How long to wait after Accutane treatment to get laser therapy for acne scars

Abstract

Background and Objective

Based on reports of poor wound healing and scarring, it is currently recommended that patients wait 6 months after completion of oral isotretinoin therapy before the safe initiation of laser therapy. Our aim was to evaluate the safety of non-ablative fractional laser (FRACTIONAL LASER) treatment for acne scars within 1 month after isotretinoin therapy.

 

Study Design/Methods

This was a randomized split-face controlled trial involving 10 patients with acne scars who had completed isotretinoin treatment. All patients received three treatments each spaced 4 weeks apart with an erbium-doped 1550 nm FRACTIONAL LASER on one side of the face within 1 month after isotretinoin therapy. The untreated side acted as a control. Wound healing and adverse effects as well as acne scar improvement were evaluated by two blinded dermatologists.

 

Results

All patients demonstrated normal wound healing post FRACTIONAL LASER treatments, and neither hypertrophic scars nor keloids were observed. Acne scar improvement was satisfactory.

 

Conclusion

FRACTIONAL LASER treatment for acne scarring appears to be well tolerated within 1 month of completing isotretinoin treatment. Dermatologists should reevaluate the current recommendation to wait 6 months after isotretinoin treatment for acne scar revision with lasers. Other larger studies are necessary to further challenge this dogma. Lasers Surg. Med. 49:886–

890, 2017. © 2017 Wiley Periodicals, Inc.

 

INTRODUCTION

Current recommendations to avoid laser treatment for 6 months after the last dose of oral isotretinoin are based on reports published decades ago of delayed wound healing, atypical scarring and keloid formation in the setting of isotretinoin treatment  Acne scarring can be psychologically detrimental, and withholding potentially effective treatments such as laser resurfacing during and after isotretinoin therapy can negatively impact a patient’s quality of life. More recent retrospective cohort studies have challenged this current recommendation and suggested that laser resurfacing (ablative and non-ablative) may be safe for acne scarring when conducted during and/or within 1–3 months of isotretinoin treatment. However, to the authors’ knowledge there are no randomized split-face controlled trials that have addressed this issue. Thus, this study was designed as a randomized split-face controlled trial to evaluate the safety of non-ablative fractional laser (FRACTIONAL LASER) treatment for atrophic facial acne scars within 1 month of completing oral isotretinoin treatment (total cumulative isotretinoin dose of ≥120 mg/kg).

METHODS

Patient Characteristics

In this single-blinded, randomized, split-face controlled study, 10 patients from the University of Utah, Department of Dermatology were selected, and signed written informed consent were obtained. The study was approved by University of Utah Institutional Review Board. Patients, aged 18 years or older, with mild to moderate atrophic facial acne scars of all types (icepick, boxcar, rolling) who had completed oral isotretinoin treatment (total isotretinoin cumulative dose of ≥120 mg/kg) were enrolled. Exclusion criteria included concurrent pregnancy or lactation, patients with a history of hypertrophic scars or keloids, porphyria or photosensitivity, immunosuppression, active infection or any laser/cosmetic treatments in the previous 6 months.

Table 1 summarizes the patients’ demographic characteristics and the details of their isotretinoin and laser treatments. There were 10 females with an age range 18–36 years (mean 24.5 years) and Fitzpatrick Skin Types I–III. The range of total cumulative dose of isotretinoin was 125–325 mg/kg (mean 172.34 mg/kg).

Table 1. Patient Demographic Data and Treatment Details

Patient Age, years Sex Skin type Total period of oral isotretinoin treatment, months Total cumulative dose of oral isotretinoin, mg/kg Interval between oral isotretinoin and laser treatment, weeks Side of the face treated with laser
1 22 F I 6 182.1 1 Right
2 28 F I 6 161.9 4 Right
3 31 F I 6 157.1 2 Left
4 18 F III 5 125.0 1 Right
5 18 F I 5 173.1 4 Right
6 22 F III 6 150.0 2 Right
7 22 F I 6 325.0 4 Right
8 28 F I 6 161.9 3 Left
9 20 F III 7 147.3 2 Left
10 36 F I 7 140.0 3 Left

 

Laser Treatments

All patients were randomly assigned (via coin flip by study coordinator) to have one side of their face treated within 1 month of completing oral isotretinoin treatment with a non-ablative fractional 1550 nm erbium-doped fiber laser (Fraxel® DUAL Laser System, Solta Medical, Inc., Hayward, CA), while the untreated side of each subject’s face served as a control. All laser treatments were performed by the same dermatologist.

