Isotretinoin and Surgery: What do we advise patients?

For Most Skin Surgery, Consensus is that Stopping is Not Necessary

There has been a concern for many years that patients using isotretinoin should not undergo surgery at any time they are using the drug for fear that wound healing could be affected. Some of the fear comes from basic science studies showing that retinoids suppress collagenase activity which may lead to excess collagen accumulation and hence produce hypertrophic and keloid scarring.

Some of the fear came from a 1986 report by Rubenstein which described atypcial keloids in those using isotretinoin and undergoing dermabrasian

A new report by Davis and Perkins describes good wound healing and good outcomes in 2 female patients who underwent breast reduction surgery while using isotretinoin.

Comment

It seems that isotretinoin does not need to be stopped for most surgeries. However, there is evidence to support delaying mechanical dermabrasion and fully ablative laser therapy in patients who use isotretinoin.

For those who question the safety of isotretinoin during surgery, a thorough review of two articles would be advised: -

Spring et al, 2017

In 2017, a panel of experts (Spring et al 2017) put forth recommendations on the safety of isotretinoin in various dermatological procedures. Thirty-two relevant publications reported outcomes of 1485 procedures. Overall, the authors concluded that “there was insufficient evidence to support delaying manual dermabrasion, superficial chemical peels, cutaneous surgery, laser hair removal, and fractional ablative and nonablative laser procedures for patients currently receiving or having recently completed isotretinoin therapy. Based on the available literature, mechanical dermabrasion and fully ablative laser are not recommended in the setting of systemic isotretinoin treatment” (Source: Spring et al 2017).

Mysore et al, 2017

In 2017, the Association of Cutaneous Surgeons of India also put forth a recommendation 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.

Mysore and colleagues point out that instead of avoiding some of these procedures, a test procedure may be performed to establish safety in selected patients at the discretion of the treating physician

The data remains confusing for patients. The American Academy of Dermatology recommends against waxing hair while on isotretinoin and for 6 months after.

REFERENCE

Davis and Perkins. Oral isotretinoin (Roaccutane) use during incisional surgery: safe or risky? Case Reports Plast Surg Hand Surg. 2022 May 13;9(1):131-134. 

Mysore V et al. Standard Guidelines of Care: Performing Procedures in Patients on or Recently Administered with Isotretinoin J Cutan Aesthet Surg. 2017 Oct-Dec; 10(4): 186–194.

Spring L et al. Isotretinoin and Timing of Procedural Interventions: A Systematic Review With Consensus Recommendations. JAMA Dermatol . 2017 Aug 1;153(8):802-809.

Rubenstein R, Roenigk HH, Jr., Stegman SJ, et al. Atypical keloids after dermabrasion of patients taking isotretinoin. J Am Acad Dermatol. 1986;15(2 Pt 1): 280–285.