Clinical trial of a pinpoint irradiation technique with the CO2 laser for the treatment of atrophic acne scars

Ablative laser resurfacing is an effective treatment for atrophic acne scars. However, it often induces complications such as edema, prolonged erythema, scarring and hyperpigmentation. Therefore, a new concept of laser treatment called fractional photothermolysis has been designed to create microscopic thermal wounds to achieve skin rejuvenation treatment of atrophic acne scars. This study was designed to prospectively evaluate the use of a technique similar to fractional photothermolysis using only the standard CO₂ laser without the fractional laser device in the treatment of atrophic scars and demonstrates it as a safe, effective and economical treatment option. Clinical improvement was achieved in all 35 patients with minimal adverse effects.     

Effectiveness of CO2 laser with subcision in patients with acne scars

Background: Post-acne facial scarring has always been a challenge to treat. It requires multiple therapeutic modalities as single modality is not hundred percent effective. Therefore, we have combined CO₂ laser resurfacing with subcision in patients with acne scars for better results. Objectives: The aim is to study the effectiveness and side effects of CO₂ laser with subcision in patients with atrophic acne scars. Methods: Fifty patients were selected for the study. Baseline grading was done with Goodman and Baron grading system. Twenty-five patients were randomly selected for subcision followed by CO₂ laser and the remaining patients were selected for CO₂ laser alone. The treatment was done for four sessions at 4-week interval. Clinical photographs were obtained for evaluation. Results: CO₂ laser with subcision showed excellent response in grade-2 and -3 acne scars. Statistically there is a significant difference between CO₂ laser following subcision and CO₂ laser alone at 5% level (p < 0.05). Both procedures were well tolerated with minimal side effects. Conclusion: The highly versatile CO₂ laser is useful for treating acne scars. Subcision prior to the CO₂ laser procedure showed better improvement when compared to CO₂ laser alone. Thus, in acne scars, multiple therapeutic modalities achieve better results.     

Efficacy of Punch Elevation Combined with Fractional Carbon Dioxide Laser Resurfacing in Facial Atrophic Acne Scarring: A Randomized Split-face Clinical Study

Background:

A number of treatments for reducing the appearance of acne scars are available, but general guidelines for optimizing acne scar treatment do not exist. The aim of this study was to compare the clinical effectiveness and side effects of fractional carbon dioxide (CO₂) laser resurfacing combined with punch elevation with fractional CO₂ laser resurfacing alone in the treatment of atrophic acne scars.

Materials and Methods:

Forty-two Iranian subjects (age range 18–55) with Fitzpatrick skin types III to IV and moderate to severe atrophic acne scars on both cheeks received randomized split-face treatments: One side received fractional CO₂ laser treatment and the other received one session of punch elevation combined with two sessions of laser fractional CO₂ laser treatment, separated by an interval of 1 month. Two dermatologists independently evaluated improvement in acne scars 4 and 16 weeks after the last treatment. Side effects were also recorded after each treatment.

Results:

The mean ± SD age of patients was 23.4 ± 2.6 years. Clinical improvement of facial acne scarring was assessed by two dermatologists blinded to treatment conditions. No significant difference in evaluation was observed 1 month after treatment (P = 0.56). Their evaluation found that fractional CO₂ laser treatment combined with punch elevation had greater efficacy than that with fractional CO₂ laser treatment alone, assessed 4 months after treatment (P = 0.02). Among all side effects, coagulated crust formation and pruritus at day 3 after fractional CO₂ laser treatment was significant on both treatment sides (P < 0.05).

Conclusion:

Concurrent use of fractional laser skin resurfacing with punch elevation offers a safe and effective approach for the treatment of acne scarring.     

Fractional CO2 lasers for the treatment of atrophic acne scars: A review of the literature

Abstract

This review examines the efficacy and safety of fractional CO₂ lasers for the treatment of atrophic scarring secondary to acne vulgaris. We reviewed 20 papers published between 2008 and 2013 that conducted clinical studies using fractional CO₂ lasers to treat atrophic scarring. We discuss the prevalence and pathogenesis of acne scarring, as well as the laser mechanism. The histologic findings are included to highlight the ability of these lasers to induce the collagen reorganization and formation that improves scar appearance. We considered the number of treatments and different laser settings to determine which methods achieve optimal outcomes. We noted unique treatment regimens that yielded superior results. An overview of adverse effects is included to identify the most common ones. We concluded that more studies need to be done using uniform treatment parameters and reporting in order to establish which fractional CO₂ laser treatment approaches allow for the greatest scar improvement.     