For patients with documented histories of herpes labialis, antiviral prophylaxis (oral valacyclovir 500 mg twice a day for 5 days, starting the day before each laser treatment) was prescribed. All patients were instructed to apply Benzocaine 20%, Lidocaine 8%, Tetracaine 4% cream to the treated side of the face 1 hour prior to treatment. Laser fluences ranged from 35 to 40 mJ/microthermal zone (MTZ) and eight passes per treatment session were performed. Treatment levels varied from 7 to 10 corresponding to treatment coverage of 20–35% with total energies of 2–3 kJ delivered per session. Each patient underwent three treatment sessions at intervals of 4 weeks. Post-treatment instructions included the use of a mild cleanser, sunscreen and sun avoidance, and a cream based moisturizer several times daily for the first 3–4 days after each treatment session.

 

Outcome Assessments

The patients were re-evaluated 7 days after each laser treatment, 4 weeks after each laser treatment, and a final assessment was performed 4 months after the last treatment (6 months from baseline). These evaluations were done in person by two blinded dermatologists. Photographs were obtained at baseline, before each treatment session, throughout the follow-up period, and at the final assessment.

The primary outcome measure included wound healing and adverse events related to laser treatments. These were performed in-person by a blinded dermatologist at each follow-up visit. Wound healing was graded on a 2-point scale (0 = appropriate, 1 = non-appropriate). Parameters, including erythema, edema, blistering, crusting, new atypical scarring or keloids, and hyperpigmentation, were graded on a 4-point scale (0 = absent, 1 = mild, 2 = moderate, and 3 = severe).

Secondary outcomes included improvement of acne scarring and patient satisfaction with the treatment. Improvement in acne scarring was graded at the final follow-up visit (4 months after the last laser treatment) by two independent blinded dermatologists using digital photographs and a quartile grading scale (1 = 1% to 25%, 2 = 26% to 50%, 3 = 51% to 75%, 4 = greater than 75%). The overall improvement in the clinical grade was assessed by averaging the two dermatologists’ grade scores. The same scale was also used to assess patient satisfaction at the end of the study. Lastly, patients also evaluated the intensity of pain during each treatment session using a visual analogue scale (0 = absence of pain, 10 = most severe pain).

 

RESULTS

All 10 patients underwent three FRACTIONAL LASER sessions and completed each follow-up visit. As expected, immediately after each laser treatment, the authors observed moderate erythema on the treated side of the face. All patients showed complete reepithelialization and normal wound healing at the 7 days follow-up visit after laser treatments (Figs. 1B and 2B). No new hypertrophic scars or atypical keloids were observed at the follow-up visits, including the final 4 month follow-up (Figs. 1C and 2C). The adverse events during the follow-up periods were minor, temporary, and expected (mild erythema and edema that resolved within a few days of laser treatment). Furthermore, no blistering, crusting, or hyperpigmentation were noted at the follow-up visits.

acne scars fig 1

Photographs of a patient with 1550 nm erbium-doped non-ablative fractional laser (FRACTIONAL LASER)-treated side of the face: (A) at baseline, (B) at 7 days after first FRACTIONAL LASER treatment, (C) at 4 months after last FRACTIONAL LASER treatment (or 6 months from baseline).

acne scars fig 2

Photographs of a patient with 1550 nm erbium-doped non-ablative fractional laser (FRACTIONAL LASER)-treated side of the face: (A) at baseline, (B) at 7 days after first FRACTIONAL LASER treatment, (C) at 4 months after last FRACTIONAL LASER treatment (or 6 months from baseline).

