Severe hyperpigmentation and scarring following glycolic acid peel treatment in combination with low-dose isotretinoin

Glycolic acid-induced disruption of epidermal homeostasis in a skin equivalent model: Insights into temporal dynamics and mechanisms

Glycolic acid (GA) is extensively used in cosmetic formulations and skin peeling treatments but its adverse effects, notably severe disruption of epidermal structure, limit its clinical utility. However, the detailed impact of GA on epidermal homeostasis, including changes in structure and protein expression over time, is not fully understood. This study employed a reconstructed human epidermis (RHE) model to assess the effects of varying GA concentrations on epidermal proliferation, differentiation, and desquamation at different time points. Through histology, immunofluorescence, and immunohistochemistry, we observed that 35% GA concentration adversely caused abnormal epidermal homeostasis by affecting epidermal proliferation, differentiation and desquamation. Our findings reveal time-specific responses of key proteins to GA: Filaggrin, Involucrin, Loricrin, and Ki67 showed very early responses; KLK10 an early response; and AQP3 and K10 late responses. This research provides a detailed characterization of GA's effects in an RHE model, mimicking clinical superficial peeling and identifying optimal times for detecting GA-induced changes. Our results offer insights for designing interventions to mitigate GA's adverse effects on skin, enhancing the safety and efficacy of GA peeling treatments.

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.

A prospective, randomized, split-face study of concomitant administration of low-dose oral isotretinoin with 30% salicylic acid chemical peeling for the treatment of acne vulgaris in Asian population

BACKGROUND

Acne vulgaris (AV) is a common dermatosis. For moderate to severe AV, isotretinoin is the first-line treatment. Chemical peeling with supramolecular salicylic acid (SSA) was developed with water solubility and advanced skin penetration properties. In the present study, we investigated the efficacy and safety of oral low-dose isotretinoin combined with 30% SSA chemical peeling.

METHODS

Thirty-three moderate-to-severe acne patients were enrolled and received oral low-dose (0.2-0.4 mg/kg/d) isotretinoin and were then randomly assigned to receive 30% SSA or not on each side of the face with 2-week intervals for four sessions. Photos, the number of lesions, GAGS score, skin indices (melanin, erythema, pore, and texture), hydration, and transepidermal water loss (TEWL) were assessed at 0, 2, 4, 6, and 10 weeks. Side effects, efficacy, and satisfactory rates were recorded.

RESULTS

A total of 29 patients completed the study. Oral isotretinoin combined with SSA decreased response time compared to isotretinoin monotherapy, with significantly improved GAGS score, count of lesions, and efficacy (%) at 4-6 weeks. Skin indices of melanin, erythema, pore, and texture evaluated at week 10 were improved as well. Oral isotretinoin with or without SSA was effective by the lesion clearance; only SSA significantly improved the TEWL. All the side effects were temporary and tolerable, and no adverse effects were observed.

CONCLUSION

Oral low-dose isotretinoin combined with 30% SSA is safe and effective, which advanced the onset of action and improves lesion clearance.

Safety of Performing Superficial Chemical Peels in Patients on Oral Isotretinoin for Acne and Acne-Induced Pigmentation

BACKGROUND

Chemical peels are an integral part of dermatology practice for the treatment of acne, photoaging, and pigmentary dyschromias. Oral isotretinoin is considered the gold standard in the management of acne. Combining both is not currently recommended, due to the increased risk of complications like dryness, erythema, post-inflammatory hyperpigmentation, and scarring.

OBJECTIVE

We sought to assess the safety and efficacy of superficial chemical peels in patients with acne taking isotretinoin and those not taking oral isotretinoin.

METHODS

A comparative, retrospective analysis of three superficial chemical peels was performed; the analysis included 60 patients and 214 sessions that took place between August 2017 and January 2018. Of these, 47 patients were on oral isotretinoin (Group A) and 13 were not on isotretinoin (Group B). In Group A, a salicylic acid-mandelic acid peel (SMP) was performed on 22 patients, a glycolic acid peel was performed on 18 patients, and a modified Jessner's peel was performed on seven patients. In Group B, an SMP on eight, glycolic acid peel on four, and modified Jessner's peel on one patient(s), respectively, were performed. Complications, if any, were noted, and incidence rates were compared by photographic assessment.

RESULTS

One patient in Group A and one patient in Group B had complications (persistent hyperpigmentation). The difference in the incidence of complications was insignificant between the two groups for all three superficial peels. Furthermore, it was noticed that patients in the isotretinoin group experienced faster and better improvement compared to those in the non-isotretinoin group.

CONCLUSION

In our study, the use of isotretinoin did not result in any complications; hence, we encourage combination therapy to achieve enhanced and faster resolution of acne.

A Review of Oral Therapies for the Treatment of Skin Hyperpigmentation

This review article examines evidence supporting the use of oral therapies in treating idiopathic, actinic, and metabolically induced skin hyperpigmentation. A thorough review of the literature regarding oral treatments for hyperpigmentation was systematically conducted through PubMed. Keywords used in the primary search include "Hyperpigmentation," "Melanosis" or "Melasma," "Lightening," "Oral," and "Therapeutics." The search was limited to the English language, and no timeframe restrictions were implemented. Numerous orally administered therapies have been proposed for the treatment of skin hyperpigmentation. There is an abundant body of literature demonstrating the efficacy of orally administered tranexamic acid, glutathione, isotretinoin, and proanthocyanidin. It is reasonable to expect that the most effective oral therapies will address known underlying causes of hyperpigmentation such as thyroid disease, diabetes, and hormonal imbalance. Improvement due to oral therapy of otherwise unresponsive skin hyperpigmentation or hyperpigmentation of unknown cause is less predictable. This review is limited by the strength of evidence contained within the available studies. Clinical studies investigating the treatments discussed within this article are limited in number, at times lack blinding in the study design, and are based on small sample sizes. Based on existing research, the most promising oral remedies for hyperpigmentation appear to be tranexamic acid, glutathione, isotretinoin, and proanthocyanidin. Additional studies to better establish safety and efficacy are necessary.

