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A pilot study has successfully challenged the current non-evidenced medical recommendation that patients with acne scars should wait six to 12 months after completion of oral isotretinoin treatment before the safe initiation of nonablative fractional laser resurfacing.
Dr. SalujaA pilot study has successfully challenged the current non-evidenced medical recommendation that patients with acne scars should wait six to12 months after completion of oral isotretinoin treatment before the safe initiation of nonablative fractional laser resurfacing.
“The current recommendation is gleaned from case reports of poor healing and atypical scarring in patients treated with dermabrasion who were taking or who recently took oral isotretinoin,” says principal investigator Sandeep Saluja, M.D., a dermatology resident at the University of Utah in Salt Lake City. “It is important to note, however, that these reports date back to the 1980s and 1990s, and none of these reports include the more recently introduced 1550 nm nonablative fractional laser [NAFL] technology.”
Dr. Saluja was inspired to undertake the study last year while treating an 18-year-old patient with severe acne. After completing a course of oral isotretinoin, the patient’s main concern was the lingering acne scarring, especially as she was starting college in the fall. “Even though I knew she would be a great candidate for laser resurfacing, all I could tell her was that my hands are tied, given the current recommendation,” Dr. Saluja says.
All 10 study patients had mild-to-moderate acne scars and had recently finished a course of oral isotretinoin therapy (with a total cumulative dose of at least 120 mg/kg). Within one month of completing their last isotretinoin dose, patients began the first of three NAFL treatments, spaced four weeks apart.
The randomized split-face controlled trial, in which one side of the face was treated with laser and the other side received no treatment, evaluated the safety of NAFL treatment for acne scars within one month after completion of isotretinoin therapy.
The Fraxel DUAL laser system (Solta Medical) was employed at a fluence between 35 to 40 mJ/microthermal zone, along with treatment coverage of 20 to 35%, with total energies of 2-3 kilojoules delivered per session.
Normal wound healing
The two main primary outcomes were wound healing and adverse events, mainly atypical scars and keloid formation.
“Back in the 1980s, there were a few case reports of dermabrasion in isotretinoin patients where patients ended up with poor wound healing and developed atypical scars and keloids,” Dr. Saluja tells Dermatology Times. “Once these findings were in the literature, it was suggested that it would be wise to delay dermabrasion or other aggressive procedures for at least six months to one year after isotretinoin treatment has been discontinued.”
Nonetheless, after completing the three NAFL treatments, all study patients had normal wound healing and none of them had any side effects, including atypical scars and keloid formation, on the treated side of the face. These observations were based on an office visit seven days after each laser treatment and a final follow-up four months after the last laser session.
Each patient was evaluated by two blinded dermatologists, who assessed both photographs and patients in-person to detect subtle changes.
“We were not surprised by these findings, as our hypothesis was that we as dermatologists should not be waiting six months to initiate NAFL treatment,” Dr. Saluja says. “By waiting, we are doing a disservice to our patients, because acne scarring can have a negative impact on quality of life.”
The secondary outcomes of the study were efficacy and patient satisfaction. “All patients were satisfied with the acne scar improvement they saw with laser on the treated side of the face, compared to the untreated side of the face,” Dr. Saluja says.
On average, there was a 25 to 50% improvement in acne scarring, according to Dr. Saluja, who presented study results in April at the annual conference of the American Society for Laser Medicine and Surgery (ASLMS) in San Diego.
Dr. Saluja says that the widely accepted recommendation of delaying laser treatment is probably more influenced by medicolegal issues than true evidence-based studies and the best interest of the patient. In fact, a recently published paper in Dermatologic Surgery journal1 found that the main concern among the experts surveyed about performing laser treatment in isotretinoin patients was medicolegal risks (74%).
Besides being the first randomized trial to challenge the dogma of delaying laser treatment, “We feel a major advantage of our study was the split-face, self-controlled design, which helped minimize any confounding factors,” Dr. Saluja says.
Two study limitations are the small sample size and no histology.
“Regardless, we hope that dermatologists will reevaluate the current recommendation to wait six to12 months after completion of oral isotretinoin treatment for acne-scar revision with laser,” Dr. Saluja says.
Disclosure: Dr. Saluja reports no relevant financial disclosures.
1. Prather HB, Alam M, Poon E, et al. Laser safety in isotretinoin use: A survey of expert opinion and practice. Dermatol Surg. 2017;43(3):357-363.