At the final 4 month follow-up visit (or 6 months from baseline), based on the blinded physicians’ assessment, four out of ten patients (40%) demonstrated acne scar improvement of 1–25%, five patients (50%) had an improvement of 26–50%, and one patient (10%) showed an 51–75% improvement after three FRACTIONAL LASER treatments (Fig. 3). All the patients were satisfied with the extent of improvement and their degree of satisfaction in most cases paralleled and in some cases exceeded the physicians’ assessment. No patient experienced worsening of acne scars during the follow-up period. Patients rated discomfort as moderate during laser treatments.

acne scar fig 3

A 22-year-old female with atrophic acne scars: (A) at baseline and (B) clinical appearance 4 months after three 1550 nm erbium-doped non-ablative fractional laser (FRACTIONAL LASER) treatments (or 6 months from baseline); (C) at baseline, and (D) clinical appearance at 6 months from baseline with no treatment (control side).

 

 

DISCUSSION

Acne scarring is a common and challenging problem confronting dermatologists. A variety of modalities have been used to treat acne scars, with varying degrees of success. Laser and energy based therapy options available to patients for treating acne scars have expanded dramatically, and continue to grow. Multiple published studies have demonstrated that FRACTIONAL LASER can be successfully utilized in the treatment of all forms of atrophic acne scarring (ice-pick, boxcar, and rolling scars) with a very favorable safety profile .

Considering that acne scars often have a deleterious psychological impact on affected individuals, early effective treatment would be beneficial. However, the current non-evidenced based medical recommendation is that patients should wait 6 months after the completion of oral isotretinoin treatment before the safe initiation of laser treatment. This recommendation is based on observational case reports of poor wound healing and atypical scarring in dermabrasion or laser (488 nm argon laser and 585 nm pulsed dye laser) treated patients who were taking or who recently took oral isotretinoin [1-5]. It is important, however, to note that these published reports date back to the 1980s and 1990s (before FRACTIONAL LASER technology). In addition, such reports are rare and mostly limited to patients who received dermabrasion, which can have a higher risk profile than FRACTIONAL LASER.

Given the lack of strong scientific evidence to substantiate the claims about poor wound healing in isotretinoin patients, recent literature has challenged the current recommendation to wait 6 months after the completion of oral isotretinoin treatment. There are a few case reports and retrospective cohort studies in the literature showing lack of adverse effects after laser procedures in isotretinoin patients [6-8, 13-16]. Khatri and his colleagues initially published case reports supporting safety and absence of complications such as atypical scarring or keloid formation after laser hair removal using long-pulse diode, flash lamp, and long-pulsed Nd:YAG lasers in patients receiving oral isotretinoin [13-15]. More recently, Khatri et al. published a case that reported safety of ablative and FRACTIONAL LASER resurfacing in isotretinoin patients [16]. In the clinical context of acne scar revision, two retrospective studies (both with at-least 20 subjects receiving 0.5–1 mg/kg of isotretinoin per day) reported that ablative carbon dioxide (CO2) resurfacing for acne scarring conducted during and/or within 1–3 months of isotretinoin treatment is safe without any adverse effects on healing [6, 7]. Another study that evaluated treatment of acne and acne scars with concomitant use of 1550 nm FRACTIONAL LASER with low-dose isotretinoin (10 mg/day) suggested improved efficacy without any adverse effects when compared with controls [8]. Furthermore, a recently published systematic review article found insufficient evidence to support delaying manual dermabrasion, superficial chemical peels, cutaneous surgery, laser hair removal, and fractional ablative and nonablative laser procedures for patients who are currently taking or have recently completed isotretinoin therapy [17].

Despite the increasing number of recent evidence showing safety of lasers in patients recently treated with isotretinoin, most physicians still advise patients to wait 6 months after completion of isotretinoin therapy before laser treatment. In a recently published study surveying 220 nationally recognized experts in cutaneous laser surgery [18], there were only a small number of physicians who would recommend that patients receive FRACTIONAL LASER, fractional ablative or fully ablative lasers within 6 months of isotretinoin use (27%, 11%, and 3%, respectively). Despite these concerns, over three-fourths of experts (76%) reported to have never observed in their own clinical practices any cases of complications arising in patients treated with laser while receiving isotretinoin or within 6 months of completing a course of therapy. Common concerns among respondents regarding isotretinoin patients were the risks of poor wound healing and scarring, but the most often reported concern was medicolegal risk (74%). Clearly, medicolegal concerns seem to have a disproportionate impact on treatment recommendations for these patients.

