Isotretinoin and timing of procedural interventions: Clinical implications and practical points

Background

For decades, the notion that elective surgeries and cutaneous procedures should be postponed for 6–12 months in patients on, or recently administered with isotretinoin, has been widely accepted. However, some recent studies showed the need for a change in this regard.

Method

Here, we reviewed the existing data in this regard through searching on PubMed, Google Scholar, and Scopus. All of the relevant papers published in English, until October, 2022, which we could access to their full-texts, were included.

Results

We found some recommendations made by plastic surgeons, dermatologists, ENT surgeons, ophthalmologists, orthopedic surgeons, and dentists regarding the correct timing of procedural interventions in patients on, or recently administered with isotretinoin and tried to summarize them to provide a practical guide for clinicians.

Conclusion

Physicians may discuss with patients regarding the known risk of abnormal wound healing in the setting of systemic isotretinoin treatment and suggest that, when possible, surgical procedures be postponed until the activity of the retinoids has time to subside. It is even more important regarding patients with darker skin phototypes to follow an even more strict guideline.     

Treatment of multiple eccrine hidrocystoma with oral isotretinoin following erbium-yttrium aluminum garnet laser

Eccrine hidrocystomes (EH) are benign cystic tumors of dermal eccrine ducts. There is still no gold standard treatment option for EH because of the large number of lesions, the risk of cicatrization and the different treatment options offered. We offer combined oral isotretinoin and following erbium-yttrium aluminum garnet laser treatment as an alternative treatment option in difficult patients with EH.     

Treatment of angiokeratoma of the vulva with pulsed dye laser therapy

Abstract

Angiokeratoma of the vulva is relatively rare with few cases reported in the literature. The lesions are usually asymptomatic, but clinical presentations can include bleeding and vulval pruritus. Treatments for symptomatic cases include surgical excision, cryotherapy and argon or carbon dioxide laser therapy. We present a case series of patients who have been successfully treated with pulsed dye laser therapy. This was performed in the outpatient setting without the need for local anaesthesia. All patients had resolution of their symptoms. This treatment modality to our knowledge has not been reported in the literature.     

A novel explanation for the healing effect of the Er:YAG laser during skin rejuvenation

Abstract

The popularity of cutaneous laser resurfacing has soared in recent years. Ablative laser skin rejuvenation with carbon dioxide (CO₂) and erbium:yttrium-aluminum-garnet (Er:YAG) lasers has been popularized and their side effects individually reported. It has been suggested that initial collagen contraction and thermal damage modulate wound healing. Progress in laser technology permits precise tissue removal and minimal thermal damage. However, mechanisms for cosmetic improvement have not yet been completely determined. In the present short communication, we would like to suggest a possible mechanism for the healing effects exerted by the Er:YAG laser.     

Erbium:yttrium aluminum garnet laser versus Q-switched neodymium:yttrium aluminum garnet laser for the treatment of xanthelasma palpebrarum

Background: Several lasers have been used for the treatment of xanthelasma palpebrarum (XP), such as Q-switched neodymium:yttrium aluminum garnet (QSNd:YAG) and erbium:yttrium aluminum garnet (Er:YAG) laser. Up to now, a comparative study among these laser options in the treatment of XP has not been reported. Objective: The aim of this study was to compare the clinical efficacy and response rates of QSNd:YAG and Er:YAG in the treatment of XP. Methods: Sixty patients with a total of 102 XP lesions were randomly and equally divided into two groups. The first group was treated with QSNd:YAG at a fluence of 10 joule/cm², 10 Hz and 2 mm spot size, and the second group was treated with Er:YAG at 200-300 millijoule, 4 Hz and 2 mm spot size. Results: In the Er:YAG group, the percentage of patients who required 3 or 4 sessions and wound healing time were higher compared to those of the QSNd:YAG group. Furthermore, the percentage of patients who had an improvement score of 4 was higher in the Er:YAG than that in the QSNd:YAG group. Conclusion: Er:YAG is an efficient, successful and minimally invasive method without long-lasting adverse effects.     

