Consensus Statement: Most Skin Procedures OK With Retinoids

Diana Swift

June 28, 2017

A new consensus statement says it is not necessary to postpone elective skin procedures for patients with concurrent or recent systemic isotretinoin therapy.

The review-based consensus statement was published online June 28 in JAMA Dermatology.

"This systematic review 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," Leah K. Spring, OD, a dermatologist at Naval Hospital (recently renamed Naval Medical Center) Camp Lejeune in Jacksonville, North Carolina, and colleagues write.

The researchers conducted a review of 32 publications reporting on 1485 procedures. The analyses ranged from case series and reports to cohort studies, systematic reviews, and randomized clinical trials.

The consensus statement recommends against mechanical dermabrasion, which may be associated with abnormal scarring in this patient population, and fully ablative laser procedures, for which there is insufficient evidence of safety, the authors add.

For more than 3 decades, the prevailing wisdom has been to delay cutaneous interventions for 6 to 12 months, as isotretinoin can cause hypertrophic scarring and delayed healing. This idea originated from three small case series involving mechanical dermabrasion in a handful of patients who had recent or concomitant oral retinoid therapy conducted during the 1980s. For example, in 1985, Henry Roenigk Jr and colleagues reported that two of 11 such patients given mechanical dermabrasion developed keloids, although nine healed normally.

"In our consensus-based assessment, these initial cases presented a hypothesis to be tested, rather than the foundation for medical dogma on which more than 30 years of clinical practice was built," Dr Springer and coauthors write.

They note that avoiding procedural interventions for up to 12 months after recent or concurrent isotretinoin for moderately to severely inflammatory acne runs counter to the imperative of early intervention and may prolong the physical and psychological scars of acne-associated disfigurement.

And as scar-ameliorating and resurfacing technology advances, a dichotomy has appeared between research and practice, they write. "This gap may be explained by the phenomenon of medical evidence evaluation bias, wherein physicians are more willing to abandon a potentially harmful practice with little evidence of harm than to adopt a potentially beneficial one."

This bias was evident in a recent survey of laser surgery experts, in which 70% said medicolegal concerns drove their clinical decisions for isotretinoin patients, the authors write. In addition, 69% of respondents were concerned about atypical or poor wound healing, 66% about scarring, and 49% about hypertrophic or keloidal scarring, despite 76% having never seen any such complications in their clinical practices.

"With the information presented in this article, physicians may have an evidence-based discussion with patients regarding the known risk of cutaneous surgical procedures in the setting of systemic isotretinoin treatment," the authors conclude. "For some patients and some conditions, an informed decision may lead to earlier and potentially more effective interventions." They call for high-quality well-controlled prospective studies in this area.

Several authors report financial relationships with companies including Amway, Allergan, Galderma, Merz, Sciton, Leo, Valeant, Lutronic, Sun Pharma/Ranbaxy, Promius Pharmaceuticals, Lumenis, Cynosure, Candela, Cutera, Syneron Candela, Thermi, Avon, PhotoSonix, Sienna, Unilever, Rodan Fields, Foamix, and Dr Reddy's Laboratories.

JAMA Dermatol. June 28, 2017. Full text

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