The results of our study (patients demonstrated normal wound healing and no new hypertrophic or keloidal scars were observed with laser treatments) challenge the previous non-evidence based recommendations to withhold laser treatment in patients recently treated with isotretinoin. Our study contributes to the discussion that lasers may be safe to use for acne scar treatment when conducted within 6 months of completing a course of isotretinoin therapy. A major advantage of our randomized clinical study was its split-face self-controlled design, which helped minimize any confounding factors. In addition, all wound healing and adverse event evaluations were based on in-person evaluations rather than photographs, enabling observers to detect subtle changes.

Limitations of our study include small sample size with all female patients, lack of patients with darker skin types (Fitzpatrick skin types IV–VI), a short follow-up period (4 months after the last treatment), and lack of histological examination to objectively evaluate the wound healing process post laser treatment. Although our results are promising and significant, other larger studies with diverse patient population and longer follow-up periods as well as histopathological evaluation are needed to further challenge the current dogma and to be certain that FRACTIONAL LASER treatment for acne scarring is safe within 1 month of completing oral isotretinoin treatment.

 

CONCLUSION

In summary, FRACTIONAL LASER treatment for acne scarring appears to be well tolerated within 1 month of completing oral isotretinoin treatment as all study patients showed normal wound healing, and neither hypertrophic scars nor keloids were observed. Most study patients demonstrated a satisfactory improvement in acne scarring after FRACTIONAL LASER treatments. Thus, as dermatologists we need to reevaluate the current recommendation to wait 6 months after completion of oral isotretinoin treatment for acne scar revision with lasers. This widely accepted recommendation is likely more influenced by medicolegal concerns than true evidence-based studies, preventing acne scar patients from receiving early and effective laser treatments.

Abstract

Background and Objective

Based on reports of poor wound healing and scarring, it is currently recommended that patients wait 6 months after completion of oral isotretinoin therapy before the safe initiation of laser treatment. Our aim was to evaluate the safety of non-ablative fractional laser (FRACTIONAL LASER) treatment for acne scars within 1 month after isotretinoin therapy.

 

Study Design/Methods

This was a randomized split-face controlled trial involving 10 patients with acne scars who had completed isotretinoin treatment. All patients received three treatments each spaced 4 weeks apart with an erbium-doped 1550 nm FRACTIONAL LASER on one side of the face within 1 month after isotretinoin therapy. The untreated side acted as a control. Wound healing and adverse effects as well as acne scar improvement were evaluated by two blinded dermatologists.

 

Results

All patients demonstrated normal wound healing post FRACTIONAL LASER treatments, and neither hypertrophic scars nor keloids were observed. Acne scar improvement was satisfactory.

 

Conclusion

FRACTIONAL LASER treatment for acne scarring appears to be well tolerated within 1 month of completing isotretinoin treatment. Dermatologists should reevaluate the current recommendation to wait 6 months after isotretinoin treatment for acne scar revision with lasers. Other larger studies are necessary to further challenge this dogma. Lasers Surg. Med. 49:886–

890, 2017. © 2017 Wiley Periodicals, Inc.

 

INTRODUCTION

Current recommendations to avoid laser treatment for 6 months after the last dose of oral isotretinoin are based on reports published decades ago of delayed wound healing, atypical scarring and keloid formation in the setting of isotretinoin treatment [1-5]. Acne scarring can be psychologically detrimental, and withholding potentially effective treatments such as laser resurfacing during and after isotretinoin therapy can negatively impact a patient’s quality of life. More recent retrospective cohort studies have challenged this current recommendation and suggested that laser resurfacing (ablative and non-ablative) may be safe for acne scarring when conducted during and/or within 1–3 months of isotretinoin treatment [6-8]. However, to the authors’ knowledge there are no randomized split-face controlled trials that have addressed this issue. Thus, this study was designed as a randomized split-face controlled trial to evaluate the safety of non-ablative fractional laser (FRACTIONAL LASER) treatment for atrophic facial acne scars within 1 month of completing oral isotretinoin treatment (total cumulative isotretinoin dose of ≥120 mg/kg).