Randomized clinical trial of CO2 LASER pinpoint irradiation technique versus chemical reconstruction of skin scars (CROSS) in treating ice pick acne scars

Abstract

Background: Pinpoint irradiation technique CO₂ LASER and Chemical Reconstruction Of Skin Scars (CROSS) are effective treatments for atrophic acne scars as fractional photothermolysis. Objective: This study was designed to prospectively compare the use of a pinpoint irradiation technique versus TCA CROSS in treating ice pick acne scars. Methods: Thirty-two patients with ice pick acne scars were included in this open, label pilot study. Pinpoint irradiation technique by CO₂ LASER and TCA CROSS were applied for the study and control group, respectively. Twenty-eight patients with ice pick acne scars were included in this open, label pilot study. They were randomly assigned to two groups: the first group (14 patients) received pinpoint irradiation by CO₂ LASER as a study group, and the second group (14 patients) received TCA CROSS as a control group. In both treatments, there were four sessions at 3-week interval, and 3 months of follow up. Results: There were statistically significant difference in acne scar severity index and qualitative scarring grading system in the improvement results between the study and control groups (p < 0.05). Conclusion: Pinpoint irradiation technique by CO₂ LASER is safe and more effective than TCA CROSS technique. Clinical improvement was achieved in all 14 patients without dramatic adverse effects.     

Efficacy and safety of a single treatment using a 10,600-nm carbon dioxide fractional laser for mild-to-moderate atrophic acne scars in Asian skin

BackgroundAblative laser therapy with carbon dioxide is effective for acne scars; however, the long downtime limits its use, especially in types III and IV skin. The fractional ablative 10,600-nm carbon dioxide laser system reportedly maximizes efficacy and minimizes side effects. The goal of this study was to evaluate the efficacy and safety of an ablative 10,600-nm carbon dioxide fractional laser system in a single treatment session on atrophic acne scars in Asian patients.MethodsTwenty-five patients with atrophic acne scars were enrolled. The laser fluences were delivered using the Deep FX mode. Comparative photographs were taken with VISIA complexion analysis. Physician evaluation and patient satisfaction were graded on a four-point scale.ResultsAt follow-up 1 month after treatment, four patients showed 51–75% improvement, 16 had 26–50% improvement, and five had minimal or no improvement. At 3 months, two patients had excellent results (76% and 100% improvement). Postinflammatory hyperpigmentation was present in six of the 25 (24%) patients; by 3 months' follow-up, this had faded in five of six cases.ConclusionA single treatment with the carbon dioxide fractional laser system is effective for acne scars in Asian patients, with minimal and acceptable side effects.     

Treatment of atrophic facial acne scars with fractional Er:Yag laser

Background: Acne scars are often a permanent disfiguring sequel of acne vulgaris. Although many treatment modalities are available, they are often non satisfactory for all patients. Objective: To determine the effectiveness and safety of fractional 1540 nm erbium_glass laser treatment of facial acne scars in Iraqi patients. Patients and methods: Twenty one patients were enrolled in this prospective clinical study. Three sessions of the 1540 nm erbium glass laser were applied at 2-week intervals. The patients were assessed at 1, 3, and 6 months after the last session. The effect of treatment was assessed by objective (Sharquie scoring system for grading acne scarring and visual analog scale) and subjective (patient satisfaction) methods. Results: Two patients were defaulted. Eleven patients (57.9%) showed improvement from moderate to mild grade, and no grade changes were detected in eight patients (42.1%). The mean score of the visual analog scale prior to treatment was 8.61 ± 0.86 and decreased to 6.15 ± 1.28 (P = 0.037). Ten patients were satisfied to varying degrees. No significant side effects were noted. Conclusion: Non-ablative fractional 1540 nm erbium glass laser is an effective and safe method to treat acne scars and represent good alternative for patients who cannot use the ablative methods because of its longer downtime.     

