Diode Laser Hair Removal and IsotretinoinTherapy

To the Editor:We read with interest the article by Dr. Khatrisuggesting the safe combination of diode laser hairremoval with oral isotretinoin therapy and the relatedcommentary of Dr. Goodman.1,2 We gained similarexperience with the use of another diode laser devicewith a wavelength of 810 nm. Our results refer to asmall series of selected cases evaluated in a 4-yearperiod, consisting of six female patients, aged 17 to 32years (mean age 26.5 years), who suffered from acnevulgaris and facial hirsutism and had Fitzpatrick skintypes II (two patients) and III (four patients). Fourpatients had nodulocystic acne, whereas the otherspresented with moderate acne resistant to conventionaltherapies and associated with relevant psychologicalimpact. Treatment with isotretinoin, at a daily dose of0.5 to 1 mg/kg, was prescribed. All of the patients weremade aware of the side effects of the drug, including therisk of epidermal stripping after waxing procedures.3–5

One to 3 months after starting therapy with isotretinoin,four patients required the use of an alternative methodof hair removal owing to the distress created by thepresence of unwanted hair, brown to black in color, ontheir face (upper lip, chin, and cheeks). Despite ourrecommendations, two of these patients used waxepilation, which caused erosions, which subsequentlyresolved without scarring but with a remarkablehyperpigmentation of the upper lip in one case. Thus,we considered the possibility of diode laser epilationbased on the overall good tolerability obtained in ourpractice. After being informed of the potential risks, thepatients gave their consent to laser treatment. The doseof isotretinoin was cautiously reduced up to 0.3 to0.5 mg/kg; treatment was continued until a sufficientcumulative total dose was achieved.6,7 Laser treatmentswere repeated at 2-month intervals, with suspension inthe summer months until the patients were no longersuntanned; the total number of treatments varied fromfour to nine. Treatment was performed with a24 � 20 mm cooling handpiece scanner in combinationwith a dynamic cooling system, which delivered acontinuous flow of chilled air to the treatment area, atfluences variable from 25 to 35 J/cm2 with a pulseduration of 120 to 200 milliseconds. The first treatmentwas done with lower fluences, which were graduallyincreased, depending on the skin reactions. Aftertreatment, each patient developed mild to moderateand transient erythema on the treated area, and threepatients also had sparse dotted crusting, which healedcompletely within a few days. At follow-up evaluations,no cutaneous changes possibly related to laser treatmentwere detected. Similar results were obtained in two pa-

tients who underwent diode laser removal of unwantedfacial hair, with the same modalities described above,soon after completing isotretinoin therapy. Interestingly,these patients complained of great psychosocial distressfrom hirsutism since their acne improved.

Oral isotretinoin is the treatment of choice of nodulo-cystic acne and is increasingly used to treat less severeacne that responds unsatisfactorily to conventionaltherapies, especially if associated with psychologicaldistress and the risk of scarring. Prescribing physiciansmust have sufficient experience of the drug to avoid andmonitor side effects, which are mostly dose related, andto inform patients correctly. Rare side effects includedelayed wound healing, atypical scarring, and keloids,which have been observed after dermabrasion or lasertherapy in patients who previously received or weretaking isotretinoin.8–10 Atypical facial scarring was alsoreported in a patient treated with dermabrasion prior toisotretinoin.11 For these reasons, it is recommended thattherapy with systemic isotretinoin should not be com-bined with any more or less ‘‘skin-damaging’’ proce-dures, including chemical peeling,12 and a sufficientperiod of time, still undetermined, should elapse betweenisotretinoin and potentially ‘‘skin-damaging’’ proceduresor between these procedures and isotretinoin.

Our results, as well as those of Dr. Khatri,1 seem tosuggest the potential safety of diode laser hair removalin patients receiving isotretinoin. Moreover, we agreethat this might not apply to all laser and light systems.While awaiting more accurate data from large patientseries, we think, however, that it is prudent to avoid orrestrict similar types of combination treatments,especially if there is no adequate experience of bothoral isotretinoin and laser therapy.