METHODS

Patient Characteristics

In this single-blinded, randomized, split-face controlled study, 10 patients from the University of Utah, Department of Dermatology were selected, and signed written informed consent were obtained. The study was approved by University of Utah Institutional Review Board. Patients, aged 18 years or older, with mild to moderate atrophic facial acne scars of all types (icepick, boxcar, rolling) who had completed oral isotretinoin treatment (total isotretinoin cumulative dose of ≥120 mg/kg) were enrolled. Exclusion criteria included concurrent pregnancy or lactation, patients with a history of hypertrophic scars or keloids, porphyria or photosensitivity, immunosuppression, active infection or any laser/cosmetic treatments in the previous 6 months.

Table 1 summarizes the patients’ demographic characteristics and the details of their isotretinoin and laser treatments. There were 10 females with an age range 18–36 years (mean 24.5 years) and Fitzpatrick Skin Types I–III. The range of total cumulative dose of isotretinoin was 125–325 mg/kg (mean 172.34 mg/kg).

Table 1. Patient Demographic Data and Treatment Details

Patient Age, years Sex Skin type Total period of oral isotretinoin treatment, months Total cumulative dose of oral isotretinoin, mg/kg Interval between oral isotretinoin and laser treatment, weeks Side of the face treated with laser
1 22 F I 6 182.1 1 Right
2 28 F I 6 161.9 4 Right
3 31 F I 6 157.1 2 Left
4 18 F III 5 125.0 1 Right
5 18 F I 5 173.1 4 Right
6 22 F III 6 150.0 2 Right
7 22 F I 6 325.0 4 Right
8 28 F I 6 161.9 3 Left
9 20 F III 7 147.3 2 Left
10 36 F I 7 140.0 3 Left

 

Laser Treatments

All patients were randomly assigned (via coin flip by study coordinator) to have one side of their face treated within 1 month of completing oral isotretinoin treatment with a non-ablative fractional 1550 nm erbium-doped fiber laser (Fraxel® DUAL Laser System, Solta Medical, Inc., Hayward, CA), while the untreated side of each subject’s face served as a control. All laser treatments were performed by the same dermatologist.

For patients with documented histories of herpes labialis, antiviral prophylaxis (oral valacyclovir 500 mg twice a day for 5 days, starting the day before each laser treatment) was prescribed. All patients were instructed to apply Benzocaine 20%, Lidocaine 8%, Tetracaine 4% cream to the treated side of the face 1 hour prior to treatment. Laser fluences ranged from 35 to 40 mJ/microthermal zone (MTZ) and eight passes per treatment session were performed. Treatment levels varied from 7 to 10 corresponding to treatment coverage of 20–35% with total energies of 2–3 kJ delivered per session. Each patient underwent three treatment sessions at intervals of 4 weeks. Post-treatment instructions included the use of a mild cleanser, sunscreen and sun avoidance, and a cream based moisturizer several times daily for the first 3–4 days after each treatment session.

 

Outcome Assessments

The patients were re-evaluated 7 days after each laser treatment, 4 weeks after each laser treatment, and a final assessment was performed 4 months after the last treatment (6 months from baseline). These evaluations were done in person by two blinded dermatologists. Photographs were obtained at baseline, before each treatment session, throughout the follow-up period, and at the final assessment.

The primary outcome measure included wound healing and adverse events related to laser treatments. These were performed in-person by a blinded dermatologist at each follow-up visit. Wound healing was graded on a 2-point scale (0 = appropriate, 1 = non-appropriate). Parameters, including erythema, edema, blistering, crusting, new atypical scarring or keloids, and hyperpigmentation, were graded on a 4-point scale (0 = absent, 1 = mild, 2 = moderate, and 3 = severe).

Secondary outcomes included improvement of acne scarring and patient satisfaction with the treatment. Improvement in acne scarring was graded at the final follow-up visit (4 months after the last laser treatment) by two independent blinded dermatologists using digital photographs and a quartile grading scale (1 = 1% to 25%, 2 = 26% to 50%, 3 = 51% to 75%, 4 = greater than 75%). The overall improvement in the clinical grade was assessed by averaging the two dermatologists’ grade scores. The same scale was also used to assess patient satisfaction at the end of the study. Lastly, patients also evaluated the intensity of pain during each treatment session using a visual analogue scale (0 = absence of pain, 10 = most severe pain).