Treatment of disseminated superficial actinic porokeratosis (DSAP) with the Q‐switched ruby laser

Background: Disseminated superficial actinic porokeratosis (DSAP) is one clinical subtype of porokeratosis, a cutaneous disorder of keratinization. A variety of approaches may be used to treat DSAP. The ruby laser appears to be a promising option for DSAP treatment. Traditionally, the ruby laser is used to treat hair removal and lesions involving hyperpigmentation. Its use may be further applied to treat the hyperpigmented lesions of DSAP. Objective: This study examines the efficacy of the ruby laser in treating a case of DSAP. Methods: A 48‐year‐old female, with a history of pseudoxanthoma elasticum and DSAP, received three Q‐switched ruby laser treatments (694?nm) to over 50 sites on the lower and upper extremities. Clinical outcome and patient satisfaction was followed‐up. Results: Minimal to moderate erythema and appropriate whitening was noted after each treatment. The patient tolerated treatments well and hyperpigmentation and erythema of the majority of the lesions decreased. The patient was very pleased with the results and reports satisfactory cosmetic outcome 3 months later. Conclusion: The results obtained from the current case suggests that the ruby laser is moderately successful in treating DSAP and may still provide a good alternative to other available treatments. Further studies are needed to investigate the potential of combined ruby laser treatment for DSAP and to determine the appropriate laser pulse duration and fluence for effective treatment.     

Pneumatic skin flattening (PSF): A novel technology for marked pain reduction in hair removal with high energy density lasers and IPLs

Background: Intense pulsed light (IPL) aesthetic treatment, such as hair removal from large areas, is often very painful. The problems of pain and discomfort can be divided into two different phases: immediate acute pain and the long‐term, milder, post‐treatment discomfort also associated with erythema. The immediate acute pain is felt during each treatment pulse and can accumulate to an intolerable sensation after a few shots, resulting in the necessity of either using topical analgesic creams which have several limitations or else to considerably slow down the process and/or apply less efficient low‐energy densities. The immediate pain is created by the stimulation of sensory nerves located near the basal layer of the epidermis and adjacent to the treated hair follicles. There is an interest in a technology which would significantly reduce acute pain and post‐treatment erythema, without the necessity of lowering the energy density or speed of treatments. Objectives: To examine the advantages of pneumatic skin flattening (PSF) with negative pressure: (i) for the reduction or elimination of pain, without chilling the skin, during hair removal with high energy density IPLs and pulsed lasers; (ii) for the reduction of post‐treatment erythema; and (iii) for the enhancement of hair removal. Materials and methods: We have removed hair from large areas such as legs and backs with a high‐energy (42?J/cm²) pulsed diode laser and an IPL (15–20?J/cm²). Room temperature gel was applied to the skin before treatment. In all cases but one, skin was not chilled by external cooling devices. We utilized a vacuum chamber and a transparent sapphire window to generate deep negative pressure in the treatment site and flatten the skin against the window. The level of applied vacuum was in the 200–600?mmHg range. We have compared the level of pain (I–V according to a modified McGill Pain Questionnaire) and the efficacy of hair removal on a total of 40 treatment sites The results of the vacuum‐assisted treatment sites were compared with the results on adjacent control areas, obtained without the application of vacuum. Post‐treatment erythema was also compared. Results and conclusions: PSF significantly reduces pain in all patients, even when higher (+30%) treatment energy levels are applied. Skin is well protected thermally by the conductive sapphire window. Post erythema and edema is considerably reduced, as well. Hair removal efficacy is preserved or enhanced. Treatment is faster and is uninterrupted by pain, without the necessity to apply topical anesthetic over a large area. Blood expulsion resulting from flattening the skin has also enabled the treatment of thin hair in light‐skinned patients, using yellow and green wavelengths (540?nm cut‐off filter) and short pulse durations with a higher efficacy than with the 650?nm cut‐off filter.     

