How long do we wait to have laser therapy for acne scars after using Accutane?
Due to complaints of inadequate wound healing and scarring, it is suggested that patients wait six months after completing oral isotretinoin medication before beginning laser treatment safely. This study aimed to determine the safety of non-ablative fractional laser (FRACTIONAL LASER) treatment for acne scars within one month of isotretinoin medication.
A study for the laser after Accutane treatment
There was a randomized split-face controlled experiment with ten individuals who had completed isotretinoin therapy and had acne scars. Within one month of isotretinoin medication, all patients had three treatments four weeks apart using an erbium-doped 1550 nm FRACTIONAL LASER on one side of the face. The side that was not treated served as a control. Two blinded dermatologists analyzed wound healing and side effects and acne scar improvement.
All patients healed normally following FRACTIONAL LASER treatments, with no evidence of hypertrophic scars or keloids. The improvement of acne scars was good.
Within one month after completing isotretinoin therapy, FRACTIONAL LASER treatment for acne scarring appears well tolerated. Dermatologists should reconsider the suggestion to wait six months following isotretinoin therapy before laser acne scar repair.
Introduction about Accutane
Current recommendations to avoid laser therapy for six months following the final dosage of oral Accutane are based on decades-old reports of delayed wound healing, aberrant scarring, and keloid development associated with isotretinoin treatment. Scarring from acne may be debilitating mentally, and delaying potentially beneficial treatments like laser resurfacing during and after isotretinoin medication can significantly affect a patient’s quality of life. Recent retrospective cohort studies have cast doubt on this guideline, indicating that laser resurfacing (ablative and non-ablative) may be safe for acne scarring when performed concurrently with and within 1–3 months of isotretinoin therapy. No randomized split-face controlled experiments have been conducted to address this problem to the authors’ knowledge. Thus, this study was intended as a randomized split-face controlled experiment to assess the safety of non-ablative fractional laser (FRACTIONAL LASER) treatment for atrophic facial acne scars within one month of completing oral Accutane therapy (total cumulative isotretinoin dose of 120 mg/kg).
Characteristics of the Accutane Patient
Ten patients from the University of Utah’s Department of Dermatology were recruited for this single-blinded, randomized, split-face controlled trial, and a signed written informed agreement was acquired. The University of Utah Institutional Review Board authorized the study. We enrolled patients aged 18 years or older who had finished oral isotretinoin therapy (total isotretinoin cumulative dosage of 120 mg/kg) and exhibited mild to severe atrophic facial acne scars of all forms (icepick, boxcar, rolling). Concurrent pregnancy or lactation was excluded, as were individuals with a history of hypertrophic scars or keloids, porphyria or photosensitivity, immunosuppression, active infection, or any laser/cosmetic treatments during the preceding six months.
The demographic features of the patients and the specifics of their isotretinoin and laser treatments are summarised in Table 1. The study included ten ladies with Fitzpatrick Skin Types I–IIIwas. Their ages ranged from 18–36 years (mean 24.5 years). Isotretinoin’s cumulative dosage ranged between 125 and 325 mg/kg (mean 172.34 mg/kg).
- Age of the patient in years
- Sex Type of skin
- Months of oral isotretinoin therapy
- Oral isotretinoin total cumulative dosage, mg/kg
- Weeks between isotretinoin oral and laser therapy
- Laser treatment on one side of the face
Within one month of completing oral isotretinoin treatment, all patients were randomly assigned to have one side of their face treated with a non-ablative fractional 1550 nm erbium-doped fibre laser (Fraxel® DUAL Laser System, Solta Medical, Inc., Hayward, CA), while the untreated side of each subject’s face served as a control. The same doctor performed all laser treatments.
