Is It Safe to Operate on Patients Taking Isotretinoin?

Acne scarring-pathophysiology, diagnosis, prevention and education: Part I

Acne scarring is common and can occur even with effective acne management. In addition, patients with acne scarring suffer from significant psychosocial morbidity, including depression and suicidality. Despite the availability and advancement of therapeutic modalities, treatment for acne scarring is not always optimized and often overlooked in patients with acne encounters. Using acne scarring assessment tools and identifying specific acne scar subtypes allows for a tailored therapeutic approach. Part I of this continuing medical education series covers the pathophysiology and morphology of textural and pigmented acne scars, scarring assessment tools, and medical treatment options. The principles reviewed will aid in approaching and initiating acne scar treatment in the outpatient setting.

Topical Tretinoin in the Management of Thick-skinned Rhinoplasty Patients

Background

Despite the increasing popularity of cosmetic surgeries, some patients still experience skin problems, particularly those with thick nasal skin. Isotretinoin is a commonly used drug for severe acne, and its effects on rhinoplasty aesthetic results have recently been studied. This placebo-controlled clinical trial aimed to investigate the effects of topical tretinoin gel on the cosmetic outcomes of rhinoplasty in patients with thick nasal skin.

Methods

Forty-nine individuals were randomly allocated to either the treatment group or the control group in Mashhad, Iran from 2019 to 2021. The treatment group received topical tretinoin gel (0.05%) beginning on the 31st postoperative day and continued for six months, while the control group received a usual dermatological recommendation as a placebo. Patients were assessed during the first, third, and sixth months after the intervention, and their cosmetic results were evaluated by an expert surgeon and dermatologist.

Results

There were no significant differences in baseline features between the two groups. The median score given by the surgeon was not significantly different between the groups. However, the median score given by the dermatologist was significantly higher in the treatment group during the first, third, and sixth months (P<0.001). Patient satisfaction scores were also significantly higher in the treatment group during the third and sixth months compared to the control group. (P=0.02 and 0.01, respectively).

Conclusion

Topical tretinoin gel could effectively reduce acne in patients with thick nasal skin after rhinoplasty and increase patient satisfaction in the early months following surgery. However, it did not significantly affect final cosmetic outcomes.

Taiwanese Dermatological Association (TDA) consensus recommendations for the definition, classification, diagnosis, and management of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory follicular disease characterized by painful, recurrent, inflamed lesions most commonly occurring in the axillary, inguinal, and anogenital regions. HS can inflict immense physical and psychological impact on patients who suffer from this distressing disease. Management of HS generally requires combining various medical and procedural treatment modalities; however, the disease is often recalcitrant to conventional treatments. In light of recent evidence supporting the effectiveness of biologic agents in the treatment of HS, the Taiwanese Dermatological Association established an expert panel of nine dermatologists to develop consensus statements aimed to provide up-to-date evidence-based guidance in optimizing HS patient management in Taiwan. The recommendations described in the statements were summarized in a management algorithm in terms of general care, topical treatment, systemic treatment, and procedural treatment.

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.

Prosthesis extrusion post total ossicular replacement ossiculoplasty (TORP) following isotretinoin use: A case report and literature review of peri-operative isotretinoin safety

Ossiculplasty is the preferred intervention to restore the mechanism of sound transmission in patients with ossicular deformities. Here, we present a case of a young female who underwent cartilage tympanoplasty with total ossicular replacement prosthesis (TORP) to the right ear. Her recovery was progressing well with signs of postoperative improvements for almost two years until she was started on Isotretinoin 40 mg by her dermatologist. A few months later, she presented with worsening hearing loss and bloody discharge to the same ear. Consequently, examination showed that part of the prosthetic device was extruding through the cartilage graft, with signs of graft thinning and documented conductive hearing loss. Although it is evident that isotretinoin has an impact on various healing processes. Literature varies on the recommendations on the use of isotretinoin before and after surgical procedures and the exact magnitude of impact is still to be determined. Our case suggests that using oral Isotretinoin may lead to the thinning of cartilage graft and thus extruding of the prosthesis. Clinicians must be aware of the possible adverse associations of oral Isotretinoin to healing, especially surgeries involving extremely delicate skin or cartilage grafts like in our case.

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Isotretinoin has an impact on various healing processes.

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Literature varies on the recommendations on the use of isotretinoin before and after surgical procedures.

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Isotretinoin may lead to the thinning of cartilage graft and thus extruding of the prosthesis.

