hey guys Dr Davin Lim board certified dermatologist today we'll be talking about
the use of isotretinoin in other words accutane or oratane in the timing of certain procedures like
lasers micro needling and even things like hair removal so a lot of this talk will be based upon
evidence-based medicine so it's not just hearsay not just how i feel but what's actually out in the
literature and what most dermatologists throughout the world practice so just as a background as you
know patients who are on accutane or attained or isotropic known as the correct name should be used
there are certain warnings in regards to procedures so in the past there's things like
laser resurfacing peels and even simple things like hair removal that you can't have what's
being on this medication but you need that six to twelve months clearance based upon pi or product
information so this has been rewritten and has been rewritten four years ago and it's been
rewritten in many peer-reviewed journals including the big jammer journal which is the journal of
the american medical association so that was done in 2017 many other peer-reviewed journals
have actually revised that so guys just as the background why are dermatologists worried in
regards to accutane in the context of procedures because historically in the 1980s in a couple of
case reports in the 1990s it showed that patients on a relatively high dose of accutane when we're
talking about around one milligram per kilogram per day so let's say if you're 70 kilos that's
70 milligrams or higher per day and had some case reports of early lasers for example argon lasers
and really really deep chemical peels causing horrendous scarring so since then based upon
those case reports there's been a blanket cover by the company initially by roche who manufactured
roaccutane that there has to be a clearance between 6 to 12 months and this stuck with
the medical community for approximately 40 years before it was revamped yeah so as
the dermatologist we know that there's a marked variability in regards to how patients tolerate
accutane so some patients may have horrendous side effects well some patients are just side
effect-free so when we talk about the safety data we've got to actually uh look at i guess the the
cases where there's a lot of uh or the people who are more prone to the side effects and go
cool is this related to the actual uh drug itself or is it related to the procedure and hence
this review articles over the last couple of years so the bottom line is this
as specialists as dermatologists we understand that certain procedures
are compatible uh with the use of oral isotropinoin so which procedures instead of
listing a whole heap of procedures i'll give you the uh two procedures or three procedures
uh which are relatively contraindicated well i wouldn't say real absolute contour indication
so the first one is deep chemical peels so deep chemical peels they're different types
just as a background if you're using something medium to deep so anything more than the tca 30
that's considered a medium depth field so all your jessner tcas um 25 30 percent they should not be
allowed i would say not allowed in extreme uh caution especially when you're doing global
appeals that doesn't apply for tca cross because tca cross whether you're using a 100 tca or
anywhere between 70 to 100 tca or if you're using uh phenol croton oil peels so 88 phenol creatine
oil they're still considered a deep peel but the flip side is that for chemical peels we can class
it as deep peels or medium depth deep peels that are global in other words whole face you can call
it segmental for example if you're doing the upper lip or upper lower lips or around the eyes that's
segmental peeling and then this focal peeling so in the context of scar revision most of the
chemical peels we're using focal chemical peel so there's not segmental and it's not global
so generally speaking you can use tca and you can use phenol croton oils only in focal
applications so that's the first thing no global nothing medium nothing deep global segmental
probably defer that and the second one is ablative laser so ablative lasers include co2 and erbium
resurfacing now co2 and erbium can be done fully ablative in other words 100 of the skin surface
is treated that's called fully ablative laser resurfacing so once again that is relatively
contraindicated if you're doing it superficial if you're doing medium to deep that's an absolute
contraindication so most of us including myself would not do a uh an aggressive uh fully ablative
laser resurfacing because we know skin takes a lot longer to heal up on accutane um so those are
the main two the third one is extensive surgery so if you're doing things like punch excision
or punch elevation or just any one of those basic procedures i don't think there's a problem at all
but if i'm doing something like complex flap surgery or even graph excluding dermal grafts but
just drafting for example in the context of skin cancer for extensive flap surgery or extensive
surgical operations where you know you're excising big portions of skin i probably think that is
that should be deferred until you you've got that clearance now the clearance in regards to the ac
in regards to academic how do we actually figure that out it's hard because there's no guidelines
if you look at the pi or product information they say anywhere between 6 to 12 months
dermatologists realize that well within that one month mark um the drug is out of your system but
your mucocutania side effects in other words the side effects on your lips on your skin on
photosensitivity it may take a couple of weeks sometimes even months before they resolve so
my the way i look at things is i base it upon the history as well so if someone's got extraordinary
muco cutaneous side effects uh drawing with the lips thin skin easily scratch lots of
photosensitivity i give them a much longer wash out compared to someone who's been on the low
dose isotretinoin regime for months or even a year who's got virtually zero um uh side effects yeah
