Oral Isotretinoin in HIV-Positive Women with Acne: Report of Three Cases

Abstract

Among the facial dermatoses in patients infected with human immunodeficiency virus (HIV), seborrheic dermatitis is the most common [1]. Follicular papular-pustular diseases have been reported and are attributed to infectious agents such as Staphylococcus aureus, Malassezia sp., Candida sp. and Demodex. Demodex-mite-positive rosacea-like eruptions are even reported in children [2, 3]. The typical flare of acne is not reported in detail in the literature, but acne rosacea is well known in men. We observed 3 HIV-positive women with acneiform eruptions on the face.A 32-year-old Caucasian woman had been infected with HIV 5 years previously by heterosexual transmission. She was highly immunosuppressed with 10 CD4/mm3 and a history of Pneumocystis carinii pneumonia (AIDS stage c3). She had had minor acne vulgaris as a teenager that was not specifically treated. On azidothymidine, dapsone and pyrimethamine treatment for several months, she developed a severe eruption on the face and shoulders treated by ketoconazole shampoo without improvement. Histology shows folliculitis and the presence of Demodex. Isotretinoin was given during 5 months (total dose of 90 mg/kg body weight). The result after 4 weeks was dramatic with disappearance of the skin lesions of the face (fig. 1). The evolution of immunological markers was good under HIV tritherapy, with an improvement of CD4 from 10 to 80 in 6 months. No relapse of the facial eruption was noted after 24 months.A 43-year-old African woman had been infected with HIV 4 years previously by heterosexual transmission. She was highly immunosuppressed with 4 CD4/mm3 and a history of tuberculosis and cryptococcosis (AIDS stage c3). She had had acne vulgaris as a teenager treated by topical applications. On treatment of pentamidine, amphotericin B, rifabutine, pyrazinamide and ethambutol, she developed papulopustular lesions on the face. No biopsy was performed, but eosinophils were found in the Giemsa stain. Isotretinoin 0.5 mg/kg was initiated but, after a dramatic response, the patient stopped the treatment after 21 days (total dose = 10 mg/kg) because of a severe xerosis with pruritus. No relapse of the facial eruption was noted after 9 months of follow-up. HIV viremia declined from 80,229 to 2,060 RNA copies/ml in 15 weeks and CD4 improvement was noted on HIV tritherapy introduced a few weeks after the end of the isotretinoin treatment.A 30-year-old Caucasian woman, an intravenous drug user, had been HIV positive for 7 years. She had less than 200 CD4/mm3 and a history of oral candidosis (AIDS stage b3). She had had acne vulgaris when she was 12–14 years old but never received isotretinoin. For the past few months, a facial papular eruption with open and closed comedones was treated by vibramicin without much success. Isotretinoin (0.5 mg/kg) was given during 15 weeks for a total dose of 83 mg/kg body weight. The acne regressed completely. The patient noted a diffuse hair loss during the treatment. No follow-up was available.A flare or outbreak of acne vulgaris seems to be common in HIV-positive patients [1]. It occurs in early or midstage disease. Acne vulgaris and rosacea are not separated in the report of Smith et al. [1]. Two of our cases with a uniform papular and pustular eruption developed exclusively on the face were diagnosed as having rosacea and 1 with a typical polymorphous eruption and presence of comedones as having acne vulgaris. All 3 had a history of acne vulgaris in the past. In 1 case Demodex was demonstrated in a skin biopsy. Two of the 3 women were severely immunosuppressed and had developed at least one major opportunistic disease. So far acneiform eruptions in HIV-positive women are less well reported in the literature than in HIV-positive men [4, 5, 6, 7]. Three male cases are diagnosed as rosacea, 3 as cystic acne and in 1 the facial eruption is not specified. In the 3 cases of rosacea in Vin-Christian et al. [6], only 1 had teenage acne. Topical treatment with ketoconazole or clindamycin was efficient in 2 of them and the third patient received oral minocycline. Our patients responded insufficiently to topical treatment and oral antibiotic but extremely well to oral isotretinoin. Martin et al. [7] published 2 cases with cystic acne in HIV-positive men who were associated with pityriasis rubra pilaris. These cases have been treated with oral isotretinoin and acne responded well in one case but not in the second who presented infectious problems. Excellent results have been obtained by using isotretinoin in the treatment of eosinophilic folliculitis in HIV-positive men. This follicular intensely pruritic eruption localized on the face, trunk and upper extremities has to be differentiated from other follicular diseases by the clinical aspect and the presence of eosinophils in the skin and the blood [8].Isotretinoin had been well tolerated in our patients studied although 1 interrupted the treatment after 2 weeks because of skin xerosis and another patient had noted hair loss but continued the treatment. This short experience suggests that lower total doses of isotretinoin may be sufficient for the treatment of acneiform eruptions in HIV-positive women. No intercurrent reactions with the HIV disease have been noted.