Antiviral prophylaxis (oral valacyclovir 500 mg twice a day for five days, beginning the day before each laser treatment) was given to individuals with documented herpes labialis. Each patient was told to apply 20% Benzocaine, 8% Lidocaine, and 4% Tetracaine cream on the treated side of the face one hour before treatment. The laser fluences were between 35 and 40 mJ/microthermal zone (MTZ), with eight passes each treatment session. Treatment levels ranged between 7 and 10, equivalent to a treatment coverage of 20%–35% and total energy delivery of 2–3 kJ each session. Each patient had three therapy sessions separated by four weeks. Post-treatment instructions included using a gentle cleanser, sunscreen, sun avoidance, and many times daily use of a cream-based moisturizer for the first 3–4 days following each treatment session.
Assessment of Outcomes
Patients were examined seven days after each laser treatment, four weeks after each, and four months after the final treatment (6 months from baseline). Two blinded dermatologists conducted these exams in person. Photographs were taken at baseline, before each treatment session, during the follow-up period, and at the final evaluation.
The key end measures were wound healing and adverse events associated with laser treatments. These were conducted in person at each follow-up visit by a blinded dermatologist. Wound healing was assessed on a two-point scale (0 being adequate, one being insufficient). On a 4-point scale, parameters such as erythema, edema, blistering, crusting, new atypical scarring or keloids, and hyperpigmentation were rated (0 being nonexistent, one being mild, two being mild, two being mild-moderate, and three being severe).
Improvements in acne scarring and patient satisfaction with the therapy were secondary findings. At the last follow-up appointment (4 months following the last laser treatment), two independent blinded dermatologists rated the improvement in acne scarring using digital pictures and a quartile grading system (1 = 1% to 25%, 2 = 26% to 50%, 3 = 51% to 75%, 4 = higher than 75%). The total improvement in clinical grade was determined by averaging the grade values of two dermatologists. After the trial, the same measure was utilized to assess patient satisfaction. Finally, patients reported the severity of pain experienced during each therapy session using a visual analog scale (0 being no pain and 10 being the most severe).
Each of the ten patients had three FRACTIONAL LASER treatments and completed all follow-up appointments. As predicted, the authors noted mild erythema on the treated side of the face immediately following each laser session. After laser treatments, all patients demonstrated full reepithelialization and normal wound healing (Figs. 1B and 2B). No new hypertrophic scars or atypical keloids were identified (Figs. 1C and 2C). The adverse events throughout the follow-up periods were modest, transient, and predictable (mild erythema and edema that resolved within a few days of laser treatment). Additionally, follow-up visits revealed no blistering, crusting, or hyperpigmentation.
After three FRACTIONAL LASER treatments, four out of ten patients (40%) displayed acne scar improvement of 1–25 percent, five patients (50%) demonstrated improvement of 26–50 percent, and one patient (10%) demonstrated improvement of 51–75 percent (Fig. 3). All patients expressed satisfaction with the magnitude of improvement, and their level of satisfaction frequently matched, if not surpassed, the evaluation. During the follow-up period, no patient observed a worsening of acne scars. Patients described their pain during laser treatments as mild.
Acne scarring is a frequent and difficult condition for dermatologists to treat. Acne scars have been treated with several techniques with various degrees of effectiveness. The number of lasers and energy-based therapy alternatives accessible to patients for acne scar treatment has increased significantly and continues to develop. Numerous published studies have indicated that fractional laser may successfully treat all atrophic acne scarring (icepick, boxcar, and rolling scars) while maintaining an extremely favourable safety profile.
Given that acne scars frequently have a detrimental psychological effect on those suffering, early and efficient treatment would be useful. However, the current unsupported medical suggestion is that patients wait six months after completing oral isotretinoin medication before safely beginning laser treatment. This advice is based on observational case reports of patients treated with dermabrasion or laser (488 nm argon laser and 585 nm pulsed dye laser) who recently took oral isotretinoin with poor wound healing unusual scarring [1-5]. However, it is critical to remember that many published findings originate from the 1980s and 1990s (before FRACTIONAL LASER technology). Additionally, such instances are uncommon and generally pertain to patients who underwent dermabrasion, with a greater risk profile than fractional lasers.