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Clinicians must be aware of the possible adverse associations of Isotretinoin to healing, especially surgeries involving extremely delicate skin or cartilage grafts.

Oral isotretinoin (Roaccutane) use during incisional surgery: safe or risky?

Two cases are presented that demonstrate normal wound healing following bilateral reduction mammoplasty, in young female patients taking therapeutic doses of Isotretinoin (Roaccutane). Review of the literature does not provide evidence that Isotretinoin impairs would healing, nor that it promotes hypertrophic or keloid scarring in surgical patients.

Isotretinoin-Induced Thrombocytosis in a Patient With Acne Vulgaris: A Case Report

Isotretinoin is one of the first-line medications for the treatment of acne. One of the reported side effects of isotretinoin is thrombocytopenia, in addition to other abnormalities such as incomplete blood count. However, reports on thrombocytosis associated with isotretinoin are controversial. The present report discusses the case of a patient with acne vulgaris who was treated with isotretinoin and consequently suffered from isotretinoin-induced thrombocytosis.

A 20-year-old female patient was diagnosed with acne vulgaris and started treatment with systemic isotretinoin (20 mg once daily) for one month. A baseline complete blood count was performed, as well as another blood count after one month of medication administration. Platelet count was recorded at each visit. The baseline platelet count was within the normal range; however, it was found to be elevated after one month of treatment. Accordingly, the medication was discontinued, and the platelet count returned to normal levels after one month, as measured during the monthly visit. The patient also experienced seizure episodes during treatment, which did not cease with the treatment discontinuation. Although isotretinoin-induced thrombocytosis is considered a rare side-effect for isotretinoin, it should be routinely monitored in high-risk patients and those undergoing surgeries. Further prospective studies on isotretinoin-induced thrombocytosis need to be conducted to gain a deeper insight into the various aspects related to the condition.

Analysis of the Effects of Isotretinoin on Rhinoplasty Patients

BACKGROUND

Although the number of cosmetic surgeries performed per year continues to increase, many candidates have skin problems. Thick-skinned rhinoplasty patients pose a real challenge for surgeons. Fear of performing surgery in patients with a history of isotretinoin use is another concern.

OBJECTIVES

The aim of this study was to study the effects of perioperative isotretinoin on rhinoplasty patient outcomes.

METHODS

This research was conducted on 350 rhinoplasty patients, divided into control and experimental groups, between 2012 and 2015. The experimental group patients were requested to consume isotretinoin from 2 weeks before surgery to 2 months following the surgery. A comparison was made between the 2 groups 1, 3, 6, and 12 months after the surgery.

RESULTS

Statistical tests indicated that the satisfaction of experimental group patients at months 1 and 3 following the surgery was significantly higher than that of control group patients (P < 0.01). Examination of the patients' noses found little evidence for soft tissue repair disturbance and cartilaginous deformities. Nine patients from the experimental group needed revision surgery during the study period, but none of the revision surgeries was for a cause clearly attributable to the intake of isotretinoin.

CONCLUSIONS

The results of this research suggest that isotretinoin causes no evident disturbance to the recovery of rhinoplastic incisions and internal nose structures. Moreover, none of the experimental group patients showed hypertrophic tissues and cartilaginous deformities, and the repair was satisfactory, similar to the control group. However, patients receiving isotretinoin were more satisfied with their operation outcomes and experienced fewer skin problems.

LEVEL OF EVIDENCE: 3

The use of isotretinoin for acne - an update on optimal dosing, surveillance, and adverse effects

INTRODUCTION

Acne is a chronic, inflammatory, and immune mediated disease of pilosebaceous unit, highly prevalent in adolescents. It involves face, trunk, and back; may leave scars and affect quality of life. Early, effective, and safe treatment is the key for disease resolution. Oral isotretinoin is the unique treatment for cure or prolonged remission for moderate and severe acne, preventing psychosocial impact and scars. It inhibits sebaceous glands activity and has anti-inflammatory and immunoregulatory properties.

AREAS COVERED

We performed a comprehensive literature search on PubMed database, up to March 2020, regarding oral isotretinoin for acne treatment. We synthetized data about acne pathogenesis and mechanism of action, efficacy, and safety of isotretinoin.