 

RESULTS

All 10 patients underwent three FRACTIONAL LASER sessions and completed each follow-up visit. As expected, immediately after each laser treatment, the authors observed moderate erythema on the treated side of the face. All patients showed complete reepithelialization and normal wound healing at the 7 days follow-up visit after laser treatments (Figs. 1B and 2B). No new hypertrophic scars or atypical keloids were observed at the follow-up visits, including the final 4 month follow-up (Figs. 1C and 2C). The adverse events during the follow-up periods were minor, temporary, and expected (mild erythema and edema that resolved within a few days of laser treatment). Furthermore, no blistering, crusting, or hyperpigmentation were noted at the follow-up visits.

acne scars fig 1

Photographs of a patient with 1550 nm erbium-doped non-ablative fractional laser (FRACTIONAL LASER)-treated side of the face: (A) at baseline, (B) at 7 days after first FRACTIONAL LASER treatment, (C) at 4 months after last FRACTIONAL LASER treatment (or 6 months from baseline).

 

Photographs of a patient with 1550 nm erbium-doped non-ablative fractional laser (FRACTIONAL LASER)-treated side of the face: (A) at baseline, (B) at 7 days after first FRACTIONAL LASER treatment, (C) at 4 months after last FRACTIONAL LASER treatment (or 6 months from baseline).

At the final 4 month follow-up visit (or 6 months from baseline), based on the blinded physicians’ assessment, four out of ten patients (40%) demonstrated acne scar and wrinkles improvement of 1–25%, five patients (50%) had an improvement of 26–50%, and one patient (10%) showed an 51–75% improvement after three FRACTIONAL LASER treatments (Fig. 3). All the patients were satisfied with the extent of improvement and their degree of satisfaction in most cases paralleled and in some cases exceeded the physicians’ assessment. No patient experienced worsening of acne scar, skin tightening and wrinkle removal during the follow-up period. Patients rated discomfort as moderate during laser treatments.

acne scar fig 3

 

A 22-year-old female with atrophic acne scars and skin tightening: (A) at baseline and (B) clinical appearance 4 months after three 1550 nm erbium-doped non-ablative fractional laser (FRACTIONAL LASER) treatments (or 6 months from baseline); (C) at baseline, and (D) clinical appearance at 6 months from baseline with no treatment (control side).

 

 

DISCUSSION

Acne scarring and wrinkles is a common and challenging problem confronting dermatologists. A variety of modalities have been used to treat acne scars and wrinkle, with varying degrees of success. Laser and energy based therapy options available to patients for treating acne scars have expanded dramatically, and continue to grow [9, 10]. Multiple published studies have demonstrated that FRACTIONAL LASER can be successfully utilized in the treatment of all forms of atrophic acne scarring (ice-pick, boxcar, and rolling scars) with a very favorable safety profile [11, 12].

Considering that acne scars and skin tightening often have a deleterious psychological impact on affected individuals, early effective treatment would be beneficial. However, the current non-evidenced based medical recommendation is that patients should wait 6 months after the completion of oral isotretinoin treatment before the safe initiation of laser treatment. This recommendation is based on observational case reports of poor wound healing and atypical scarring in dermabrasion or laser (488 nm argon laser and 585 nm pulsed dye laser) treated patients who were taking or who recently took oral isotretinoin [1-5]. It is important, however, to note that these published reports date back to the 1980s and 1990s (before FRACTIONAL LASER technology). In addition, such reports are rare and mostly limited to patients who received dermabrasion, which can have a higher risk profile than FRACTIONAL LASER.