New clinical outcomes utilizing a 1064-nm Nd:YAG laser for lipolysis of the torso oblique region

Abstract

Objectives: The safety and efficacy of a 1064-nm Nd:YAG laser (Cynosure, Westford, USA) utilizing a 300-μm optical fiber and a 1-mm diameter micro-cannula were evaluated as a treatment for reduction in the appearance or elimination of unwanted fat in the lower back/flanks (‘love handles’). In addition, the use of the laser for tightening the skin and collagen regeneration in the area of lipolysis was assessed through biopsies. Methods: Ten subjects with unwanted flaccidity and fat deposits in the oblique region of the torso were enrolled in the study. Subjects underwent a single laser lipolysis treatment followed by aspiration of the treatment area. The total tumescence used, laser energy delivered, and tissue removed was recorded for each subject. All subjects had baseline photographs taken and their weight recorded prior to treatment. Pregnancy tests (if applicable) were performed prior to treatment as well. Three subjects had 4-mm biopsies taken at baseline and 6 months to evaluate collagen regeneration. Collagen and elastic tissue fibers were evaluated using special routine stains and histochemical stains designed to highlight these dermal components. Follow-up visits were conducted at 1 week, 1 month, 3 months and 6 months following treatment to evaluate side effects, weight loss and laxity. Additionally, patients kept an evaluation log for each of the first 7 days following treatment. At the 6-month conclusion, patient satisfaction was recorded. Results: Laser lipolysis procedures with subsequent aspiration were performed bilaterally on the flanks of 10 subjects. At 1-week post-treatment, 80% of the subjects demonstrated reduction in laxity. Similarly, 100% of patients showed visible skin improvement at 1 month, with 70% recording a score of 2 (good improvement). Three-month evaluations yielded one patient (10%) with a score of 3 (excellent improvement) and seven patients (70%) with a score of 2. Histology reports confirmed the visual clinical outcomes, describing thicker collagen bundles at 6 months, as well as coagulation of blood vessels and adipocytes. Side effects were mild and transient in nature, and the majority of discomfort, redness, bruising, swelling, and tingling experienced was resolved within 1 week post-procedure. The treatment was well tolerated and efficacious, with 90% of patients rating their results as good or excellent and 100% of patients reporting that they would recommend the procedure. Conclusion: The use of the 1064-nm Nd:YAG laser with a 300-μm fiber demonstrated the ability to treat adipose tissue in the highly vascular flank area with favorable efficacy and safety. Patients exhibited a quick recovery time and excellent tolerance, as well as visually improved skin.     

Cosmetic therapies for Chinese patients with acne taking concomitant or recent intake of oral isotretinoin: A retrospective study

Background

The current standard recommendation is to initiate the cosmetic therapies after discontinuing taking oral isotretinoin for at least 6 months. However, this recommendation has been questioned in several recent publications, and it is difficult to operate in clinical practice as early initiation of effective treatment is desirable for patients with acne sequelae.

Objective

The purpose of this study is to evaluate the efficacy and safety of chemical peeling and light/laser or radiofrequency treatments combined with oral isotretinoin for patients with acne vulgaris and acne scars.

Method

A retrospective study of 511 patients on/or recently administered with isotretinoin treated with glycolic acid, intense pulsed light, nonablative fractional laser, fractional radiofrequency, and ablative carbon dioxide laser. A total of 1352 interventions were performed. The medical follow-up lasted for at least 1 year. The efficacy and safety of different procedures were evaluated.

Results

A total of 511 patients, who were treated with isotretinoin orally or stopped for <6 months, received 477 sessions of glycolic acid chemical peeling treatment, 588 sessions of intense pulsed light treatment, 61 sessions of nonablative fractional laser treatment, 101 sessions of fractional radiofrequency treatment, and 125 sessions of ablative fractional carbon dioxide laser treatment. No hypertrophic scars and keloids were found, and the incidence of serious adverse reactions such as scarring, erythema, blisters, and postinflammatory hyperpigmentation did not increase.

Conclusions

It is safe to perform skin procedures in patients with acne and acne scars during or after discontinuation of isotretinoin for <6 months. Invasive treatments such as ablative fractional carbon dioxide laser treatment can be performed, as appropriate, by an experienced physician. The guideline of avoiding chemical and physical procedures in such patients taking oral isotretinoin should to revised.     