Standard Guidelines of Care: Performing Procedures in Patients on or Recently Administered with Isotretinoin

BACKGROUND

Currently, the standard protocol regarding the performance of procedures on patients receiving or having recently received isotretinoin (13-cis-retinoic acid) states that the procedures should not be performed. The recommendations in standard books and drug insert require discontinuation of isotretinoin for 6 months before performing cosmetic procedures, including waxing, dermabrasion, chemical peels, laser procedures, or incisional and excisional cold-steel surgery. These recommendations have been followed for over two decades despite little evidence for the stated increased risk of scarring.

OBJECTIVE

The Association of Cutaneous Surgeons (I) constituted a task force to review the evidence and to recommend consensus guidelines regarding the safety of skin procedures, including resurfacing, energy-device treatments, and dermatosurgical procedures in patients with concurrent or recent isotretinoin administration.

MATERIALS AND METHODS

Data were extracted from the literature through a PubMed search using the keywords "isotretinoin," "safety," "scarring," "keloids," "hypertrophic scarring," and "pigmentation." The evidence was then labeled and circulated to all members of task force for review.

RESULTS

The task force is of the opinion that there is insufficient evidence to support the current protocol of avoiding and delaying treatments in the patient group under consideration and recommends that the current practice should be discontinued. The task force concludes that performing procedures such as laser hair removal, fractional lasers for aging and acne scarring, lasers for pigmented skin lesions, fractional radio-frequency microneedling, superficial and medium-depth peels, microdermabrasion, dermaroller, biopsies, radio-frequency ablation, and superficial excisions is safe in patients with concurrent or recent isotretinoin administration.

A Systematic Review on Oral Isotretinoin Therapy and Clinically Observable Wound Healing in Acne Patients

The association between isotretinoin and atypical wound healing remains controversial. It is common practice to delay elective procedures for 6 to 24 months after oral isotretinoin therapy. The studies supporting common practices (SCP) recommend extending this period to include the 6 to 24 months preceding treatment. The opposing studies (challenging common practices; CCP) state that the rate of scarring in isotretinoin patients is low and that delaying elective procedures is unnecessary. These practices impact a large number of dermatology patients undergoing acne treatment. This systematic review compiled articles obtained from online databases and examined data from both SCP and CCP studies. The inconsistencies in the reported data and the methodological flaws in the literature preclude any firm conclusions that can resolve the controversy. As such, this review demonstrates that there is insufficient evidence to either corroborate or refute delaying elective procedures in isotretinoin acne patients. Although the recent literature trends toward removing the procedural delay, we advocate for clinicians to consider the research presented in this review in the context of their own clinical experience and each individual patient’s situation. The possible negative procedural outcomes must be weighed against the severity of the patient’s acne scarring and the psychosocial impact of this scarring on the patient.

[Post-inflammatory hyperpigmentation occuring after cosmetic procedures]

A post-inflammatory hyperpigmentation (PIHP) can occur after cosmetic procedures such as chemical peels and lasers. Patients must be informed about this risk. Precautionary measures before, during and after the procedure can prevent or reduce the risk of PIHP. These procedures should not be done in summer on suntanned skin and patients have to be aware of the importance of an effective photoprotection. The PIHP occurs more frequently on dark-skinned patients, in Asians as well as in women with melasma history. In these cases, risk/benefit assessment of the cosmetic procedure is required: no risky procedure in patients at risk! PIHP can also be related to technical errors such as too high concentration or too long exposure time during peel procedure as well as excessive threshold fluences during laser procedure. If many therapies for PIHP damages can be proposed, patients feel frequently that they are not as quickly effective as they would like. Patients must be reassured as many PIHP resolve spontaneously. If photoprotection is always required, it is also possible to accelerate the pigmentation's clearing using the Kligman trio or the numerous topical lightening agents targeting several steps of the hyperpigmentation process. More invasive and expensive therapies such as peels, lasers, IPL or radiofrequency might be used for refractory cases. As a pigmentary relapse might occur after these procedures, the traditional Kligman trio should be always considered.

Chemical peels in active acne and acne scars

Chemical peeling is a widely used procedure in the management of acne and acne scars. It causes controlled destruction of a part of or the entire epidermis, with or without the dermis, leading to exfoliation and removal of superficial lesions, followed by regeneration of new epidermal and dermal tissues. The most frequently used peeling agents are salicylic acid, glycolic acid, pyruvic acid, lactic acid, mandelic acid, Jessner solution, trichloroacetic acid, and phenol. The appropriate peel is chosen based on the patient's skin type, acne activity, and type of acne scars. Combination peels minimize side effects. In acne scars, chemical peels may be combined with other procedures to achieve better clinical results. A series of chemical peels can lead to significant improvement over a short period, leading to patient satisfaction and maintenance of clinical results. © 2016 Elsevier Inc. All rights reserved.