Electrocardiogram abnormalities in patients with acne undergoing isotretinoin therapy: a focused review

Abstract

Isotretinoin is an extremely successful treatment for acne, widely prescribed for moderate to severe cases unresponsive to conventional therapy that is commonly used in dermatology. While its systemic side effects, particularly those related to hepatic and lipid metabolism, are extensively documented, its impact on cardiac electrophysiology is little understood. Metabolic abnormalities are frequent, with hypertriglyceridemia occurring in up to 44% of patients, elevated total cholesterol in 30%, and transient liver enzyme elevation in approximately 10%–11%. This focused review summarizes the existing research on electrocardiographic (ECG) alterations associated with isotretinoin medication. Reported cardiac abnormalities are rare, with isolated case reports and small studies describing transient arrhythmias in fewer than 1%–2% of users, including premature ventricular contractions (PVCs), atrial tachycardia, and, in exceptionally rare instances, cardiomyopathy < 0.01%. Mechanistic ideas suggest changes in human ether-a-go-go-related gene (hERG) potassium channels, dyslipidemia-induced atherosclerosis, electrolyte imbalances, and sympathetic overactivity. However, large population-based studies have not found a significant increase in major cardiovascular events. Most ECG abnormalities, when noted, appear to be reversible with discontinuing isotretinoin. This review is unique in that it focuses on isotretinoin from both dermatological and cardiac viewpoints. It identifies important shortcomings in standardized ECG monitoring procedures and underscores the scarcity of large, prospective, controlled trials. Future research should focus on longitudinal, multicenter trials using serial ECG evaluations to better define risk profiles and guide clinical monitoring. Understanding infrequent but potentially serious cardiac effects is critical for improving isotretinoin's safety profile and guiding evidence-based therapy.