Effects of intense pulsed light in microstomia in patients with systemic sclerosis: A pilot study

Introduction: The effects of intense pulsed light (IPL) on collagen structures are well known in the treatment of photodamaged skin. Objective: The objective of this study was to investigate the effect of IPL on sclerotic skin by treating patients with microstomia due to systemic sclerosis. Methods and materials: 13 patients all with microstomia and systemic sclerosis were treated with IPL, PR (530-750 nm filter) and/or VL (555-950 nm filter) applicator. They were treated in the perioral area 8 times with 3–4 weeks of interval and follow-up for 6 months. The outcomes were the inter-incisal distance and the inter-ridge distance. Results: A significant increase in mouth opening of 4.1 mm (95% confidence interval, 1726–6638, p < 0.005) was found in the inter-ridge distance when comparing the distance before treatment with the distance at six-month follow-up. No significant difference was found in the inter-incisal distance. The patients experienced improved mobility and better control of lip movements after the treatments. Conclusion: IPL can improve the inter-ridge distance between the lips in patients with microstomia due to systemic sclerosis but does not affect the inter-incisal distance, which is also dependent on the mobility of the mandibular joints. This treatment can be considered an adjunctive therapy in patients with microstomia due to systemic sclerosis.     

Picosecond alexandrite laser is superior to Q-switched Nd:YAG laser in treatment of minocycline-induced hyperpigmentation: A case study and review of the literature

Background: Minocycline is a commonly prescribed tetracycline antibiotic used for the treatment of a number of dermatological conditions including acne and rosacea. Long-term adverse effects of minocycline include cutaneous hyperpigmentation. Various treatment options have been suggested for the treatment of minocycline pigmentation. We report a case of a patient on long-term low-dose minocycline for the treatment of rosacea with type III minocycline hyperpigmentation. A comparison was made between Q-Switch Nd:YAG and picosecond laser over a nine 9-period with treatments spaced 1 month apart, with a clearance in the patient pigmentation after four treatments with picosecond laser.     

Low dose isotretinoin as an adjuvant therapy for treatment of different clinical variants of warts: A case series

Warts constitute the most frequently observed dermatological manifestations of human papillomavirus (HPV). Although an extensive range of treatments exist for local warts, there is no specific therapy based on high‐quality evidence of notable treatment success or high cure rate, or minimal adverse effects. Recalcitrant warts are, therefore, a common therapeutic problem. This case series refer to 14 immunocompetent patients with recalcitrant warts, who experienced full resolution of their warty lesions when treated with addition of low dose isotretinoin, in a dose of 0.1–0.2 mg/kg/day, for a 3‐month course, with no significant adverse effects. Long‐term remission was noted for up to 3 years with no signs of active lesions. Low dose isotretinoin should be in the priority of the treatment options of recalcitrant warts, alone or in combination.     

Case report: A successful combined treatment of severe lupus miliaris disseminatus faciei with oral isotretinoin and methylprednisolone

Lupus miliaris disseminates faciei (LMDF) is a rare inflammatory dermatosis characterized by an asymptomatic papular eruption in the central face, of which the etiology and pathogenesis are not clear. There is a lack of standard treatment recommendations, especially for severe cases. Here we report a new case of successful treatment of severe LMDF by the combination therapy of oral isotretinoin and methylprednisolone.     

To test or not to test: A study examining the return rates of rosacea patients treated with a pulsed dye laser

Pulsed dye laser (PDL) is an effective treatment option for erythematotelangiectatic rosacea. The use of a test spot allows patients to experience the procedure on a small area prior to further treatment. The purpose of this study was to elucidate whether the use of a no charge test spot influenced return rates for further PDL treatment. Data were obtained retrospectively using International Classification of Diseases (ICD)-10 codes for rosacea. Sixty charts were identified: 26 patients initially received a PDL test area free of charge, whereas 34 patients initially underwent full PDL treatment. Patients who experienced the test spot laser treatment had a lower return rate compared to those that directly underwent full PDL treatment. However, this difference was not statistically significant (Fisher’s exact test p = 0.2883). Future studies evaluating and identifying factors that influence PDL return rates are needed.