Combination of intense pulsed light and fractional CO2 laser treatments for patients with acne with inflammatory and scarring lesions

Background. Various laser and light sources are been used increasingly in cosmetic dermatology. Aim. To evaluate the efficacy and safety of combination intense pulsed light (IPL) and fractional CO₂ laser in treating patients with acne with both inflammatory and scarring lesions. Methods. In total, 37 Chinese patients with acne with facial inflammatory and scar lesions were treated. Successive sessions of 4–6 IPL treatments followed by 2 sessions of fractional CO₂ laser treatments were applied. Effectiveness was determined by the dermatologist’s evaluation, patient self‐assessment, and devices that measure skin colour, sebum secretion and skin hydration. Results. IPL treatments significantly reduced the inflammatory lesion score and the atrophic scar score compared with baseline. Subsequent fractional CO₂ laser treatments further decreased the atrophic scar score. Both scores remained low when patients were followed up at 6 months. Around 90% of the patients experienced significant or moderate overall improvement, and almost 80% patients rated their results as ‘excellent’ or ‘good’. The melanin index (MI), erythema index (EI) and skin sebum level all significantly decreased after IPL treatments, and the EI and sebum level were still low when assessed at the 3‐month follow‐up, although the MI had increased again. The adverse effects (AEs) of both treatments were transient and bearable. Conclusions.  IPL in combination with fractional CO₂ laser was effective in treating patients with acne with both inflammatory lesions and atrophic scars, and the AEs were acceptable.     

Treatment of atrophic facial acne scars with fractional Er:YAG laser in skin phototype III–IV: A pilot study

Background: Fractional ablative lasers have recently been used for the treatment of skin scars. The objective of this study was to assess the efficacy and safety of the fractional erbium-doped yttrium aluminum garnet (Er:YAG) laser (2940 nm) in the treatment of skin scars. Materials and methods: A total of 9 patients (8 female, 1 male) with Fitzpatrick skin types III and IV suffering from atrophic facial acne scars were treated with a fractional Er:YAG laser for 2–5 (mean 3.3) sessions 4–6 weeks apart. One independent investigator assessed the efficacy, using standardized photographs, before and 1 month after the last treatment. The patients’ satisfaction rate was also evaluated. Results: The treatment was well tolerated by all patients without any anesthesia. The downtime was 2–3 days. All patients showed improvement in scars: excellent in 1, good in 1, and fair in 7 patients. Six patients were highly satisfied and 3 were satisfied with treatment. No adverse effect was noted. Conclusion: A fractional Er:YAG laser can deliver an effective and minimally invasive treatment for acne scars.     

Fractional CO2 laser treatment for a skin graft

Skin grafts are widely used in reconstructive and plastic surgery, leaving an inevitable scar appearance on the body, affecting the quality of life of the patients. Fractional ablative lasers have become a leading procedure for the treatment of acne and burn scars. We report a case of a skin graft showing excellent improvement in overall appearance after three sessions of fractional CO₂ laser. The undamaged tissue left between the microthermal treatment zones is responsible of collagen formation and reepithelialization. Remodeling and collagen formation are observed even 6 months after a fractional CO₂ laser session.     

Treatment of striae distensae using fractional ablative CO2 laser in skin types II-IV: a retrospective case series study

Striae distensae (SD) are atrophic dermal scars often found on abdomen, breasts, thighs, and hips of pregnant women. The strias’ self-healing without any intervention is a poor possibility. Till now, several lasers and light sources have been used for treatment of SD. However, there are no integrated therapeutic approaches determined for treatment of SD yet. So, in this study, the therapeutic effect of fractional ablative CO₂ laser in women with pregnancy was assessed. Twenty-four ethic Iranian women aged between 20 and 42 years with various severity of pregnancy SD enrolled in retrospective case series study. Participants with skin types II-IV were treated in four sessions with a one-month interval by fractional ablative CO₂ laser. The severity of striae was determined by Daveys scoring. Clinical improvement was assessed by comparing pretreatment and posttreatment clinical photographs based on global improvement scoring. The evaluation of clinical results showed that fractional ablative CO₂ laser was an effective treatment. Twenty of 24 (83.3%) patients showed improvement. Clinical improvement was affected by striae severity (P = 0.03). Also, there were no statistical differences between clinical improvements with skin types, striae scar severity, number of pregnancy, and striae location.     

