@Obi wanThank you for sharing this, it's fascinating. I am thankful for Dr. Lim's service to the community. Just some thoughts...

Here are my objective concerns:

• Most doctors who are Derms or PS are dial a treatment doctors. What does this mean. They use the same settings on everyone without understanding how the energy and various perimeters effect one another. They want to be done in 15/30 mins for maximum $$$$ and do not really know the purpose for which they use the laser, how it works, nor the proper aftercare to make sure the patient heals right. This of course would be exacerbated by someone on Accutane which adds another variable.
• Do they have the time to hand hold and maintain someone on Accutane who has Acne Scar revision. There are hundreds if not thousands in scale of people who I know have been cut off from their doctors after treatment. They do not have the bandwith or desire to handle them. They thus come here and want me to solve bacterial or other issues related to poor treatment.
• I feel PRP - growth factors along with any treatment are a must if your treating a patient with Accutane. Why because the skin has been altered chemically and you need all the help you can get to heal. I think using ultrasound to assist in procedures, and thermal readings of the skin would be a must if one is resurfacing (more on that below).
• I have done all treatments numerous times, I can only imagine how doctors could do silly things like pulse stack, use multiple treatments at once quickly making fat loss or thermal damage, or other careless mistakes.
• Having had major fat loss from doctors with lasers, using manufacturer approved settings from basic training, this adds another level of complexity most doctors cannot meet. For instance if one grabs (pinches) the skin while on Accutane (I have been twice on high dosage and a few times on low dosage in my life)... You realize your skin is thinned out, it does take longer to heal. For anyone on Accutane, have you got a cut, it just seems to take longer because of the changes in your body that occur. I could take my finger and feel bone easier. As a side effect of Accutane you have thinned out skin (just like a retin A cream can do) sometimes this leads to dryness, tears, fissures, cracks. I can only imagine a harsh resurfacing CO2/ Erbium while on Tane. How will the doctor monitor dermis depth (does he ultrasound your skin before or during treatment to monitor things). If the infini needles go too deep you hit fat and have fat loss, how is Accutane factored into this with skin changes (dermis thinning), changes of thickness / quality.
• I advocate most patients to do one major treatment at a time ( this is hard if they fly in / have no down time requirements). Collagen takes months to heal and the body does not like to many things quickly. For instance Many doctors will subcise and right after fill during Edema / Swelling. Then come here and ask about the "bumps" which could have been avoided if the swelling went down before injection or the doctor used 3 lases at once and they are scarred (in their own words) for life, which could have been avoided by spacing things out / proper healing.
• I am seeing differing data. This paper says non - ablative laser resurfacing. But then in other papers I see co2 / erbium ablation is ok. Why is one showing caution with safer laser devices. (See below paper).
• That is a very small sample size in the paper below.What about sensitive patients, or those who heal poorly. Some acne scar suffers are notorious for healing poorly or they would not have acne scars to begin with. He does not go into aftercare, are we using special biogel masks or antibacterials, etc...
• One can put nitrous on their car and drive a sports car on a packed freeway at full speed, but should they for their own safety, ...we only have one face...

_______________________________________________________________________________

Isotretinoin study: Laser treatment safe one month post-treatment July 17, 2017

Current recommendations based on case reports that do not include 1550 nm NAFL technology

A 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 patients 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 tellsDermatology 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 inDermatologic Surgeryjournal¹found 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.

Agree with your viewpoints. From what I gather acne scar revision is a speciality within a specialist degree. Much like paediatric ankle orthopaedic surgeons - yes, orthopaedics dealing with broken bones, but now one is dealing with children and only ankles. This should, in theory make one experienced surgeon. For dermatologists and plastics who 'dabble' in acne scar management these Specialist are general dermatologists and Plastics, and practice a variety of consults and procedures ranging from rashes, skin checks, breast implants, butt lifts etc.... When it comes to acne scarring I do believe that the majority is profit driven - as BA suggested most would place patents on a ' laser program' and not targeted scar revision. Why? Because understanding the patients expectations and manual removal of scars take time... .and time is money driven, without the passion to help patients. This statement is a generalised comment as there are passionate doctors who actually take pride in their work.

Comments on PRP and scar revision, I have had friend who had PRP after RF microneedling, and with out doubt, it does indeed speed up recovery. I am sure papers will be out shortly. My observations are not scientific, as its just an subjective viewpoint, so really it does not count, however the science behind healing with PRP is sound.

Providing Specialist are well trained, I am just assuming they know what pulse stacking means, and the delivery of say a very powerful device can do 4 mm into the fat layer, no doubt with pulse stacking of say a insulated INFINI will cause fat loss. Well trained Specialist will understand histology and should avoid this - unless they are ill informed or delegate to less informed assistants (once again with no disrespect to providers, but their level of expertise, and formal training may not be to the highest standards)

I have read 16 of the 32 papers, and analysed (within my limitations of understanding), the one scar that resulted in fully ablative laser was performed by a Specialist who used 8, yes EIGHT passes of fully ablative erbium. I am no expert, but 8 passes of fully ablative erbium on some 19 year old guy on 80 mg (yes eighty mg ) of Accutane? That's brave, or purely stupid. BA you are indeed correct, no consistency in any papers. All had different dosages everything from less than 0.2 mg kg per day all the way to that paper on 80mg per day. No consistency with densities, Joules, Accutane dosage, and retinoid sensitivity etc... etc.. many variable in all the papers. The white paper by the Australian dermatologist at least has some variables taken into consideration- namely a large cohort of patients (over 300), using one energy deliver system (RF) in patients on a low dose of isotertinion. The aim of that study was to demonstrate ONE energy delivery, side effects seen and patient satisfaction rates. IMO not the best paper but at least variables are controlled with a large cohort since 2012.

The positives- I think in the correct hands, this gives an avenue to remodel scars early, treat patients early and prevent or at least reduce scarring. The doctor must understand not only lasers, energy devices, peels, and surgical techniques , but like you said the pharmacokinetic effects of isotretinoin on individuals. The effects of Accutane vary widely between individuals. They must then carry our procedures that will benefit THAT person. I can see I the wrong hands these papers can be dangerous, but in correct hands, its a step in the right direction that has challenged the 3 decade old paradigm. I wonder what will pan out in the future?

I asked for accutane back in 2007 when I was 19 years old. I had been dealing with acne for 8 years by that point, but it was at a mild stage when I went for my appointment. The NHS dermatologist took one look and said no.

In the following years my acne fluctuated. I kept getting cysts and eventually I started scarring, including this one on the bridge of my nose.

Come 2015 I was still dealing with this nonsense until I read a post on here which changed everything. What if I could pay a doctor to prescribe accutane? I did just that. I went private, took a 6 month course and I have not had another cyst since. You know what annoyed me the most? Private care is expensive so I switched back to the NHS during my course, the very same department that denied me back in 2007. This time they were more than happy to write me a prescription.

If it wasn't for that bastard NHS doctor I never would have developed any acne scars. Prevention is better than the cure. Sure, I would have had a few ice-picks but that is nothing.

Accutane is a hell of a journey (especially on 70mg like I was) but these doctors who always think they are right make me absolutely sick. I told them that I had been suffering for years and they didn't even care.

On 9/17/2017 at 8:06 PM, Shades said:

I asked for accutane back in 2007 when I was 19 years old. I had been dealing with acne for 8 years by that point, but it was at a mild stage when I went for my appointment. The NHS dermatologist took one look and said no.

In the following years my acne fluctuated. I kept getting cysts and eventually I started scarring, including this one on the bridge of my nose.

Come 2015 I was still dealing with this nonsense until I read a post on here which changed everything. What if I could pay a doctor to prescribe accutane? I did just that. I went private, took a 6 month course and I have not had another cyst since. You know what annoyed me the most? Private care is expensive so I switched back to the NHS during my course, the very same department that denied me back in 2007. This time they were more than happy to write me a prescription.

If it wasn't for that bastard NHS doctor I never would have developed any acne scars. Prevention is better than the cure. Sure, I would have had a few ice-picks but that is nothing.

Accutane is a hell of a journey (especially on 70mg like I was) but these doctors who always think they are right make me absolutely sick. I told them that I had been suffering for years and they didn't even care.

 

the same thing happened to me, and I was a victim of idiot doctors who not prescribed me accutane and end up with severe scars in face and shoulders from my cystic acne.

sorry for my english.

@Obi wanThank you for your follow up. I agree with your general thoughts on the issue. My fear is 99% of the doctors are not "acne specialists" and selling themselves as such. Possibly there should be another board certification for this.

You go into their practice and the first thing they offer is laser, sometimes not even looking at you, or simply over the phone. This is gross negligence I am speaking of where they are dial a setting doctors with the magic cure of laser. Laser in the right hands can be amazing, ... and for the right things. I do not feel it's fair to offer someone a "golden ticket" of laser as a 100% cure for acne scars. As we all know lasers are never one and done. Often treatment occurs over 3 years of multiple modalities and the bodies ability to heal. Also the patients down time availability. Even a "board certified" dermatologist should not be doing laser if that is something they do not specialize in. I realize those who are good at it have had massive schooling and investment in the topic to make it a viable and beneficial treatment. Sadly the many give the few a bad name, it's become almost to common of a acne scar solution.

I do think Infini is a much safer option than laser for today's acne scar suffer, less side effects (epidermis is not harmed). Hopefully i the near future they will work out lasers without thermal damage or some type of insulation like infini. Wouldn't that be cool, co2 that is in insulated, or cryo cooled like needles or fibers. Notice Infini was not mentioned in the study ( devices with insulated/protected/cryo - cooled features). It was interesting in the study the patients who had keloids /healing issues from V-beam which has these features.

Maybe that would be a good topic to help and educate@Obi wan what is a "good candidate "and a "bad candidate" for treatment of young scarring soon after /during Accutane in detail (ie. prone to keloids, poor healers / auto immune, blood deficiencies, Diabetes, Rosacea ). Who should avoid this (under which conditions).

I glean from the papers that the usage of lasers / treatments for topical purposes, if not overly harsh ablation and the patient is a "good candidate" with proper support from staff and aftercare. This is contingent on one stopping Accutane during treatment or slowly weans themselves off higher dosage with proper buffer time. This is why I think patients with this situation should have ultrasound or heat monitoring to make sure settings are not do high, deep, or dangerous. They have done this with other procedures such as thermi-tight and removing items from the skin. I think many doctors will avoid this because of potential liability, and lack of knowledge, staying current with education of the subject yet going off what is taught in med school. I have been to many a board certified derm who "wasn't aware," yet acted offended by their prestige when I spoke of current data and treatments. Even some of the doctors I list as acne scar specialists on the faq here I do not necessarily promote for laser treatments, they all have their specialties . I often think one should start with non energy device treatments and make their way to laser as a finishing (resurfacing) or a sedated TCA if it's strong enough.

Ultimately it is put on the patient to know how they heal , education, and avoid poor outcomes , which is sad because so many just trust their doctor. Caveat emptor - Buyer be ware.

Accutane was originally made for acute cases where nothing else worked, ... it has become more common place. Accutane will eventually go the way if the dinosaur with the acne vaccination to kill - P.acnes bacteria they discovered recently, and topicals with these properties. To all who read this and...

Want another option / alternative to Accutane there is PDT- or Photo Dynamic Therapy using leds or lights and cream to kill the bacteria, see if your doctor has this alternative. Sublative RF / Ematrix has also been shown to work on young scars or acne issues.

The participants of the study seemed to be on low dosage Accutane under 60mg per day. Can a conclusion that low dosage over a longer period of time to reach saturation of the drug is better than high dosage especially with the ability of aesthetic treatments. The best outcomes stopped the drug during treatment and healing.

• "Although it is not clear lower doses ... Accutane, when performing procedures, it may be prudent to treat with lower dose isotretinoin(e.g.20 40 mg; 0.250.5 mg/kg)."

Most of the safer treatments they say did not have "keloid" were non-ablative (with exception to mild/medium tca peels). So when can we suppose one can do a fully ablative Erbium Yag Resurfacing with this new data for Accutane usage (it seems to infer 6 months still)? Or is the new data one can only have non ablative treatment sooner than 6 months. What good could a "mild" peel do to acute acne scars if the patient needs resurfacing.