and so with those i may give them a wash out of anywhere between six weeks to three months
before the fully ablative deep fully ablative and also the um extensive surgical procedures
so those are my guidelines guys and that's reflected like i said not only in one or two
journals it's been in peer-reviewed journals where it's multi-center studied over many many years now
does every dermatologist a plastic surgeon follow this the answer is no so your dermatologist may
have their own opinions maybe they don't read the literature i don't know but it's been out there
it's in all the dermatology journals in regards to the safety so once again it's not an absolute
safety you've got to understand guys it's not absolute safety it's based upon relative safety
so you're when we're looking at the side effects from any one of those procedures whether it be
radio frequency micro needling micro needling laser resurfacing chemical peels laser hair
removal we look at that compared to the population base which has not been an isotropic knowing
in the population base has been on relatively i wouldn't say low but within you know anywhere
between five to forty milligrams isotropic but once again your dermatologist will base that upon
your individual side effects and come up with the safety profile based upon you okay the
other thing i would like to touch on is um the other side effects of isotretinoin or accutane
so one thing we know when patients are on this medication it changes the flora of your skin so in
other words your staph colonization in other words the bacteria on your skin actually is increased
this colonization is increased especially intra nasally up your nose and that's why we have
things like colitis in other words chapped lips or cracked lips or infections angular colitis on the
sides of your lips they can all increase uh with uh isotretinoin use so when i perform procedures
when patients are on isotretinoin or accutane even if they're on the low low dose you know
like 10 milligrams or 20 milligrams it's usually my recommendations and my standard of practice
is to prescribe them an antibiotic so there's a relative contraindication with antibiotics
for example like doxycycline minocycline because you can have increased side effects in your brain
increase blood pressure there so we call it benign intracranial hypertension
so most of us prescribe either erythromycin and we normally do it a short course so i normally
go erythromycin twice a day for a period of about seven days after the procedure so the skin's going
to heal up expected heal up time of let's say five six days if you have some mild mucocutania side
effects from accutane it may take you that extra 12 24 hours longer and hence i cover with that
antibiotic for that period of time and once again that's out of safety rather than anything else
what i normally do as well if i'm having patients who i'm doing a for example a
relatively aggressive fractional ablative laser or even rfm radiofrequency microneedling
coupled with subcision i normally ask them to cease the isotretinoin maybe a week before
even three four days before and then pick it back up when the skin heals so it might be another
five to eight to ten days so just by that by by doing that it increases the safety profile
uh and importantly it actually increases the um the healing well it decreases the healing up time
and it can mitigate the side effects from staph colonization so guys this is how i do it your
dermatologist your plastic surgeon will have their own viewpoints in regards to that the last thing
i'll talk about is other procedures which can be allowed with uh isotretinoin why has the big
question i guess is why has the manufacturers of these of this drug yeah of isotropin why
haven't they changed it in the pi or the product information i guess it's pretty easy to understand
because they're probably lazy um it's it's not only that it's much easier to do a blanket cover
rather than revise things based upon um evidence-based medicine so as far as i'm
concerned the product information still says that six to 12 months washout but like i said it's
basically the companies just can't be bothered doing that so the other thing we'll talk about
like the last thing i'll talk about are procedures for example laser hair removal
now even before the revision most dermatologists know that using sensible settings with good lasers
epidermal cooling contact gel all that sort of stuff that can decrease the side effects of
any potential adverse outcomes from laser resurfacing or in this situation hair removal
so in my practice certainly everyone's got the go ahead the green light for um for laser
hair removal based upon those guidelines now if anyone's in doubt it's really easy if anyone's in
doubt someone's got really brittle skin someone who peels very easily gets sunburned scratches
poor wound healing really easy do a test spot so what you want to do is just fire a couple of shots
on the site maybe about two or three shots uh call the patient back or ask them to send you
some photos in the weeks time to have a look is this is the skin healing up uh as expected that's
one way to uh to test and and the other thing as well is just ask yeah so when we're looking at
for side effects we're asking like i mentioned you know whether they when they shave their legs for
example or guides when they show off their face if their skin gets increased fragility that's when
your red flags happen and just go you know what for this patient i might want to reduce
the dose i'm going to speak to the dermatologist to reduce the dose i might want to do test spots
i might want to use a lower fluence a longer pulse duration um so many ways to mitigate a
lot of the risk guys i hope you liked that video it's a short one but it's a it's a problem which
is which we see all the time as consultant dermatologists and i hope it clarifies things
thanks for watching if you like please like share subscribe give me your thoughts see you later bye