Common Acne Medications Can Cause Intracranial Hypertension

Intracranial hypertension, a rare neurological disorder that can cause headaches, pulsatile tinnitus and vision loss, can be induced by medications commonly used for skin care. A recent study published in Journal of Neuro-Ophthalmology reports that among 839 patients treated for idiopathic intracranial hypertension at Cleveland Clinic Cole Eye Institute, 68 (8.1%) had drug-induced disease.

Tetracyclines (e.g., minocycline, doxycycline) and vitamin A derivatives (e.g., retinoid cream, tretinoin), often found in prescription or over-the-counter acne medications and antiaging products, have been linked with drug-induced intracranial hypertension (DIIH). But that adverse effect doesn’t always make the list of warnings in pharmaceutical advertisements.

“You typically don’t see DIIH included in warnings, so it’s no surprise that patients are unaware of the risk,” says Devon Cohen, MD, a neuro-ophthalmologist at the Cole Eye Institute. “That’s why ophthalmologists and providers prescribing these medications — often dermatology providers — need to have increased awareness. We need to educate patients to watch for signs of DIIH and know that vision loss is a risk of using certain over-the-counter creams and prescription medications.”

Primary care providers also should be aware in case a patient mentions visual concerns or new-onset headaches and is using one of the agents, she adds.

To raise awareness of DIIH, Dr. Cohen and a research team published the recent study of Cole Eye Institute patients. Their paper is among the first not only to report longitudinal visual outcomes of patients with DIIH but also recommend management guidelines.

Adverse effect of tetracyclines and vitamin A derivatives

Patients in the study were seen at the Cole Eye Institute between 2012 and 2023. All were diagnosed with idiopathic intracranial hypertension and were using medication that included tetracycline or a vitamin A derivative. Of these 839 patients, 88% were female, 84% were white, and the mean age was 25.

Data showed that 68 (8.1%) of the patients had intracranial hypertension due to medication (63.5% tetracycline, 16.2% vitamin A derivative, 12.2% both). Most patients (83.8%) were taking the medication to treat acne. Diagnosis of intracranial hypertension was made an average of 26 weeks after beginning use of the inciting medication.

On follow-up six months to 1.5 years after diagnosis of DIIH, three patients recorded poor visual outcome (visual field mean deviation of -7 dB or worse).

“All three of these patients with the worst visual outcomes had not stopped taking the medication that originally caused their DIIH,” Dr. Cohen says. “All were taking a vitamin A derivative with or without tetracycline.”

Future research will need to assess whether vitamin A derivatives are associated with more vision loss in DIIH.

7 guidelines for managing patients at risk for DIIH

“Many patients have come to me after years of being treated elsewhere for refractory intracranial hypertension,” Dr. Cohen says. “Some have been treated with shunts, stents and other advanced therapies. When I ask them about their skin care, they’re surprised. I’ve heard multiple times how no other provider had asked them about their skin care or told them about the correlation between topical agents and intracranial hypertension.”

DIIH can start as early as a few weeks after beginning use of a medication, Dr. Cohen notes. Although rare, one of her patients presented with fulminant idiopathic intracranial hypertension — a more aggressive condition that can cause rapid, permanent blindness — weeks after symptom onset.

The article in Journal of Neuro-Ophthalmology recommends these seven guidelines for managing patients with suspected DIIH:

1. If patients present with new reports of headache, pulsatile tinnitus or vision changes (including peripheral vision changes or blackouts of vision when bending), immediately refer them to ophthalmology.
2. Review their medication list for drugs known to provoke idiopathic intracranial hypertension, including tetracycline and vitamin A derivatives.
3. Advise patients to immediately stop using the medication that induced the disease.
4. Consult with neurology, ophthalmology or a neuro-ophthalmologist, who can consider prescribing acetazolamide or topiramate to treat DIIH symptoms and vision deficits.
5. Monitor visual fields.
6. Advise patients to avoid future use of the medication that induced DIIH.
7. Advise patients to see their regular eye doctor for screening of optic disc edema within three months of beginning future medication that could induce DIIH.

“It’s not just oral medication that can cause DIIH,” Dr. Cohen says. “Topical medications can do it as well. When screening patients, remember to ask them about any over-the-counter skin creams they may be buying at the drugstore and using on their own. Then, if they’re having symptoms of intracranial hypertension, have them stop using the offending agent right away and refer them to a specialist for further evaluation.”