When can you begin your acne scar treatment after discontinuation of Accutane, Roaccutane & isotretinoin?

A Laser & Acne scar Specialist Explains

BY ULRIK KNAP, MD, LASER & ACNE SCAR SPECIALIST

BY ULRIK KNAP, MD, LASER & ACNE SCAR SPECIALIST

I often get this question from my patients: “When can I begin my acne scar treatment after finishing a course of Accutane (isotretinoin)?”

Well, this is a very relevant question because research shows that the earlier one starts his or her acne scar treatment, the easier the scar tissue is to remodel, and the better the outcome (though even old acne scars can be improved). 

So. should you really wait 6 - 12 months? Or can you start your treatment even earlier after finishing your Accutane treatment? In the second part of this article, I’ll dive into the literature and answer this question for you. 

But first, let’s take the basics about Accutane (Part 1 of the article). What is Accutane? How does Accutane work? Are there any side effects? 

Those are some of the questions, I’m about to discuss in this article.

Let’s begin...

Part 1: Isotretinoin (Accutane / Roaccutane) & Acne treatment

What is isotretinoin and how does it work?

Isotretinoin is sold under the brand name Accutane and Roaccutane among others and is a form of vitamin A. 

This medication is usually prescribed for patients with moderate to severe acne who don’t respond to any other kind of medicine, and for patients who have acne and a tendency to develop acne scars.

Accutane / Roaccutane is generally very effective in preventing extensive scarring.

…But how does isotretinoin (Accutane) work? 

As you might already know, acne is a skin condition that occurs when your oil glands (sebaceous glands) and hair follicles of the skin become clogged with oil (sebum) and dead skin cells (keratin). It often causes whiteheads, blackheads, and pimples, and usually appears on the face, forehead, chest, upper back and shoulders.

When the oil glands get clogged, inflammation occurs in the skin which appears as a red pimple that hurts when it is touched. 

Basically, Accutane has an immense effect on the oil glands by reducing the size of the oil glands, cell shedding and the stickiness of cells in the glands.

The upside of these effects is that much less oil is produced in the oil glands and that they don’t get clogged as easily due to less cell shedding. 

And the result…? That is a reduction in acne activity with fewer whiteheads, blackheads, and pimples

Does Accutane really prevent acne scarring?

YES, the best thing about Accutane is that it prevents acne scarring because it is highly effective in clearing up acne.

Should I take isotretinoin?

For me, as a laser and acne scar specialist, there is no doubt that isotretinoin (e.g. Accutane or Roaccutane) is the right medication for you if you’re otherwise healthy, have moderate to severe acne and either have a tendency to develop acne scars or you have acne that doesn’t respond to other forms of medications.

Acne can cause a lot of mental stress and last for years. In my opinion, as a specialist, prescribing Accutane for my patients is not only a question about the severity of the skin disease but also a question about the mental stress which acne causes to the patient. Prescribing Accutane might completely cure acne, hence improving the patient’s self-esteem and mental health, which I believe is just as important.

I wouldn’t care too much about the side effects at first if you’re otherwise healthy and the abovementioned conditions are met. In most patients, the side effects are so mild (e.g. dry skin and lips) that they shouldn’t lead to discontinuation of the medication. If otherwise, the side effects are intolerable, then simply discontinue the medication. No harm done!

Dr. knap about safety and Isotretinoin (e.g. Accutane or Roaccutane) for Acne

As a patient without a medical healthcare background or a doctor’s degree, you might be uncertain about whether Accutane is a good thing or not! You might even have heard an aunt talk about the severe side effects of Accutane or read about Accutane on some blog forums and how “dangerous” it is and it’s severe side effects. 

Well, that would be an exaggeration in my eyes so say that Accutane is dangerous!

Just think of it this way: Why would doctors all over the world prescribe isotretinoin (Accutane) for millions of acne patients each year if it was so dangerous [ref]?

Personally, I have prescribed Accutane for several hundreds of my patients during my career as an acne scar specialist. And of course, side effects do occur once in a while. I’d rather expect them than not, but the most frequent side effects are quite mild and are simply a result of how Accutane works.

Some might experience side effects while others don’t have any side effects whatsoever. Although not all of these side effects may occur, if they do occur and if they are not to endure during the entire course of therapy, then simply stop taking the medicine!