Treatment of Striae Distensae with Nonablative Fractional Laser versus Ablative CO2 Fractional Laser: A Randomized Controlled Trial

Background

Striae distensae are atrophic dermal scars with overlying epidermal atrophy causing significant cosmetic concern. Although a variety of laser and light sources have been used for the treatment of striae distensae, to date no definite ''gold standard'' treatment modality has been determined.

Objective

To assess and compare the efficacy and safety of nonablative fractional photothermolysis and ablative CO₂ fractional laser resurfacing in the treatment of striae distensae.

Methods

Twenty-four ethnic South Korean patients with varying degrees of atrophic striae alba in the abdomen were enrolled in a randomized blind split study. The patients were treated with 1,550 nm fractional Er:Glass laser and ablative fractional CO₂ laser resurfacing. Each half of the abdominal lesion was randomly selected and treated three times at intervals of 4-weeks using the same parameters. Digital photography was conducted and skin elasticity and the width of the widest striae in each subject were measured at the baseline and 4 weeks after the final treatment. Clinical improvement was assessed by comparing pre- and post-treatment clinical photographs by two blinded physicians and participant satisfaction rates were evaluated. Skin biopsies were taken from three participants. All adverse effects were reported during the study.

Results

Although they do not statistically differ, both treatments with nonablative fractional laser and ablative CO₂ fractional laser showed a significant clinical and histopathologic improvement of striae distensae over pretreatment sites.

Conclusion

These results support the use of nonablative fractional laser and ablative CO₂ fractional laser as effective and safe treatment modalities for striae distensae of Asian skin. However, neither treatment showed any greater clinical improvement than the other treatment.     

Evaluation of autologous platelet-rich plasma plus ablative carbon dioxide fractional laser in the treatment of acne scars

Introduction: Acne scar is a common distressing complication of acne vulgaris. CO₂ laser resurfacing proved effective for the treatment of this problem, but the associated complications may limit its use. Platelet-rich plasma (PRP) may increase the chance of favorable outcome. Aim of the work: To evaluate the synergistic effects of autologous PRP with fractional CO₂ laser resurfacing in the treatment of acne scars among Egyptian patients. Patients and method: This study included 30 patients suffering from post-acne scars. CO₂ laser treatment was applied to both sides of the face followed by PRP injection for the right side. Evaluation was carried out through operating physicians, two blinded physicians as well as through patient’s satisfaction. Result: The right side of the face (PRP-treated side) achieved excellent improvement in 13.3% of the patients, while there was no excellent improvement on the left side. Conclusion: Combination of fractional CO₂ laser resurfacing and intradermal PRP was superior to CO₂ laser alone for acne scar treatment.     

A novel fractional micro-plasma radio-frequency technology for the treatment of facial scars and rhytids: A pilot study

Abstract

Introduction: Fractional ablative and non-ablative lasers have gained popularity in the treatment of acne scars and rhytids due to their efficacy and improved tolerability. Plasma and radio frequency (RF) have also emerged as methods for ablative or non-ablative energy delivery. We report preliminary experience with a novel fractional micro-plasma RF device for the treatment of facial acne scars and rhytids. Methods: Sixteen patients with facial acne scars or rhytids were treated at 4-week intervals. Treatment parameters were titrated to an immediate end point of moderate erythema. The clinical end point for cessation of treatment was the attainment of satisfactory clinical results. Results were monitored photographically up to 3 months after treatment. Results: Acne scars showed marked improvement after two to four treatments. Facial rhytids demonstrated reduced depth after two treatments and marked improvement after four treatments. Treatment was well tolerated by all participants, with transient erythema and short downtime. These results provide initial evidence for the safety and effectiveness of fractional micro-plasma RF as a low-downtime and well-tolerated modality for the treatment of acne scars and facial rhytids.     

