Medical Aesthetics for People on Medication or with Chronic Conditions: What to Watch Out For and What to Ask Your Physician

Is medication or a chronic condition a barrier to an aesthetic procedure?

In most cases, no. However, the same procedure carries different risks in different people. In someone taking a blood thinner the likelihood of bruising increases; in someone whose blood sugar is not under control, infection and wound-healing problems become more important; in someone with a tendency to keloids, procedures that injure the skin may leave scars. The physician’s task is to weigh these risks and, if necessary, to change the procedure, postpone it or advise against it.

Most of the evidence on these subjects comes from expert consensus reports, reviews and clinical experience; for many questions there is no single rule that fits everyone. The information below is therefore a general framework and does not replace an examination. For the full list of information to give the physician before a procedure, see our article “Preparing for a Medical Aesthetic Procedure: What to Tell Your Physician, Timing and the Day Itself”.

Summary table: situation, points to note and what to ask the physician

What changes if I take a blood thinner?

Blood thinners fall into two main groups: anticoagulants, which affect the clotting system (for example warfarin, rivaroxaban, apixaban, dabigatran), and antiplatelets, which affect the blood platelets (for example acetylsalicylic acid, clopidogrel). These medicines are mostly given to prevent serious events such as a stroke, a heart attack or a blocked blood vessel.

A recent review on skin surgery emphasises that there is no agreed guideline on how these medicines should be managed around the time of a procedure and that practice varies from physician to physician, while stopping the medicine increases the risk of events such as stroke, heart attack and blocked blood vessels. A consensus report prepared for botulinum toxin and hyaluronic acid filler also states that people taking prescription blood thinners can be treated and that the balance of benefit and harm does not favour stopping these medicines.

• The main difference to expect is more bruising that lasts longer; knowing this in advance and planning the procedure accordingly may be enough.
• Your physician may choose a less traumatic technique, divide the procedure into sessions or advise against the procedure in some areas.
• If any change to the medicine is needed, this decision is made by the cardiology, neurology, haematology or internal medicine physician who prescribed it.
• Painkillers you take without a prescription and supplements such as fish oil, vitamin E, garlic, ginger and ginkgo can also affect clotting; mention these too.

On the course of bruising and when you need to worry, you can read our article “Bruising and Swelling: How Long Do They Last after an Aesthetic Treatment, How Can They Be Reduced and When Should You Worry?”.

Can I have a procedure while taking isotretinoin or after stopping it?

For many years it was taught that in people taking oral isotretinoin, and within 6–12 months of stopping the medicine, laser, peels and similar procedures could lead to poor wound healing and scarring. It was later shown that this approach rested on a small number of small case series published in the 1980s.

Two separate consensus studies published in 2017 (one a systematic review published in the journal JAMA Dermatology, the other the task force report of the American Society for Dermatologic Surgery) reassessed the existing publications. Their shared conclusion is this: in people taking isotretinoin or who have recently stopped it, sufficient evidence was not found to justify postponing procedures such as superficial chemical peels, laser hair removal, vascular lasers, and non-ablative and fractional lasers. By contrast, deep and intensive procedures such as mechanical dermabrasion and fully ablative laser applied to the whole face were not recommended during this period.

• These reports do not say that 'every procedure is safe'; they say that the decision should be made separately according to the type and depth of the procedure.
• The medicine’s package leaflet continues to carry a recommendation to wait, and many physicians prefer to wait, especially for deep procedures. Both approaches can be weighed up in discussion with the physician.
• Isotretinoin dries the skin and makes it sensitive; for this reason irritation can occur even with simple treatments such as waxing. Say that you are taking it before every procedure.
• Do not stop isotretinoin, or change its dose, on your own in order to have an aesthetic procedure.

For the treatment options for acne scars, see our article “Acne Scars: Types, Treatment Options and Realistic Expectations”.