Given the lack of strong scientific evidence to substantiate the claims about poor wound healing in isotretinoin patients, recent literature has challenged the current recommendation to wait 6 months after the completion of oral isotretinoin treatment. There are a few case reports and retrospective cohort studies in the literature showing lack of adverse effects after laser procedures in isotretinoin patients [6-8, 13-16]. Khatri and his colleagues initially published case reports supporting safety and absence of complications such as atypical scarring or keloid formation after laser hair removal using long-pulse diode, flash lamp, and long-pulsed Nd:YAG lasers in patients receiving oral isotretinoin [13-15]. More recently, Khatri et al. published a case that reported safety of ablative and FRACTIONAL LASER resurfacing in isotretinoin patients [16]. In the clinical context of acne scar revision, two retrospective studies (both with at-least 20 subjects receiving 0.5–1 mg/kg of isotretinoin per day) reported that ablative carbon dioxide (CO2) resurfacing for acne scarring and wrinkle removal conducted during and/or within 1–3 months of isotretinoin treatment is safe without any adverse effects on healing [6, 7]. Another study that evaluated treatment of acne and acne scars and wrinkle removal with concomitant use of 1550 nm FRACTIONAL LASER with low-dose isotretinoin (10 mg/day) suggested improved efficacy without any adverse effects when compared with controls [8]. Furthermore, a recently published systematic review article found insufficient evidence to support delaying manual dermabrasion, superficial chemical peels, cutaneous surgery, laser hair removal, and fractional ablative and nonablative laser procedures for patients who are currently taking or have recently completed isotretinoin therapy [17].

Despite the increasing number of recent evidence showing safety of lasers in patients recently treated with isotretinoin, most physicians still advise patients to wait 6 months after completion of isotretinoin therapy before laser treatment. In a recently published study surveying 220 nationally recognized experts in cutaneous laser surgery [18], there were only a small number of physicians who would recommend that patients receive FRACTIONAL LASER, fractional ablative or fully ablative lasers within 6 months of isotretinoin use (27%, 11%, and 3%, respectively). Despite these concerns, over three-fourths of experts (76%) reported to have never observed in their own clinical practices any cases of complications arising in patients treated with laser while receiving isotretinoin or within 6 months of completing a course of therapy. Common concerns among respondents regarding isotretinoin patients were the risks of poor wound healing and scarring, but the most often reported concern was medicolegal risk (74%). Clearly, medicolegal concerns seem to have a disproportionate impact on treatment recommendations for these patients.

The results of our study (patients demonstrated normal wound healing and no new hypertrophic or keloidal scars were observed with laser treatments) challenge the previous non-evidence based recommendations to withhold laser treatment in patients recently treated with isotretinoin. Our study contributes to the discussion that lasers may be safe to use for acne scar and wrinkle treatment when conducted within 6 months of completing a course of isotretinoin therapy. A major advantage of our randomized clinical study was its split-face self-controlled design, which helped minimize any confounding factors. In addition, all wound healing and adverse event evaluations were based on in-person evaluations rather than photographs, enabling observers to detect subtle changes.

Limitations of our study include small sample size with all female patients, lack of patients with darker skin types (Fitzpatrick skin types IV–VI), a short follow-up period (4 months after the last treatment), and lack of histological examination to objectively evaluate the wound healing process post laser treatment. Although our results are promising and significant, other larger studies with diverse patient population and longer follow-up periods as well as histopathological evaluation are needed to further challenge the current dogma and to be certain that FRACTIONAL LASER treatment for acne scarring and skin tightening is safe within 1 month of completing oral isotretinoin treatment.

 

CONCLUSION

In summary, FRACTIONAL LASER treatment for acne scarring and wrinkle removal appears to be well tolerated within 1 month of completing oral isotretinoin treatment as all study patients showed normal wound healing, and neither hypertrophic scars nor keloids were observed. Most study patients demonstrated a satisfactory improvement in acne scarring and skin tightening after FRACTIONAL LASER treatments. Thus, as dermatologists, we need to reevaluate the current recommendation to wait 6 months after completion of oral isotretinoin treatment for acne scar and wrinkle removal revision with lasers. This widely accepted recommendation is likely more influenced by medicolegal concerns than true evidence-based studies, preventing acne scar and wrinkles patients from receiving early and effective laser treatments.

Important notice: this post is an edited copy of an article entitled “Safety of non-ablative fractional laser for acne scars within 1 month after treatment with oral isotretinoin: A randomized split-face controlled trial” for Smart et al., published at the journal of lasers in surgery and medicine

 

 

Keywords

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Fact of Edmonton
In Edmonton, showers and thunderstorms are normally short. However, most rain in the city occurs in July.
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2018-06-29T14:45:51+00:00

About the Author:

Ph.D., MSc, CDE, CRE, APA, MBA candidate, Director of Albany Cosmetic and Laser Centre INC

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