Research

Case Report/Case Series

Lip Abscess Associated With Isotretinoin Treatment

of Acne Vulgaris
Kevin C. Huoh, MD; Kay W. Chang, MD

IMPORTANCE Isotretinoin is frequently prescribed for the treatment of acne vulgaris. Among

the numerous documented adverse effects, most common are xerostomia and cheilitis. Lip
abscesses as a consequence of cheilitis present dramatically and may pose a diagnostic
challenge.
OBSERVATIONS We present a case of a 15-year-old boy with a severe lip abscess requiring
incision and drainage and hospital admission for intravenous antibiotic treatment of
methicillin-resistant Staphylococcus aureus. We discuss the pathophysiologic characteristics
of isotretinoin therapy and the likely causative role that the medication played in the
development of the lip abscess.
CONCLUSIONS AND RELEVANCE Although rare, lip abscesses related to isotretinoin therapy
present with substantial morbidity and should be promptly recognized. Misdiagnosis of
mucositis and angioedema may delay appropriate therapy.
JAMA Dermatol. 2013;149(8):960-961. doi:10.1001/jamadermatol.2013.4066
Published online June 12, 2013.

sotretinoin is commonly prescribed to adolescents for the

treatment of acne vulgaris.1 Numerous adverse effects are
well documented and include xerostomia and cheilitis.2
However, perioral abscesses as a complication of isotretinoinassociated cheilitis are not commonly reported but represent
substantial morbidity to patients. The rarity of such occurrences can lead to misdiagnosis or delayed diagnosis.3
The overall incidence of perioral abscesses, including lip
abscesses, is not reported in the pediatric literature to our
knowledge, but the condition can be regarded as an unusual
entity. We present the dramatic case of a severe lip abscess in
a 15-year-old boy likely related to concurrent use of isotretinoin. Although uncommon, this entity should be recognized
as a potential complication of isotretinoin therapy and differentiated from angioedema or severe mucositis in order for appropriate therapy to be started promptly.

Report of a Case
A 15-year-old boy presented urgently to the pediatric otolaryngology clinic with a 2-day history of lower lip swelling. He
and his mother described rapid onset of edema, erythema, and
pain of the lower lip. Because his symptoms were initially
thought to be caused by allergic angioedema, corticosteroid
therapy was initiated by a pediatrician. This did not lead to resolution of the edema. The patient was then prescribed cephalexin antibiotic therapy for presumed infection. Despite 3 doses
of the medication, the lip swelling had progressed substan960

Author Affiliations: Division of

Otolaryngology, Department of
OtolaryngologyHead and Neck
Surgery, Stanford University School
of Medicine, Palo Alto, California
(Huoh, Chang).
Corresponding Author: Kevin C.
Huoh, MD, Department of
OtolaryngologyHead and Neck
Surgery, Stanford University, 801
Welch Rd, Palo Alto, CA 94304
(khuoh@ohns.stanford.edu).

tially. He otherwise felt well and did not have fevers or chills.
His medical history was notable only for acne vulgaris, for
which he was taking systemic isotretinoin. Both parents were
health care providers.
On examination, the patient was afebrile and normotensive. The lip was extremely edematous and erythematous
(Figure). Both sides of the lower lip were exquisitely tender to
palpation and indurated. Facial strength and sensation were
intact. The remainder of his physical examination was unremarkable.
Given the suspicion of abscess formation, needle aspiration of the lip was performed with return of frank purulence.
The lip was then incised and drained under local anesthesia
with release of a copious amount of purulence. The abscess
pocket extended the full length of the lip. Samples were obtained for culture. The patient was admitted for empirical intravenous ampicillin-sulbactam and vancomycin therapy.
He remained afebrile throughout the hospitalization, with
substantial improvement in lower lip edema, erythema, and
pain. The cultures grew methicillin-resistant Staphylococcus
aureus (MRSA) that was also resistant to clindamycin. The patient was discharged with a prescription for trimethoprimsulfamethoxazole oral therapy.

Discussion
Since its approval by the Food and Drug Administration in 1982,
isotretinoin has been frequently prescribed for a variety of cu-

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Lip Abscess Associated With Isotretinoin Treatment

Case Report/Case Series Research

Figure. Severe Edema and Erythema of Lower Lip Caused by Lip Abscess

taneous conditions, most commonly cystic nodular acne vulgaris. It is estimated that more than 20 million people worldwide have taken isotretinoin.4
The exact mechanism of isotretinoin in its function in the
treatment of acne is not well understood. Isotretinoin (13-cisretinoic acid), a vitamin A derivative, regulates transcription in
order to decrease proliferation, differentiation, and activity of
basal sebocytes. In addition, isotretinoin induces apoptosis of
sebocytes, thereby reducing the overall sebum excretion rate.
By altering the microfollicular environment, isotretinoin also
decreases the total number of Propionibacterium acnes, which
are follicle-dwelling bacteria often implicated in acne vulgaris.5
Despite its elusive mechanism of action, much has been
published regarding the adverse effects of isotretinoin. Most
notable and controversial are the teratogenic effects of the
medication that are so severe that dual methods of contraception are required for young women taking the drug.

ARTICLE INFORMATION
Accepted for Publication: February 6, 2013.
Published Online: June 12, 2013.
doi:10.1001/jamadermatol.2013.4066.
Author Contributions: Both authors had full access
to all of the data in the study and take responsibility
for the integrity of the data and the accuracy of the
data analysis.
Study concept and design: Both authors.
Acquisition of data: Both authors.
Analysis and interpretation of data: Both authors.
Drafting of the manuscript: Huoh.
Critical revision of the manuscript for important
intellectual content: Chang.
Administrative, technical, and material support:
Both authors.
Study supervision: Chang.

However, a plethora of other adverse effects are also well

described, including xerostomia, cheilitis, depression and
suicidal ideation, acral desquamation, alopecia, ocular
abnormalities, and hypertriglyceridemia.2 The mucocutaneous effects of isotretinoin are so common that the absence
of these symptoms implies medication nonadherence. 4
More than 90% of patients taking isotretinoin report dry
mucous membranes and cheilitis. This is usually treated
with topical emollients and steroids.2
The fissuring and cracking of the lips associated with cheilitis lead to the breakdown of an important mucocutaneous barrier, which can predispose patients to bacterial or viral infection. Dramatic presentations of complete mucosal denuding
of the lip have been described.6 In addition to causing breakdown of the mucosal membrane barriers, isotretinoin also leads
to increased colonization with S aureus, which increases the
incidence of folliculitis and furunculosis.7
This perfect storm of isotretinoin leading to cheilitis, decreased mucocutaneous barriers, and staphylococcal colonization likely caused the severe lip abscess in our patient that
was initially misdiagnosed as allergic angioedema. In addition, both of the patients parents were health care providers
and presumably exposed the patient to carriage of MRSA.8
Prompt recognition of a lip abscess led to successful and rapid
treatment and resolution of the problem.
Our case is strikingly similar to one previously reported by
Beer et al.3 In the previous report, the authors present a case
of a MRSA lip abscess thought to be related to concurrent
isotretinoin use. To our knowledge, no other cases have been
reported in the literature. By presenting our case, we hope to
raise awareness of the development of severe lip abscesses related to isotretinoin use and prevent delayed diagnosis or misdiagnosis of this serious complication of a commonly used acne
treatment. Pediatricians of patients receiving isotretinoin
should suspect infectious etiology in the presence of rapid and
dramatic lip swelling.

Conflict of Interest Disclosures: None reported.

REFERENCES
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8. Albrich WC, Harbarth S. Health-care workers:

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