Expert Panel: Little support for delaying cosmetic procedures after isotretinoin

In most cases, there is little evidence to support delaying cosmetic procedures, such as laser therapy or chemical peels, in patients who have recently been treated with isotretinoin for acne, according to a consensus statement from the American Society of Dermatologic Surgery (ASDS).

An expert panel convened by the ASDS issued specific recommendations that supported safe, early initiation of cosmetic procedures in most cases. It noted that the likelihood of any potential harms from initiating cosmetic procedures after recent isotretinoin treatment is “low to very low” and that such harms have been reported only in case reports and case series.

Notable exceptions included dermabrasion and full-face ablative resurfacing; the experts recommended against having such procedures within 6 months of isotretinoin use because of potentially increased risks of adverse events in some patients.

“Potential benefits of this guideline include early access to scar treatments for many patients who are at the highest risk for scarring and, thereby, potentially improved patient quality of life,” Abigail Waldman, MD, of the department of dermatology at Brigham and Women’s Hospital, Boston, and her coauthors wrote in the consensus statement (Dermatol Surg. 2017 Oct;43[10]:1249-62). This is the first consensus statement document published by the ASDS to address this topic.

Dr. Abigail Waldman

Isotretinoin was approved by the Food and Drug Administration in 1982 for treating severe and nodulocystic acne. Because of a perceived higher risk of scarring or irritation associated with isotretinoin use, standard clinical practice has been to avoid performing laser procedures, chemical peels, waxing, dermabrasion, and incisional or excisional cutaneous surgeries on patients within 6 months of their using isotretinoin, according to the authors. A warning regarding the potential for scarring with cosmetic procedures meant to smooth the skin is even included in the patient information leaflet for isotretinoin.

“This is in contradistinction to the observation that nodulocystic or severe inflammatory acne patients who have recently completed treatment with isotretinoin are among those most likely to benefit from treatment of their acne scars with modalities such as laser, dermabrasion, or chemical peels,” the experts wrote in the consensus recommendations.

Following a review of the 36 source documents, the task force concluded that, for patients currently or recently receiving isotretinoin, evidence was “insufficient” to justify delaying treatment with superficial chemical peels, vascular lasers, and nonablative modalities, such as hair removal lasers and lights. They also stated that superficial and focal dermabrasion “may also be safe when performed by a well-trained clinician” in a clinical setting.

The panel recommendations covered the following four key areas:

• Dermabrasion. Treating specific facial areas while the patient is on isotretinoin or within 6 months of discontinuation “is not associated with increased risk of scar or delay in wound healing, and there is no evidence in the literature that supports a need to delay treatment,” they wrote. In contrast, they did not recommend full-face or mechanical dermabrasion with rotary devices within the 6-month window because it may be “associated with increased risk of adverse events in selected patients.”
• Lasers and energy devices. Similarly, the panel found no evidence that would justify delaying use of vascular lasers, hair removal lasers and lights, and nonablative or ablative fractional devices among patients recently treated with isotretinoin. However, they said fully ablative treatment of the entire face or regions other than the face should “generally be avoided until 6 months after completion of isotretinoin treatment because of the likely elevated risk of avoidable adverse events.”
• Chemical peels. Patients currently on isotretinoin or who have recently discontinued it can safely undergo superficial chemical peels, according to the panel. For medium or deep chemical peels, there was “insufficient data … to preclude a recommendation in this case,” the panel wrote.
• Other surgeries. Because of the risk of dry eyes, isotretinoin should be discontinued prior to laser eye surgery. For incisional and excisional cutaneous surgery, the data on isotretinoin were insufficient to make any recommendations, the experts concluded, though they acknowledged that in some cases, the surgeries may be “medically necessary.”

Most of these recommendations were based on case series and cohort studies, the panel said, rather than higher-quality, randomized clinical trials, which are “generally impractical and not likely forthcoming in this setting.” Moreover, they cautioned that insufficient evidence to make a recommendation should not be misconstrued as a confirmation of safety or a warning about risk.

Overall, the results of the analysis suggested that “procedural interventions during or soon after isotretinoin treatment can safely and effectively address acne scarring and similar disorders, thus providing relief to patients without the need for protracted waiting,” the authors wrote.

In August, another expert panel’s recommendations were published, which concluded that skin procedures, including superficial chemical peels, laser hair removal, minor cutaneous surgery, manual dermabrasion, and fractional ablative and fractional nonablative laser procedures, can be performed safely on patients who have recently been or are currently being treated with isotretinoin (JAMA Dermatol. 2017 Aug 1;153[8]:802-9).

The authors of the ASDS statement reported no relevant financial conflicts.