Abbreviations: ETR: Erythematotelangiectatic rosacea; PDL: pulsed dye laser; ICD: International classification of diseases     

Laser-assisted hair removal for facial hirsutism in women: A review of evidence

Poly cystic ovarian syndrome (PCOS) has been described as the common diagnosis for hirsutism in women. Facial hirsutism is by far the most distressing symptom of hyperandrogenism in women with PCOS. A statistically significant improvement in psychological well-being has been reported in patients with PCOS allocated for laser-assisted hair removal. The theory of selective photothermolysis has revolutionized laser hair removal in that it is effective and safe, when operated by sufficiently trained and experienced professionals. Long-pulsed ruby (694 nm), long-pulsed alexandrite (755 nm), diode (800–980 nm), and long-pulsed Nd:YAG (1064 nm) are commercially available laser devices for hair removal most widely studied. This article will introduce the fundamentals and mechanism of action of lasers in hair removal, in a contemporary literature review looking at medium to long term efficacy and safety profiles of various laser hair removal modalities most widely commercially available to date.     

Curative effects of microneedle fractional radiofrequency system on skin laxity in Asian patients: A prospective,double-blind,randomized, controlled face-split study

Background: To date, no studies compared curative effects of thermal lesions in deep and superficial dermal layers in the same patient (face-split study). Objective: To evaluate skin laxity effects of microneedle fractional radiofrequency induced thermal lesions in different dermal layers. Methods and Materials: 13 patients underwent three sessions of a randomized face-split microneedle fractional radiofrequency system (MFRS) treatment of deep dermal and superficial dermal layer. Skin laxity changes were evaluated objectively (digital images, 2 independent experts) and subjectively (patients’ satisfaction numerical rating). Results: 12 of 13 subjects completed a course of 3 treatments and a 1-year follow-up. Improvement of nasolabial folds in deep dermal approach was significantly better than that in superficial approach at three months (P=.0002) and 12 months (P=.0057) follow-up. Effects on infraorbital rhytides were only slightly better (P=.3531). Conclusion: MFRS is an effective method to improve skin laxity. Thermal lesion approach seems to provide better outcomes when applied to deep dermal layers. It is necessary to consider the skin thickness of different facial regions when choosing the treatment depth.     

Removal of a toothpick penetrated into foot by Er:YAG laser ablation

Although rare, foot injuries caused by toothpicks can result in serious complications such as severe pain, local inflammation and infection in several days, and a delayed granulamatous foreign-body reaction in weeks or months. For this reason they should be removed from the tissue in the early phase. Here, we report case of penetration injury caused by a toothpick treated using Er: YAG laser ablation.     

Fractional ablative laser skin resurfacing: A review

Abstract

Ablative laser technology has been in use for many years now. The large side effect profile however has limited its use. Fractional ablative technology is a newer development which combines a lesser side effect profile along with similar efficacy. In this paper we review fractional ablative laser skin resurfacing.     

A gender-based comparison of pain tolerance during pulsed dye laser therapy

Abstract

Background: Cosmetic laser treatments are frequently performed without anesthesia in the clinic setting and there is a need to better understand the factors that may impact patient pain levels during these procedures. There has been prior research suggesting that there are significant gender-based differences in pain experiences with a variety of interventions. Aims: We sought to examine the influence of gender and specific emotional factors on pain perception during pulsed dye laser treatments. Patients/Methods: We conducted a questionnaire-based study of 84 adult patients (42 males and 42 females) who underwent facial pulsed dye laser treatments in our clinic for cosmetic purposes. Questionnaires were completed by each patient after his or her initial laser treatment and patients were queried as to their perceived levels of pain during the procedure. Additional information regarding quality of life measures and patient motivation was also collected. Results: Contrary to prior research suggesting lower pain thresholds for women in other clinical or experimental settings, we found no statistically significant differences in mean pain levels reported between patients of each gender. There was a trend toward females being somewhat more likely than males to see the pain of the treatment as justified for an improvement in appearance. Conclusions: Patient motivation and pain tolerance levels may be similar between genders among patients undergoing non-invasive cosmetic procedures. Clinicians may, therefore, expect patients of either gender to tolerate such treatments equally well.