengin O, Kalem A, Kimyon G, Kilinc EO, Pehlivan Y, Kirtak N, Onat AM, Kisacik B. Isotretinoin-induced spondyloarthropathy-related symptoms: a prospective study. The Journal of … Continue reading.
In this blog post, we’ll explore a study that investigated the relationship between isotretinoin and joint pain, offering valuable insights for both patients and healthcare providers.
Mechanisms of Action
Isotretinoin, the active ingredient in Accutane, is a derivative of vitamin A. Its primary mechanism of action involves reducing sebum production, an oily substance secreted by sebaceous glands that can contribute to acne. Accutane achieves this by targeting the sebaceous glands, shrinking them and ultimately decreasing sebum production.
Additionally, isotretinoin has anti-inflammatory properties and can prevent the formation of comedones (clogged pores), further contributing to its acne-fighting capabilities.
Common Side Effects – Joint and Back Pain
Accutane has been linked to joint pain, back pain, and other musculoskeletal issues in some patients.
These side effects are thought to result from the drug’s anti-inflammatory properties, which may lead to decreased production of substances that protect and cushion joints, such as synovial fluid and cartilage.
Headaches and Pain in Knees, Joints, Muscles, and Back – Are exercises allowed?
While light exercise is generally well-tolerated, heavy exercise may exacerbate pain. If you are experiencing unbearable pain, consult your doctor or pharmacist for appropriate pain relief options.
Musculoskeletal Side Effects of Isotretinoin
A study conducted on 94 patients treated with isotretinoin for acne found that many of them experienced musculoskeletal pain. Researchers compared these patients with 100 healthy controls to determine the prevalence and severity of joint pain and related symptoms in individuals taking isotretinoin[2]Karaosmanoğlu N, Mülkoğlu C. Analysis of musculoskeletal side effects of oral Isotretinoin treatment: a cross-sectional study. BMC Musculoskeletal Disorders. 2020 Dec;21(1):1-0..
The study confirmed that musculoskeletal side effects, such as myalgia (muscle pain), low back pain, and sacroiliitis (inflammation of the sacroiliac joints), were common in patients taking isotretinoin. The onset of these symptoms typically occurred within the first three months of treatment, emphasizing the need for clinicians to closely monitor patients during this period.
According to the authors:
Low back pain is one of the very common complications of isotretinoin. It can be mostly mechanical or inflammatory. Isotretinoin-induced low back pain is dose-related, and inflammatory back pain without sacroiliitis is also frequent. The clinicians should be aware of the back pain may be a reflective of sacroiliitis during isotretinoin usage.
Notably, the study found that the total cumulative dose of isotretinoin was significantly higher in patients with low back pain than in those without this symptom.
This suggests that adjusting the dosage of isotretinoin may help alleviate low back pain in some patients. However, the total cumulative dose of isotretinoin did not appear to be related to other musculoskeletal side effects, such as mechanical or inflammatory back pain.
Isotretinoin and Achilles Tendinopathy
One interesting aspect of the study involved the examination of Achilles tendinopathy, a painful condition affecting the Achilles tendon. Research on rats found that isotretinoin had a negative impact on the biomechanics and histopathology of the Achilles tendon, suggesting that patients experiencing tendinopathy should be asked about their use of isotretinoin.
In the study, only 4.3% of patients in the isotretinoin group had Achilles tendinopathy, while none in the control group had this condition. This highlights the importance of considering isotretinoin use when evaluating patients with tendinopathy.
Isotretinoin and Sacroilitis – an inflammatory joint pain
The exact mechanism behind the development of sacroiliitis in patients using isotretinoin remains unclear[3]Bachmeyer C, Charoud A, Turc Y, Callot V, Blum L, Aractingi S. Isotretinoin-induced bilateral sacroiliitis. Dermatology. 2003;206(3):285-6.. It is believed that isotretinoin induces alterations in the lysosomal membrane structure of cells due to its detergent-like effects, leading to degeneration in synovial cells.
Retinol and retinoic acid derivatives, such as isotretinoin, can also stimulate matrix metalloproteinase-2 (MMP-2) activity and cause membrane damage in joints. This suggests that isotretinoin treatment may render cells susceptible to mild traumas that normally would not cause injury.
What to do about Pain Treatment?
