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