Given the lack of good scientific data to support allegations of impaired wound healing in isotretinoin patients, recent research has questioned the existing recommendation to wait six months following the completion of oral isotretinoin treatment. A few case reports and retrospective cohort studies demonstrate that laser operations in isotretinoin patients have no harmful effects. Khatri and colleagues first published case reports demonstrating the safety and absence of problems such as atypical scarring or keloid development following laser hair removal in individuals receiving oral isotretinoin. Khatri et al. recently published a case report demonstrating the safety of ablative and FRACTIONAL LASER resurfacing in isotretinoin-treated patients. In the clinical setting of acne scar revision, two retrospective studies (each involving at least 20 subjects receiving 0.5–1 mg/kg isotretinoin daily) concluded that ablative carbon dioxide (CO2) resurfacing for acne scarring performed during and within 1–3 months of isotretinoin treatment is safe and has no adverse effect on healing. Another research evaluating the concurrent use of 1550 nm FRACTIONAL LASER with low-dose Accutane (10 mg/day) for treating acne and acne scars found enhanced effectiveness without any side effects compared to controls. Furthermore, a recent systematic review concluded insufficient evidence to justify delaying manual dermabrasion, superficial chemical peels, cutaneous surgery, laser hair removal, and fractional ablative and non-ablative laser procedures in patients who are currently receiving or have recently completed isotretinoin therapy.
Despite a growing body of recent information demonstrating the safety of lasers in patients recently treated with isotretinoin, most of us continue to urge patients to wait six months after isotretinoin medication is completed before undergoing laser treatment. According to newly published research, only a minority of clinicians would propose that patients have FRACTIONAL LASER, fractional ablative, or ablative lasers within six months after isotretinoin usage (27 percent, 11 percent, and 3 percent, respectively). Despite these concerns, more than three-quarters (76%) of professionals reported having never noticed any issues in patients treated with a laser while receiving isotretinoin or within six months after finishing a course of medication. Concerns about isotretinoin patients included the dangers of poor wound healing and scarring, but the most often expressed worry was a medicolegal risk (74 percent ). Medicolegal considerations appear to have an outsized influence on treatment decisions for these individuals.
Our findings (patients displayed normal wound healing and no additional hypertrophic or keloidal scars were found following laser treatments) call into question earlier unsupported advice to postpone laser treatment in patients recently treated with isotretinoin. Our work adds to the growing knowledge that lasers may be safe to employ for acne scar repair when performed within six months after completing an isotretinoin course. A significant feature of our randomized clinical trial was the split-face self-controlled design, which helped to eliminate confounding variables. Additionally, all wound healing and adverse event evaluations were conducted in person rather than via pictures, allowing observers to notice small differences.
Our study has several limitations, including a small sample size of all female patients, a lack of patients with darker skin types (Fitzpatrick skin types IV-VI), a brief follow-up period (4 months after the last treatment), and a lack of histological examination to objectively assess the wound healing process following laser treatment. While our findings are encouraging and significant, additional large studies with a diverse patient population and longer follow-up periods and histopathological evaluation are needed to challenge current dogma further and establish that FRACTIONAL LASER treatment for acne scarring is safe within one month of discontinuing oral isotretinoin treatment.
In summary, FRACTIONAL LASER treatment for acne scarring appeared to be well tolerated within one month after discontinuing oral isotretinoin therapy since all research participants had normal wound healing and no hypertrophic or keloidal scars were detected. The majority of research subjects significantly reduced acne scarring following FRACTIONAL LASER treatments. Thus we must reconsider the suggestion to wait six months following the completion of oral isotretinoin treatment before doing laser acne scar correction. This widely accepted approach is likely motivated more by medicolegal considerations than real evidence-based studies, depriving acne scar sufferers of timely and effective laser therapy.