Patients experiencing joint and back pain during Accutane treatment should consider the following recommendations:
- Light exercise: Engaging in light exercise, such as walking, swimming, or yoga, can help alleviate joint pain and maintain flexibility. However, avoid high-impact or heavy exercises, which may exacerbate symptoms.
- Pain relief: Over-the-counter pain relievers, such as acetaminophen or ibuprofen, may help manage joint and back pain. Consult your healthcare provider before taking any pain medication to ensure it is safe and appropriate for your situation.
- Posture and ergonomics: Maintaining proper posture and using ergonomic furniture can help minimize joint and back pain, particularly for those who sit for extended periods.
- Consult your healthcare provider: If joint or back pain becomes severe or persistent, discuss your symptoms with your healthcare provider. They may adjust your Accutane dosage or recommend alternative treatments to help manage your discomfort.
Treatment options for chronic and recurrent back pain from Accutane
Pain Medications
The first line of treatment for chronic back pain is to take over-the-counter pain medications such as paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs). Though these medications can provide a degree of relief, their effect size and duration are limited.
Opioid medications, muscle relaxants, benzodiazepines, gabapentin, and tricyclic antidepressants have been recommended for more persistent and unremitting low back pain. Still, their use should be monitored closely for adverse reactions and risks, as they can lead to substance use disorders, overdose, and prolonged work absence without significant improvements in symptoms or function.
Systemic corticosteroids are not recommended for this type of pain. Passive treatments such as massage and manipulation should be used cautiously, as there is a lack of long-term evidence for their effectiveness. In addition, there is no evidence that these treatments impact functional outcomes or return to work.
Manipulation is recommended for short-term relief to facilitate increased activity.
Exercise is essential to chronic back pain treatment since it can help the patient avoid developing to a chronic level of disability. Although yoga and hydrotherapy have been demonstrated to be moderately helpful for pain relief and functional impairment improvement, there is no clear consensus on the most effective exercise programs.
CBT (Cognitive Behavioral Therapy) can also assist in alleviating pain and improving functional impairment. CBT therapy use a variety of approaches such as creative visualization, imagery, progressive muscle relaxation, and problem-solving, to help patients comprehend, accept, and control their discomfort. Studies have demonstrated CBT to be an effective treatment for persistent low back pain; however, doctors should be aware of the incidence of depression in this population and refer them for appropriate mental health care as needed.
Finally, multidisciplinary programs have been shown to impact pain, functional status, and work performance positively. Multidisciplinary programs involve addressing all barriers to recovery identified through red, yellow, and blue flags, and can include functional restoration components and a focus on return to work.
Studies have shown that multidisciplinary programs are more effective than more conventional physical therapy and less structured treatment programs and have similar long-term outcomes as surgery for chronic NSLBP.
Conclusion
It’s important to remember that everyone’s experience with acne and treatments like Accutane is different. For those who’ve struggled with severe acne and the emotional toll it can take, this journey can be life-changing
Isotretinoin is a potent medication for treating severe acne, but it can also cause musculoskeletal side effects such as joint pain, low back pain, and tendinopathy. This study provides valuable insights into the relationship between isotretinoin and these side effects, offering guidance for patients and healthcare providers to make informed decisions about acne treatment.
As with any medication, it is crucial to consult a healthcare professional before starting, stopping, or changing your isotretinoin treatment plan.
M.D. Orthopaedic Pain Management - University of São Paulo
References
| ↑1 | Alkan S, Kayiran N, Zengin O, Kalem A, Kimyon G, Kilinc EO, Pehlivan Y, Kirtak N, Onat AM, Kisacik B. Isotretinoin-induced spondyloarthropathy-related symptoms: a prospective study. The Journal of rheumatology. 2015 Nov 1;42(11):2106-9. |
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| ↑2 | Karaosmanoğlu N, Mülkoğlu C. Analysis of musculoskeletal side effects of oral Isotretinoin treatment: a cross-sectional study. BMC Musculoskeletal Disorders. 2020 Dec;21(1):1-0. |
| ↑3 | Bachmeyer C, Charoud A, Turc Y, Callot V, Blum L, Aractingi S. Isotretinoin-induced bilateral sacroiliitis. Dermatology. 2003;206(3):285-6. |