Immunosuppressant medicines, diabetes and autoimmune disease

When assessing the risk of infection, the consensus report on filler treatments lists a suppressed immune system, uncontrolled type 2 diabetes, chronic or recurrent skin conditions and previous problems with filler among the situations that should be asked about. These situations do not in themselves rule out the procedure; however, they require the physician to take greater care in choosing the procedure, preparing for it and following you up.

For autoimmune diseases, the same report states that filler is not an absolute contraindication in people whose disease is under control and that each patient should be assessed individually. Another consensus report, examining reactions that appear late after filler, lists active autoimmune disease and recent dental treatment among the possible patient-related risk factors. Research in this field is limited; for this reason, postponing the procedure during a flare of the disease is a common approach.

• State the name of your condition, its current status and all the medicines you take (including biological medicines and corticosteroids).
• You can ask for the opinion of the rheumatology, endocrinology, nephrology or oncology physician who looks after you to be obtained.
• If you have diabetes, share your recent blood sugar control; if control is not good, postponing the procedure may be recommended.
• If after the procedure you have redness, warmth, discharge, fever or hard swellings that appear weeks later, see your physician without waiting. For details, see our article “Infection after Aesthetic Treatments: Symptoms, Cold Sore Flare-ups, Late Infection and What to Do”.
• Diseases affecting the neuromuscular junction (for example myasthenia gravis) are of particular importance with regard to botulinum toxin; if you have this diagnosis, be sure to mention it.

Tendency to keloids or raised scars

A keloid is a raised scar that grows beyond the boundaries of the wound, and it can develop after any kind of intervention that injures the skin. The American Academy of Dermatology recommends that people with a tendency to keloids tell the physician about this before a cosmetic procedure or surgery and, if the procedure is still wanted, that a small test area be treated first and the area watched for thickening. The U.S. Food and Drug Administration also states that the safety of fillers is not known in people with a tendency to excessive scarring.

In practice, this does not mean staying away from all procedures. Procedures that do not injure the skin, or injure it very little, do not carry the same risk as procedures that cause more tissue damage, such as ablative laser, medium and deep peels and thread lifts. Which procedure is suitable for you is decided by the physician, who assesses your previous scars and your family history.

History of recurrent cold sores

The cold sore virus stays dormant in the body and can be reactivated by factors such as skin trauma, sun, fever or stress. It is accepted that a cold sore flare-up after aesthetic procedures is uncommon, but there are no reliable data on how often it happens. Although a flare-up heals by itself, it can be painful; if it spreads on skin that has been peeled by laser or a chemical peel, it can leave scars.

• Injections of the lips and around the mouth, ablative lasers and medium to deep peels matter more where cold sores are concerned.
• Your physician may plan preventive antiviral treatment according to your history and the procedure. These medicines are used on prescription and in the way the physician specifies; do not use medicine left over at home on your own.
• If on the day of the procedure there are signs of a cold sore such as tingling, burning or blisters, the procedure is usually postponed.

For information specific to laser and peels, see our articles “Fractional Laser: How Suitable Is It for Acne Scars, Wrinkles and Skin Texture?” and “Chemical Peels: What They Are, Who They Suit and What Recovery Involves”.

How is the decision made?

In a good assessment the physician weighs first the benefit the procedure will bring you and then the risks specific to your situation. The outcome may not always be 'go ahead': postponing the procedure, moving to a milder option, increasing the number of sessions or advising against the procedure are also correct decisions. Asking for an opinion from the physician who prescribed your medicine is not a delay but a safety step.

Pregnancy and breastfeeding are a separate subject; we deal with this in our article “Medical Aesthetics in Pregnancy and Breastfeeding: Which Treatments Should Be Postponed, and What Should You Discuss with Your Physician?”. Be careful about places that do not ask in detail about your medical and medication history or that recommend a procedure without examining you; on this, you can refer to our article “A 10-Point Safety Checklist for Choosing a Clinic and Physician for Medical Aesthetics”.