The efficacy of fractional ablative carbon dioxide laser combined with other therapies in acne scars

Fractional ablative carbon dioxide laser resurfacing is a frontline treatment for acne scars. It creates multiple microscopic treatment zones to accelerate the collagen formation and the healing process of reepithelialization, according the principle of fractional photothermolysis. At present, the fractional CO₂ laser with a wavelength of 10,600 nm is commonly used in the field of cosmetology and clinical therapies for various skin diseases, and it can effectively improve skin regeneration and scar formation. To obtain satisfactory results for patients with scars, repetitive fractional laser therapy is always required; however, this treatment could easily lead to complications such as erythema, edema, infection, and post‐inflammatory hyperpigmentation. In addition, different types of acne scars may have different responses to laser, further limiting its widespread use. In recent studies both home and abroad, a new pattern of fractional laser combined with other therapies to improve acne scar has been recommended to guarantee the safety and effective of treatment. This article reviews the recent pertinent literatures and summarized the progression of ablative fractional CO₂ laser combined with other therapies on acne scar.     

Laser treatment for facial acne scars: A review

Background and Objectives: Acne scarring is a widely prevalent condition that can have a negative impact on a patient’s quality of life and is often worsened by aging. A number of options are available for the treatment of acne scarring, including retinoids, microdermabrasion, dermal fillers, and surgical techniques such as subcision. The aim of this review is to evaluate the different laser modalities that have been used in peer-reviewed clinical studies for treatment of atrophic acne scars, and summarize current clinical approaches.

Materials and Methods: A Medline search spanning from 1990 to 2016 was performed on acne scarring. Search terms included “atrophic acne scars,” “ablative’’, “nonablative,” “fractional,” “nonfractional,” “neodymium,” “alexandrite,” “pulsed dye” lasers, and results are summarized.

Results: Various types of lasers have been evaluated for the treatment of atrophic acne scars. While they are efficacious overall, they differ in terms of side effects and clinical outcomes, depending on patients skin and acne scar type. A new emerging trend is to combine lasers with other energy-based devices and/or topicals.

Conclusion: Evaluation of the literature examining acne scar treatment with lasers, revealed that clinical outcomes are dependent on various patient factors, including atrophic acne scar subtype, patient skin type, treatment modality, and side-effect profile.     

Evaluation of the efficacy and safety of fractional bipolar radiofrequency with high-energy strategy for treatment of acne scars in Chinese

Background: Fractional technology overcomes several problems of ablative lasers such as a high incidence rate of post- inflammatory hyperpigmentation (PIH). A new technology fractional radiofrequency, which induces deep dermal heating and leaves the epidermal less affected results in less adverse effect in Chinese. Objective: To evaluate the efficacy, safety and tolerance of fractional bipolar radiofrequency (RF) in the treatment of acne scars in Asian people with the strategy of high energy. Methods: Twenty-six healthy Asian patients with acne scars received four monthly high energy (85–95mj/pin) treatments with a fractional bipolar RF device. Improvement and tolerance were evaluated at each treatment and a 4-week and 12-week follow-up visit. Results: Twenty-three patients completed the study. Acne score showed a significantly decrease at 4-week and 12-week follow-up visits. Patients’ evaluation of global improvement and satisfaction increased at the 12-week visit compared with baseline. Side effects were limited to transient pain, erythema, dryness and low risk of PIH. Conclusion: Treatment with high energy of fractional bipolar RF is safe and effective for acne scars in Asian people. Common side effects such as PIH, eschars are less than fractional lasers.     

Single‐pass CO2 laser skin resurfacing of light and dark skin: extended experience with 52 patients

BACKGROUND: Multiple‐pass carbon dioxide (CO₂) laser skin resurfacing has been a favored treatment modality for photodamaged and acne‐scarred skin over the past several years. Its association with numerous side effects and complications, particularly prolonged erythema and dyspigmentation, however, has dampened the initial enthusiasm reserved for its use. By reducing the laser‐associated tissue ablation depth and degree of thermal necrosis, it is possible that the incidence of these side effects can also be reduced.

PURPOSE: To evaluate the clinical efficacy and side effect profile of single‐pass CO₂ laser skin resurfacing in a large series of patients.

MATERIALS AND METHODS: A total of 52 consecutive patients (skin phototypes I–VI) with mild facial rhytides, atrophic scars, or infraorbital hyperpigmentation underwent single‐pass treatment with a high‐energy, pulsed CO₂ laser. Side effects to treatment were closely monitored and tabulated. Clinical improvement using a quartile grading scale was assessed independently by two masked medical evaluators at 1, 3, 6, and 12 months postoperatively.

RESULTS: Significant clinical improvement was seen in all patients, with peak improvement scores noted at 12 months. Greater clinical improvement was seen in patients with darker skin tones despite the near universal incidence of transient postoperative hyperpigmentation in these patients.

CONCLUSIONS: Single‐pass CO₂ laser skin resurfacing can improve the appearance of fine rhytides, mild atrophic scars, and infraorbital hyperpigmentation in all skin types. The severity and duration of side effects and complications are reduced with this technique (compared with multiple‐pass procedures) and may offer a possible solution to the problem of treating patients with darker complexions.     

Fractional CO2 laser for the treatment of acne scars

Background Numerous reports have been published on skin rejuvenation by the so‐called fractional laser device that delivers a laser beam in a dot form over a grid pattern. Aims In this study, we characterized the effects of a fractional CO₂ laser on atrophic acne scars at the clinical and ultrastructural levels. Methods Seven healthy adult Japanese volunteers (aged 32–46 years, mean 37.6, five men and two women of Fitzpatrick skin type III) were recruited for this study. A fractional CO₂ laser device, SmartXide DOT (DEKA, Florence, Italy), was used with irradiation parameters set as follows: output power 10 W, pulse width 600 μs, dot spacing 800 μm, and stack 2 (irradiation output power 0.91 J/cm²). A clinical examination and punch biopsy of each subject was performed before and just after the irradiation, and also at week 3 after three irradiation sessions. The biopsy specimens were stained with toluidine blue and were examined ultrastructurally. Results Clinical improvement of the atrophic acne scars was observed at week 3 after the third irradiation session in all cases compared with the condition before treatment. Histologically, outgrowths of many degenerated elastic fibers were observed as irregular rod‐shaped masses in the superficial dermis prior to the treatment in the region of the acne scars. At week 3 after the third irradiation, the degenerated elastic fibers were no longer observed, and the elastic fibers were elaunin‐like. Conclusions The fractional CO₂ laser is considered to be very effective for treating atrophic acne scars.     

Treatment of atrophic facial acne scars with the 1064-nm Q-switched Nd:YAG laser: six-month follow-up study

OBJECTIVES: To quantitatively assess improvement in acne scarring after a series of nonablative laser treatments and to determine efficacy at 1-, 3-, and 6-month follow-up after treatment. DESIGN: Before-after trial of consecutively selected patients. SETTING: Private practice at the Laser and Skin Surgery Center of New York, New York. PATIENTS: Eleven patients with mild to moderate atrophic acne scarring were treated. INTERVENTIONS: A 3-dimensional optical profiling imaging system was used to assess skin topography before, during, and after treatment. Patients were treated with a 1064-nm Q-switched Nd:YAG laser and reassessed after 3 treatment sessions and at 1, 3, and 6 months after the fifth treatment session. MAIN OUTCOME MEASURES: The skin roughness analysis was quantified at baseline and at each follow-up interval. Pain, erythema, and petechiae formation were assessed on 3-point scales. RESULTS: At midtreatment (1 month after the third treatment session), an 8.9% improvement in roughness analysis was seen. This improvement increased to 23.3%, 31.6%, and 39.2% at 1, 3, and 6 months after the fifth treatment, respectively. Patients reported mild to moderate pain with treatment. The only adverse effects noted were transient erythema and mild pinpoint petechiae. CONCLUSIONS: Treatment with the nonablative 1064-nm Q-switched Nd:YAG laser results in significant quantitative improvements in skin topography in patients with mild to moderate atrophic acne scars. Continued incremental improvements were noted at 1-, 3-, and 6-month follow-up, indicating ongoing dermal collagen remodeling after the treatment.