The most frequently occurring adverse events are listed below:

 

Frequent side effects: 

  1. dry skin and dry lips – you can use a lotion for the skin and a lip balm for the lips
  2. dry eyes – use artificial tears, and don’t use contact lenses
  3. dry nose – this side effect can give a nosebleed. This is an annoying side effect but not dangerous and shouldn’t necessarily lead to discontinuation of treatment
  4. joint pain and muscle aches
  5. biochemical changes of lipids and liver enzymes – blood samples are collected frequently during the treatment to make sure that the enzymes don’t get too elevated. Though an increase in liver enzymes and lipids might occur, that is usually not any worse than the increase that occurs after consumption of a beer or two. My point is that from a medical point of view, a moderate increase in liver enzymes is not dangerous and doesn’t necessarily have to lead to discontinuation of the treatment. 

 

Birth control 

There are lots of different precautions to take if you’re a woman and are planning to get pregnant at some point. However, Accutane is not compatible with pregnancy, because Accutane can lead to birth defects, just as alcohol and other forms of medication can.

Hence, a woman in the childbearing years should be aware to use an appropriate birth control method for 1 month before therapy begins, during the entire course of therapy, and for 2 full months after therapy stops. Pregnancy tests should be taken every month during the entire course of treatment.

How long is a course of Isotretinoin (Accutane or Roaccutane)?

Usually, oral isotretinoin should be taken until it clears acne. 

Evidence supports that a total dosage of 120 – 150 mg/body weight decreases the risk of flares after discontinuing the treatment. This corresponds to a daily dosage of 20-60 mg during the course of some months.

The aim is to go for a daily dosage that doesn’t give too many side effects in terms of dry skin, lips and eyes.

Part 2: Isotretinoin and Timing of Procedural Interventions

Why should you start you acne scar revision early on?

You might ask yourself why early procedural intervention, e.g. with a fractional CO2 laser, punch excision, skin surgery or subcision, is better than delayed acne scar revision?

This is a very good question, and I’ll give you some reasons why you should begin acne scar revision as early as possible, and why you shouldn’t delay the treatment more than absolutely necessary.

There are basically three types of arguments why you don’t have to delay your acne scar treatment including procedures such as fractional CO2 laser:

  1. Patients who start early acne scar treatment after cessation of oral isotretinoin therapy experience less physical and mental sequelae of acne scarring
  2. Early treatment with lasers gives a better cosmetic outcome
  3. The evidence which supports delayed procedural intervention is very weak (I’ll come to that in a minute). Therefore there’s no need to delay acne scar revision after a course of isotretinoin therapy.
acne scars - treatment - dr Knap
Severe acne scarring can be avoided when relevant treatment is given early on.

The well-known result of moderately to severely inflammatory acne is disfiguring, life-altering scarring, which should be treated as soon as possible. Hence, patients with acne scarring experience both physical and mental sequelae of acne scarring [ref]. Early intervention reduces mental sequelae of acne scarring and increases the patient’s self-esteem. 

There is even evidence that supports a better cosmetic outcome when treating acne scars early on. 

The fact is that laser intervention at an early state simply provides more controlled scarring as evidenced in a randomized split-wound trial where one-half of surgical scars were treated with a fraction laser and significantly improved both wound healing and cosmetic outcome as shown in the photo below [ref].

Please note, that the left side (t) was treated with a fractional laser while the right side (c) was not treated at all. The bottom picture shows the result several weeks after the laser treatment. The treated (t) side healed much better than the untreated side (c).

When can I start acne scar revision with fractional lasers after finishing Accutane treatment?

For years it has inappropriately been taught and practiced that acne scar revision has to be delayed at least 6-12 months after finishing a course of isotretinoin (e.g. Accutane). This practice was based on 3 very small case series including only some few patients from the mid-1980s (in other words, the evidence was very weak).

Therefore, a panel of independent dermatologists and plastic surgeons set up to investigate the evidence gathered since the 1980s. This was published in two systematic reviews in 2017 [1][2] including a total of 1485 procedures.

The conclusion was crystal clear that there was insufficient evidence to support delaying laser treatment of acne scars in patients currently receiving or who have recently completed isotretinoin therapy. The investigated procedures included fractional CO2 laser treatment, other fractional ablative laser procedures as well as non-ablative laser procedures.

Hence, these procedures can be performed in patients currently receiving or who have recently completed isotretinoin therapy without any increased risk of adverse events.

Nevertheless, it will take years for the old dogma to fade out of clinical practice, and at many centers around the world the old dogma is still practiced even this day today.