NICOLETTA CASSANO, MDBari, Italy

Rome, Italy

NICOLA ARPAIA, MDGINO ANTONIO VENA, MD

Bari, Italy

References

1. Khatri KA. Diode laser hair removal in patients undergoingisotretinoin therapy. Dermatol Surg 2004;30:1205–7.

2. Goodman G. Commentary. Dermatol Surg 2004;30:207.3. Holmes SC, Thomson J. Isotretinoin and skin fragility. Br J Dermatol

1995;132:165.4. Egido Romo M. Isotretinoin and wax epilation. Br J Dermatol 1991;

124:393.5. Woollons A, Price ML. Roaccutane and wax epilation: a cautionary

tale. Br J Dermatol 1997;37:839–40.6. Harms M. Systemic isotretinoin (active ingredient of Roaccutane).

Basel: Editions Roche; 1990.

r 2005 by the American Society for Dermatologic Surgery, Inc. � Published by BC Decker Inc.ISSN: 1076-0512 � Dermatol Surg 2005;31:380–381

7. Cassano N, Vena GA. Acne e retinoidi. Roma: Performance S.r.l.;2000.

8. Rubenstein R, Roenigk HH Jr, Stegman SJ, Hanke CW. Atypicalkeloids after dermabrasion of patients taking isotretinoin. J Am AcadDermatol 1986;15:280–5.

9. Zachariae H. Delayed wound healing and keloid formationfollowing argon laser treatment or dermabrasion during isotretinointreatment. Br J Dermatol 1988;118:703–6.

10. Bernestein LJ, Geronemus RG. Keloid formation with the 585-nmpulsed dye laser during isotretinoin treatment. Arch Dermatol1997;133:111–2.

11. Katz BE, Mac Farlane DF. Atypical facial scarring after isotretinointherapy in a patient with previous dermabrasion. J Am AcadDermatol 1994;30:852–3.

12. Rubin MG. Manual of chemical peels: superficial and mediumdepth. Philadelphia: JB Lippincott; 1995.

Tubed Pedicled Transposition Flap for AuricularReconstruction

To the Editor:I agree with Suchin and Greenbaum’s excellent choiceof the tubed preauricular pedicled flap for reconstruc-tion of a large anterior ear defect with cartilage expo-sure.1 There is a significant literature on pedicled flapsavailable to the interested surgeon, dating back to thepost–World War I days of the early evolution of plasticsurgical concepts in Britain, France, and Germany.2,3

We use them infrequently now because they requiretwo stages (or more) to accomplish movement to adistant site. Perhaps we are a bit remiss and shouldaccept more complicated challenges such as these withgreater frequency. I found the pedicles to be quite har-dy, wrapping them in protective thin gauze and thenplacing a wick into the dressing, with patients thenmoistening the pedicles and implanted flap tips withsterile normal saline solution. A special protective eardressing is mandatory.

In addition to reconstruction of the upper anterioror midear by either superiorly or inferiorly based pe-dicles arcing across to the defect, the tubed pedicle flapcan be inferiorly based and allow reconstruction of theantitragus and adjacent antihelix (see Field,2 Figures11 and 12), as well as the mid- and lower ear scaphaand rolled helical margin. This approach may also beused to replace some of the transcartilaginous postau-

ricular-to-anterior ear tissue movements, which havebecome vogue to some. Furthermore, the random cir-culation pedicle allows delivery of somewhat thickerflap tips than those obtained from retroauricular lo-cations to fill those deeper defects when cartilage hasbeen fully or partially sacrificed but the posterior earskin is intact as a base for the distal flap placement.The inadvertent inclusion of hair is less problematicnow with the advent of hair removal laser apparatus,but it should be noted that the infra-auricular skin ishairless in varying distances from the infra-auriculargroove. Extending the excision inferiorly while curvingunder the dependent lobe allows harvesting of thathairless tissue4 and results in a hidden closure belowand just posterior to the ear lobe.

LAWRENCE M. FIELD, MD, FIACSFoster City, CA

References

1. Suchin K, Greenbaum S. Resolution of conundrum. Dermatol Surg2004;10:240–1.

2. Field L. The preauricular tubed pedicle flap. J Dermatol Surg Oncol1989;15:614–8.

3. Field L. The preauricular pedicled flap. In: Haut-und-Geschlechts-Krankheiten, XIIth International Congress of Dermatologic Surgery,Book of Abstracts. Berlin: Springer-Verlag; 1991. p. 329–30.

4. Field L. The infra-auricular full-thickness donor site with V-Y clo-sure. J Dermatol Surg Oncol l984;10:345.

Dermatol Surg 31:3:March 2005 COMMUNICATIONS AND BRIEF REPORTS 381