The world of beauty has changed so much over the last decade. No longer is it a simple case of which facial we might like but a much bigger question of what we want to achieve and what lengths will we go to in order to achieve our outcome. The world of science and beauty is firmly bonded together and a great deal of transformational changes can now be achieved using nonsurgical cosmetics.
There are a number of non-surgical cosmetic treatments out there however some treatments such as injectables, microblading and tattooing are more invasive than others. These can be potentially problematic for people on anticoagulants, antiplatelets, non-steroidal anti-inflammatory medication and some herbal preparations or supplements.
All these procedures carry a risk of bleeding and bruising so how should one go about these treatments if on anticoagulation medication such as injectable heparins, or oral anticoagulants like apixaban, dabigatran, edoxaban, rivaroxaban and warfarin?
You may be surprised but there are no formal guidelines in place to address this situation and information out there is confusing. It is also worth knowing that the cosmetic industry in the UK lacks regulation and some of these risky procedures can be conducted by people with a lack of medical knowledge around anticoagulation therapy and related conditions. Tattooing and microblading (a technique whereby semi-permanent ink is applied to the eyebrow area by making tiny incisions to the skin to create defined eyebrows) are provided mainly by beauty therapists and guided by their insurers which generally excludes patients on anticoagulation. The practitioner should ask if the patient is on anticoagulation and may ask you to sign a consent form to state that they are not liable should anything go wrong, if it’s a treatment that you are determined to try.
So, what is it that you need to think about before opting for an injectable non-surgical cosmetic treatment?
- Is the treatment safe for me to have because I’m on anticoagulation and what are the risks?
- Will the treatment work if I am on anticoagulation?
- Can the practitioner provide the treatment safely?
Is the treatment safe for me and how do I minimise risk?
This is based on the balance of risks and benefits. Many practitioners will be happy to provide wrinkle relaxing treatments which are sometimes referred to by one of the brand names, e.g. Botox, but there are many other brands on the market.
Of greater concern is the use of cosmetic injectable dermal fillers which carry greater risks of bleeding and bruising.
This is because evidence on safety of cosmetic injectables in patients on anticoagulation is limited and the risks of bruising and bleeding due to cosmetic procedures are unknown in such patients. Pharmaceutical company, Allergan, cautions that their dermal filler products have not been researched on individuals on anticoagulants. They, therefore, recommend that a patient should seek a risk-benefit assessment from their GP before undergoing treatment.
Two other pharmaceutical companies, Teoxane and Merz, recommend waiting for 7 – 10 days after the end of anticoagulation treatment before any injections are administered.
The British Society of Dermatological Surgery Guidance on Antithrombotic and Skin Surgery (2016)1 has produced guidelines on anticoagulation management for surgical intervention but does not include prescriptive cosmetic procedures. It is noted that some herbal preparations and dietary supplements may also increase bleeding risk and should be stopped before surgery.
Ideally, it’s advisable to discuss potential cosmetic treatments with the healthcare professional responsible for your anticoagulation therapy, however, they may not be able to help with or provide any advice required in relation to aesthetic treatments given the current high demand for cosmetic procedures and the stretched NHS.
Making a decision – what you need to consider
- How long will you need be to be on anticoagulation medication for?
- Can you be treated after you have finished your treatment or can the treatment be paused?
In most cases its best to finish your anticoagulation medication therapy and consider cosmetic procedures afterwards.
However, if you are on long term-treatment or you would not like to wait to complete the course of anticoagulation then this should be discussed with a suitably qualified healthcare professional and you should be aware of the risks and benefits of continuing or stopping treatment. This is especially important in cases when anticoagulants are given to prevent blood clots and stroke risk for long term conditions such Atrial Fibrillation, Mechanical Valve replacement, clotting disorders or prevention of recurrent blood clots.
The advice here is always to continue taking your anticoagulation as the risk of developing a serious medical complication is greater than the cosmetic benefit.
Warfarin is a particular challenge because it stays in the body for a longer duration and can pose a challenge when planning any form of invasive treatment. This can include dental work too2
Close monitoring and an INR test to check your clotting levels may be required to plan your treatment safely and if a practitioner has limited understanding of how anticoagulants work and the risk of bleeding then this could pose a serious risk for the individual.
Newer anticoagulants such as apixaban, dabigatran, edoxaban and rivaroxaban are cleared from the body much quicker and there may be an opportunity to simply adjust the timing of the dose without having to stop treatment. However, this is something to talk to your healthcare practitioner about and mutually agree a plan in partnership with your GP or anticoagulation clinic.
It is therefore absolutely essential that you make sure that your treatment is done by a healthcare practitioner who can ensure your treatment is safe and they can minimise the complications of bleeding and/or bruising should you decide to proceed with the treatment.
Will the treatment work?
Antiwrinkle injections and dermal filler injections will be as effective as they would in someone who is not on anticoagulation but with an increased risk of bleeding and bruising.
Cosmetic tattooing is a challenge if you are on anticoagulants as excessive bleeding mixes with pigments and this can mean that the result may be unpredictable.
Can the practitioner provide the treatment safely?
One of the challenges here is that the aesthetics field is relatively unregulated. Changes are underway but these are not holistically in place at the moment and there are many beauty therapists delivering injectable treatments. If you are taking anticoagulants for any duration and you wish to have injectable therapy you are strongly advised to discuss the proposed treatment with the healthcare professional who is managing your anticoagulation therapy.
Some therapists have a medical background and will give you advice around the proposed treatment but you should be satisfied that you understand the risks especially if you are advised to stop taking your anticoagulants.
Healthcare professionals who carry out invasive aesthetic treatments will be registered and adhere to the standards of their clinical professional bodies3. They may also opt to register with voluntary organisations such as Saveface4 or the Joint Council for Cosmetic Practitioners (JCCP)5
When it comes to cosmetic tattooing6, again, you should seek guidance from a suitably qualified healthcare professional to ensure you still have the maximum protection provided by anticoagulation whilst reducing possible effects of bleeding that may occur.
Key points to consider
- The safest way forward is for the anticoagulation treatment course to be completed before any injectable aesthetic treatment or tattoo work is undertaken
- If you are taking regular anticoagulant therapy you will have discussed the reasons for this with a healthcare professional and you should be aware of the risks and benefits of continuing, pausing or stopping treatment.
- Any procedure can be associated with a risk of bruising or bleeding. This may result in personal harm or failure of the procedure. This risk will be increased if you are taking anticoagulants (like warfarin, dabigatran, rivaroxaban, apixaban or edoxaban) or medicines which affect platelet function (like aspirin and other antiplatelets)
- In general, warfarin, aspirin and any other antiplatelet are present in your body for a longer period that the newer anticoagulants(apixaban, dabigatran, edoxaban or rivaroxaban) General advice about stopping anticoagulation without knowledge of how a particular anticoagulant works could present a higher risk for some people and result in clot formation
- Do not stop your anticoagulation medication without seeking advise
- If you decide to have a procedure, ensure you have information on who you can contact should you experience any unusual symptoms.
Anticoagulation UK would like to thank Sharron Gordon and Mehnaaz Khan for their contribution to this article. ACUK has commissioned this article in response to enquiries from the public and have received no funding from industry and has not made any payments to the authors.
The content of this article does not seek to replace medical advice and any person wishing to undertake any of the procedures detailed above should seek medical guidance in respect of their current health circumstances.
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