What is the evidence behind early procedural intervention with fractional lasers versus delayed intervention (6 months or more) after finishing isotretinoin treatment?

There are many case series and 1 randomized clinical trial demonstrating normal wound healing after treatment with ablative and nonablative fractional lasers in patients receiving systemic isotretinoin.

For instance, in a randomized study 60 patients were treated with a non-ablative fractionated laser for acne scarring. Half of the patients were treated while taking isotretinoin and the other half of the patients had completed a course of isotretinoin treatment more than 6 months prior. There was no difference in either the recovery process or the final cosmetic improvement between the 2 groups.

In another case series of 20 patients, normal reepithelialization and no hypertrophic scars or keloids were reported at 6 months in patients treated with full-face fractional CO2 laser resurfacing for acne scarring during and/or within 1 to 3 months of discontinuing oral isotretinoin treatment (10–60 mg/d).

Table 1 below summarizes the available literature regarding early procedural intervention with ablative and non-ablative lasers. Basically, all the literature supports early procedural intervention such as acne scar revision with fractional CO2 laser [ref].

The evidence supports early acne scar revision

In other words, the evidence supporting acne scar revision in patients currently receiving or who have recently completed isotretinoin therapy is much stronger than the few small cases series from the mid-1980s which inappropriately have formed the foundation for delayed acne scar revision since then.

What other procedures can be done without an increased risk of adverse events?

The panel of independent dermatologists and plastic surgeons also investigated the literature regarding other procedures and concluded that neither was there any evidence to support delayed procedural intervention with manual dermabrasion, superficial chemical peels, cutaneous surgery, nor laser hair removal.

Which lasers can be used to manage acne scarring without delay during or after discontinuation of oral isotretinoin?

There are many different kinds of lasers that can be used to treat and improve acne scars. 

Based on the current literature, there’s strong support to use both fractional non-ablative and ablative fractional lasers without delay in patients currently receiving or who have recently completed isotretinoin therapy.

E.g. early acne scar revision can be done with a fractional CO2 laser which I personally think is an excellent and very powerful laser to treat acne scars. 

The figure below shows the difference between a fully-ablative non-fractional laser (left), non-ablative fractional laser (middle) and an ablative fractional laser (right).

However, the evidence is currently insufficient to support the use of a fully-ablative laser in patients currently receiving or who have recently completed isotretinoin therapy.

Which laser should I choose for my acne scar management?

Planning to have your acne scars managed, you should look for a skilled acne scar specialist who has a variety of methods rather than which lasers he uses. 

There are a lot of good lasers out there which can all improve acne scars. The important thing is how the lasers are used by the specialist rather than the laser itself.

Dr. Knap about his approach

Why is my approach unique?

My approach is unique in that way that I always use the best methods for each individual acne scar. 

My first step when I consult a patient in my clinic who suffers from acne scars is to analyze the skin and identify the acne scar type of each individual acne scar. This is done in tangential lighting. I’ll also have the patient mimic and smile when I look for any tethered and anchored scars, as well as touching the skin to get a feeling of any deep fibrosis in the skin. 

When I have performed my initial skin analysis of each individual acne scar, mapping and photographing the scars are done. 

This is the foundation for the planning of the acne scar revision program which I tailor for each individual patient.

I rarely use only a single method to manage all acne scars in a patient, since most patients have a variety of different acne scar types including enlarged pores, ice pick scars, boxcar scars, rolling scars, tethered scars, etc. Hence, different methods are matched to each individual acne scar type to achieve the highest possible cure rate, and each individual acne scar has to be individually managed. 

My approach is to treat the most obvious and deepest acne scars first. These are the acne scars which the patient typically is most anxious about. Combining different methods is necessary when treating deep acne scars including TCA cross for enlarged pores, ice pick scars and narrow boxcar scars; subcision for tethered and anchored rolling scars and boxcar scars; and punch excision for wide boxcar scars and very deep ice pick scars. 

When the deep acne scars have been managed, the final step is to treat the superficial acne scars. This can be done with a laser, e.g. a fractional CO2 laser

Most of these methods can be done in the same session to achieve results within a reasonable time horizon.

As mentioned earlier, I always tailor an individual acne scar revision program to each individual patient. A program might last between 2-12 months (and sometimes longer), but typically between 4-8 months.

Best Regards

Ulrik Knap, MD., Laser & Acne scar specialist

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