EXPERT OPINION

This drug is effective, despite common, controllable, and reversible mucocutaneous side effects. Serious adverse events are rare and represent individual reactions. Teratogenicity is the most severe, requiring rigorous control. We believe that no other therapeutic option, even topicals combined to oral antibiotics accomplish same results. Recurrence after treatments other than isotretinoin is the rule, prolonging risk of scars, compromising skin appearance, and causing emotional distress in teenagers. If there is no absolute contraindication, isotretinoin should be the first line treatment for moderate to severe inflammatory acne.

Low dose of isotretinoin: A comprehensive review

Isotretinoin is a first-generation retinoid initially approved for the treatment of severe cases of acne vulgaris (nodulocystic acne). Because of its broad anti-inflammatory and immunomodulatory properties, it has been used beyond its initial approval in a myriad of other indications. Adverse effects of isotretinoin vary from xerosis to teratogenicity. Herein, we reviewed the literature, through date-unlimited PubMed search, from inception till December 2019, using the following search terms: "low-dose isotretinoin" and "dermatology," "isotretinoin and safety," "isotretinoin, off-label uses," "isotretinoin and male fertility," "isotretinoin, iPLEDGE system," aiming to deliver a therapeutic update relevant to clinical practice. All English-language articles were considered with no limitation based on the articles' type. Low-dose isotretinoin is not limited to old and novel dermatological conditions, but also showed promising results in the field of infertility and safety in the field of gastroenterology. We also highlight on the safety profile of the drug and experts' recommendations to enhance safety measures to decrease fetal risk while on isotretinoin.

The safety of isotretinoin treatment in patients with bone fractures

Isotretinoin is widely applicable in dermatology, although it may develop severe side effects in the skeletal system. An intention of this review was to establish the safety of oral isotretinoin in patients with bone fractures. Both MEDLINE/Pubmed and SCOPUS databases were searched to investigate the influence of isotretinoin on the skeletal system. The drug shows a strong osteoporotic activity in rats whereas this effect is milder in humans. Biochemical markers of bone turnover remain unchanged except for serum calcium in patients receiving a high dose of isotretinoin. An excessive intake of vitamin A may impair functioning of vitamin D especially in people with a vitamin D deficiency, therefore a similar side effect may also occur in patients on isotretinoin treatment. We suggest reducing the use of isotretinoin after bone injury or continuing the treatment at low dosing with a concomitant correction of vitamin D and calcium status.

Systemic Retinoids and Scar Dehiscence

Systemic retinoids such as isotretinoin and acitretin are associated with numerous side effects but are therapeutically valuable in dermatological practice. Several studies have reported the wound-healing effects of treatment with concurrent systemic retinoids in addition to surgical treatments. Herein, we describe two patients with scar dehiscence that developed after initiation of systemic retinoid treatment following cutaneous surgery. In Case 1, isotretinoin was thought to decrease collagen production to a greater degree than did degradation during the wound remodeling phase, which resulted in wound dehiscence. In Case 2, acitretin was thought to decrease fibroblast proliferation and collagen production during the proliferation phase of wound healing, which resulted in wound dehiscence. Based on the two presented cases, it is advisable to postpone systemic retinoid treatment for 6 months to 1 year following cutaneous surgery, located especially in cosmetically important sites.

Oral Isotretinoin in the Treatment of Postoperative Edema in Thick-Skinned Rhinoplasty: A Randomized Placebo-Controlled Clinical Trial

BACKGROUND

The thick-skinned nose is still one of the most challenging aspects of rhinoplasty. The possible effects of oral isotretinoin on cosmetic results of rhinoplasty in patients with thick nasal skin have been considered during recent years.

METHODS

In this double-blind placebo-controlled clinical trial, 48 cases were divided into two groups randomly. Oral isotretinoin (0.5-mg/kg) was started on the 31st day after surgery and given every other day for 1 month and after that daily for two additional months in the first group. The second group received a placebo in the same form, sequence and interval as the first group. The cosmetic results based on patient satisfaction and ranking by an expert surgeon were compared between the two groups at 3 months, 6 months and 1 year after surgery.

RESULTS

Patient satisfaction and ranking by an expert surgeon in the isotretinoin group at 3 months and 6 months after surgery were significantly better than in the placebo group (p value < 0.05); however, at 12 months after surgery there was no statistically significant difference between the two groups (p value > 0.05).

CONCLUSION

Though postoperative use of oral isotretinoin in patients with thick nasal skin accelerates improvement in cosmetic results during the early months after surgery, it does not significantly affect the final cosmetic result 1 year after surgery.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .