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• W2626919230 abstract "To the Editor: Although safe use of oral retinoids with dermabrasion and resurfacing laser procedures have been reported in patients on isotretinoin, waiting 6-12 months after isotretinoin cessation is typically recommended before undergoing elective surgery.1Roenigk Jr., H.H. Pinski J.B. Robinson J.K. Hanke C.W. Acne, retinoids, and dermabrasion.J Dermatol Surg Oncol. 1985; 11: 396-398Crossref PubMed Scopus (72) Google Scholar, 2Khatri K.A. Iqbal N. Bhawan J. Laser skin resurfacing during isotretinoin therapy.Dermatol Surg. 2015; 41: 758-759Crossref PubMed Scopus (17) Google Scholar This recommendation arose from theoretical concern and from 9 prior cases (6 dermabrasions, 3 laser procedures) of delayed wound healing or keloid formation after cosmetic procedures in patients on isotretinoin.2Khatri K.A. Iqbal N. Bhawan J. Laser skin resurfacing during isotretinoin therapy.Dermatol Surg. 2015; 41: 758-759Crossref PubMed Scopus (17) Google Scholar, 3Rubenstein R. Roenigk Jr., H.H. Stegman S.J. Hanke C.W. Atypical keloids after dermabrasion of patients taking isotretinoin.J Am Acad Dermatol. 1986; 15: 280-285Abstract Full Text PDF PubMed Scopus (153) Google Scholar We aimed to evaluate the prevalence of scarring and postoperative complications in patients exposed and not exposed to isotretinoin in the perioperative period. One thousand six patients with isotretinoin and its brand names mentioned in their medical records from 1995-2011 were identified from the Mayo Clinic Data Discovery and Query Builder clinical database; medical records were searched for procedures in which a skin incision was made (Fig 1). After 282 patients were excluded because of unclear isotretinoin exposure, the patients were divided into 3 groups on the basis of isotretinoin exposure: exposed to isotretinoin within 2 years before surgery, exposed to isotretinoin >2 years before surgery, acne severe enough for mention of but never exposed to isotretinoin who underwent surgery within 2 years before surgery. Each group was followed for at least 2 years after surgery to look for surgically related adverse events (AE) defined as significant or abnormal scarring, wound infection, poor healing, excessive bleeding, and wound dehiscence. Within 2 years of follow-up after surgery, 2 of 76 (2.6%) patients who had incisional surgery with exposure to perioperative isotretinoin and 2 of 82 (2.4%) patients who had surgery without exposure to isotretinoin experienced AE related to surgery. Of the 2 exposed patients with an AE, 1 was taking isotretinoin at the time of surgery and continued postoperatively until course completion and 1 had completed the course 2 months prior (Table I).Table ISummary of adverse postoperative events in patients with incisional surgery exposed to isotretinoin, remotely exposed to isotretinoin, and those never exposed to isotretinoinIsotretinoin exposure?Patient no.RaceSexFitzpatrick skin typeAge at day 0,∗The first day of treatment with isotretinoin was set as the day 0 for the exposed group. The first mention of isotretinoin was day 0 for the unexposed. yType of surgeryLength of isotretinoin discontinuationCumulative dose at time of surgery, mgCumulative dose at end of drug course, mg (mg/kg)Adverse eventNever exposed1WMII31Open right thumb metacarpophalangeal fusionN/A00Mild maceration, periarticular thickness and swelling2WMNR16Tooth extractionN/A00Subperiosteal abscessRecently exposed3WFII17Wisdom tooth extraction2 months†Patient completed course of treatment.Total, completed dose7200 (120)Poor, edematous, and erythematous healing at incision sites4WFII18Tooth extraction0 days‡Patient started treatment 2 weeks before surgery and continued taking isotretinoin after surgery until course completion 5.5 months later. This patient's cumulative dose at time of surgery was 560 mg.5606000 (120)Alveolar osteitisRemotely exposed5WFII19Excision and drainage of a pilonidal cyst12 years†Patient completed course of treatment.NRNRExcessive postoperative bleeding and delayed wound healing6WMNR24Adenoidectomy12 years†Patient completed course of treatment.Total, completed dose13,500 (120)Postoperative bleeding§Mild, more than expected per surgical record. and delayed wound healing7WMIII18Tonsillectomy4 years†Patient completed course of treatment.Total, completed dose10,080 (120)Intermittent postoperative bleeding7WMIII18Excisional biopsy of the breast15 years†Patient completed course of treatment.Total, completed dose10,080 (120)Wound dehisced small distance laterally8WFIII35Double mastectomy11 years†Patient completed course of treatment.Total, completed dose12,600 (168)Superficial area of wound dehiscence on the left central breast9WFIII20Excisional biopsy of a left plantar compound nevus15 years†Patient completed course of treatment.NRNRCentral region of incision had dehisced and peripheral regions exhibited maceration10WFIII21Excision of a right Bartholin duct cyst13 years†Patient completed course of treatment.NRNRInfection at incision site11WFIII21Primary low transverse cesarean section with right inferolateral extension5 years†Patient completed course of treatment.Total, completed dose60 (0.85)Postoperative infection with poor healing and dehiscence12WFI/II40Bilateral reduction mammoplasty22 months†Patient completed course of treatment.NRNRFatty necrosis and dimpling, worse on the right breast than the leftF, Female; M, male; N/A, not applicable; NR, not reported; W, white.∗ The first day of treatment with isotretinoin was set as the day 0 for the exposed group. The first mention of isotretinoin was day 0 for the unexposed.† Patient completed course of treatment.‡ Patient started treatment 2 weeks before surgery and continued taking isotretinoin after surgery until course completion 5.5 months later. This patient's cumulative dose at time of surgery was 560 mg.§ Mild, more than expected per surgical record. Open table in a new tab F, Female; M, male; N/A, not applicable; NR, not reported; W, white. Oral retinoids have been associated with suppression of collagenase, potentially causing excessive collagen accumulation and keloid formation, and possible atrophy of the pilosebaceous unit, where re-epithelialization for wound healing originates.1Roenigk Jr., H.H. Pinski J.B. Robinson J.K. Hanke C.W. Acne, retinoids, and dermabrasion.J Dermatol Surg Oncol. 1985; 11: 396-398Crossref PubMed Scopus (72) Google Scholar, 2Khatri K.A. Iqbal N. Bhawan J. Laser skin resurfacing during isotretinoin therapy.Dermatol Surg. 2015; 41: 758-759Crossref PubMed Scopus (17) Google Scholar, 3Rubenstein R. Roenigk Jr., H.H. Stegman S.J. Hanke C.W. Atypical keloids after dermabrasion of patients taking isotretinoin.J Am Acad Dermatol. 1986; 15: 280-285Abstract Full Text PDF PubMed Scopus (153) Google Scholar, 4Mahadevappa O.H. Mysore V. Viswanath V. et al.Surgical outcome in patients taking concomitant or recent intake of oral isotretinoin: a multicentric study-ISO-AIMS study.J Cutan Aesthet Surg. 2016; 9: 106-114Crossref PubMed Scopus (19) Google Scholar, 5Wootton C.I. Cartwright R.P.E. Manning P. Williams H.C. Should isotretinoin be stopped prior to surgery? A critically appraised topic.Br J Dermatol. 2014; 170: 239-244Crossref PubMed Scopus (21) Google Scholar A review of the literature showed that the AEs associated with surgical procedures performed on persons with isotretinoin exposure included nasal tip deformities (2 patients), slow wound healing (1 of 3 patients undergoing otolaryngologic surgery), slow healing (1 patient undergoing pilonidal cyst excision), and dry socket (3 of 25 patients with wisdom teeth extractions) (Table I).5Wootton C.I. Cartwright R.P.E. Manning P. Williams H.C. Should isotretinoin be stopped prior to surgery? A critically appraised topic.Br J Dermatol. 2014; 170: 239-244Crossref PubMed Scopus (21) Google Scholar The largest published study of 183 patients who underwent 504 surgical interventions while on isotretinoin reported 2 AE (0.4%) of keloid formation: 1 after radiofrequency ablation and the other after glycolic acid peel.4Mahadevappa O.H. Mysore V. Viswanath V. et al.Surgical outcome in patients taking concomitant or recent intake of oral isotretinoin: a multicentric study-ISO-AIMS study.J Cutan Aesthet Surg. 2016; 9: 106-114Crossref PubMed Scopus (19) Google Scholar These complications could have been attributed to the aforementioned procedures; thus a causative effect of isotretinoin exposure was not clearly demonstrated. Our study evaluated surgical outcomes in an otherwise healthy and similar population of patients exposed and unexposed to isotretinoin who had a large number and variety of incisional procedures. The large sample of patients with acne severe enough to be considered for isotretinoin therapy allowed us to effectively control for acne severity, a factor which could also contribute to scar formation or alteration in wound healing. In summary, from medical record review, wound healing did not appear to be affected, and abnormal scarring did not appear to be evident in patients undergoing isotretinoin therapy as compared with those not exposed to the medication in the perioperative period. Because this study is limited by an overall low level of AE and its retrospective nature, the findings challenge the current practice of waiting 6-12 months to have elective surgery after isotretinoin exposure. Taking into consideration the small pool of case-based literature from which the recommendation to discontinue isotretinoin developed, a re-evaluation of this practice should be considered. The authors thank Shadi Rashtak, MD, and Shahryar Khaleghi, PharmD, for their contribution in identifying the initial patient population." @default.
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• W2626919230 title "Surgical outcomes of patients on isotretinoin in the perioperative period: A single-center, retrospective analysis" @default.
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