• "Fully ablative (i.e., nonfractional) treatment of the entire face or nonfacial regions should generally be avoided until 6 months after completion of isotretinoin treatment because of the likely elevated risk of avoidable adverse events."
• "Full-face dermabrasion and mechanical dermabrasion with rotary devices is not recommended within 6 months of isotretinoin use, as it may be associated with increased risk of adverse events in selected patients."
• "Lasers/energy devices There is no evidence to justify delaying treatment with hair removal lasers and lights, vascular lasers, nonablative fractional devices, and ablative fractional devices in patients who are receiving isotretinoin or have received isotretinoin within the past 6 months."
• "Chemical peels Supercial chemical peels can be safely administered to patients taking isotretinoin or within 6 months after isotretinoin therapy."
• "Insufcient data on the use of medium or deep chemical peels while on isotretinoin to preclude a recommendation in this case."
• "Other surgeries, including incisional and excisional surgery and nondermatologic procedures Isotretinoin should be stopped before LASIK surgery because of the risk of dry eyes."

It does not speak to "subcision" other than surgery/ excision so don't know what to conclude from the data on that. A side effect even in non- Accutane users is possible Keloids so that only increases risks of that outcome during/ shortly after Accutane usage.

Further ... It does not mention the usage of filler which many patients want with highly atrophic scarring / pitting during Accutane.

Quote Source:ASDS Guidelines Task Force:Consensus Recommendations Regarding the Safety of Lasers, Dermabrasion,ChemicalPeels,EnergyDevices,andSkin Surgery During and After Isotretinoin Use- 2017

I don't see anything revolutionary really. The overall take away is still the same - anything that leaves an open wound meant to heal through secondary intention is still not recommended within 6 months after accutane (ablative lasers, dermabrasion, deep chemical peels). Things like excisions are also still not recommended because of impaired wound healing. The only change listed is that mild lasers that do NOT wound the skin are possibly fine. That's not surprising at all because there is no open wound left to heal on it's own.

Temporary fillers are definitely safe. As someone who has had accutane, I personally noticed a change in how my skin healed. I had punch excisions before and after accutane, and the ones after all healed significantly more poorly.

Beg to differ as what is perceived a mild ( even fully ablative lasers) all the way to RF etc... can remodel early scars. So, if you can prevent scars, its quite a good thing. Fully ablative lasers and microneedling provide an open wound as the s. corneum is breached. NA laser (non ablative), no breach also indicated and safe- s. corneum is not breached. The consunsus for surgical is fence sitting, must agree, but flip side, surgical punch excision, elevation, etc.. all deemed OK, confusing I must agree. But at least a starting point. Glass half full...

Very interesting. I am on a 10mg long term dose, because I have very persistent acne (mostly whiteheads). My dermatologist doesn't do any scar treatment at all, but he is a big believer in low dose accutane being just as effective as larger doses (I do weight 85kgs). I could be on this low dose for several more months (been almost five). Recent studies also suggest that this is true, with a lot less side effects to boot! He states the reaching a culmitative dose theory is outdated.

I do live in Australia and I might explore David Lim in the future. It looks like he wouldn't hesitate to treat me even with accutane. However, I am cautious and David Lim is so far the only dermatologist I would consider visiting (too many horror stories with scar revision, you have to be very careful who you see).

A very interesting paper. He does mention low dose accutane, so it could be quite a few other derms in Australia are following the newer low dose treatment in general.

Dr Davin Lim is by no means the only dermatologist out there - he does more acne scar revision than other dermatologist as most of his practice is geared up towards scars. IN theory, he should have higher numbers of horror stories, given the total amount of work. There are many good dermatologist who he has learned from including Prof Goh, Chu and others when he trained in Singapore, and the NHS, and even Prof Goodman from Melbourne who was at one time the best - most committed dermatologist in regards to scars. Also not to mention Dr Emil who learned from Dr Chu as well, and countless others.

You are correct with the low dose isotretinoin thing, as most dermatologist now practice the low dose rather than the 120-150 mg kg total cumulative dose. My friend who works as a Dermatology SPR in the NHS told me thats still the go in their catchment area. ie. get them in push the dose, high as possible, then get them out. The only way the department can get funding is via numbers. Not ideal for patients, but its the governments incentive.