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Fractional Carbon Dioxide Laser: Optimizing Treatment Outcomes for Pigmented Atrophic Acne Scars in Skin of Color

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Dark skin type has high propensity to acne scarring and is often complicated by persistent erythema or pigmentation at the base. Fractional lasers are available for the longest period and are able to improve most atrophic acne scars. Often pigmented scar bases and dark skin types limit the use of aggressive laser parameters. Long pulse mode is preferred over short pulse to prevent epidermal damage; low fluence is chosen versus high fluence and low density versus high density. Repeated treatments are needed to minimize complications and optimize results; all these must be achieved through a controlled stage of inflammation. Interventional priming with chemical peels and laser toning before ablative fractional carbon dioxide laser helps to reduce photodamage, recent tan, and pigment at scar base, thus minimizing the risk of post-inflammatory hyperpigmentation. Multiple recent literature evidence validates the combinations to optimize outcomes in atrophic acne scars as discussed in this review article.
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DOI:
10.4103/JCAS.JCAS_171_18
85
Address for correspondence: Dr. Shehnaz Z. Arsiwala,
Renewderm Skin Hair Lasers Aesthetics Centre,
Nesbit Road, Mazgaon, Mumbai 400010,
Maharashtra, India.
E-mail: drshenaz@gmail.com
© 2019 Journal of Cutaneous and Aesthetic Surgery | Published by Wolters Kluwer - Medknow
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How to cite this article: Arsiwala SZ, Desai SR. Fractional carbon
dioxide laser: Optimizing treatment outcomes for pigmented atrophic
acne scars in skin of color. J Cutan Aesthet Surg 2019;12:85-94.
Symposium: Lasers Review Article
Fractional Carbon Dioxide Laser: Optimizing Treatment
Outcomes for Pigmented Atrophic Acne Scars in Skin of Color
Shehnaz Z. Arsiwala, Swasti R. Desai1
Renewderm–Skin Hair Lasers Aesthetics Centre, Mumbai, Maharashtra, India, 1Consultant dermatologist, Janta hospital, Surat, Gujarat, India
Abstract
Dark skin type has high propensity to acne scarring and is often complicated by persistent erythema or pigmentation at the base.
Fractional lasers are available for the longest period and are able to improve most atrophic acne scars. Often pigmented scar bases
and dark skin types limit the use of aggressive laser parameters. Long pulse mode is preferred over short pulse to prevent epidermal
damage; low fluence is chosen versus high fluence and low density versus high density. Repeated treatments are needed to minimize
complications and optimize results; all these must be achieved through a controlled stage of inflammation. Interventional priming
with chemical peels and laser toning before ablative fractional carbon dioxide laser helps to reduce photodamage, recent tan, and
pigment at scar base, thus minimizing the risk of post-inflammatory hyperpigmentation. Multiple recent literature evidence validates
the combinations to optimize outcomes in atrophic acne scars as discussed in this review article.
Keywords: Combination therapies, fractional ablative lasers, pigmented atrophic acne scars, skin of color
IntroductIon
Acne scars are a sequela of deep, persistent, and
inflammatory acne. Individuals who scar after acne have
specific biochemical characteristics in their skin, which
predispose them. Managing acne scars is a challenge, and
treating pigmented acne scars in skin of color multiplies
this challenge.
Multiple treatment modalities for surgical to nonsurgical,
peels to lasers and energy-based devices, and ablative to
nonablative fractional and nonfractional are available in our
armamentarium to improve acne scars [Table 1]. Of all the
various modalities available, fractional lasers are available for
the longest period and are able to improve most atrophic acne
scars. Combination of technologies when used sequentially
or rotationally improves outcome, thus minimizes side effects.
The results are better lasting. Multiple recent literature
evidence validates combinations to optimize outcomes in
atrophic acne scars as discussed in this review article.
Acne scars morphology
Progressive scarring with acne clearance is a known
phenomenon. Scars have various morphological
characteristics and vary in size, shape, and depth, and
are thus graded in various types as rolling, boxcar, and
ice pick types. Goodman and Baron classification for
acne scars is a standard tool for assessing atrophic scars
and are graded from types 1–4.[1] Clinically, in addition to
grades of atrophic scars, one needs to assess their stage
of development, early scars may be erythematous, as they
progress they may get purplish or pigmented. Pigmented
scars are a prominent feature in Indian skin, which
belongs to Fitzpatrick types 3–5[2,3] [Figures 1 and 2].
Acne scars in an individual maybe of mixed types and
may be distributed pan-facially with variable appearance
in different face zones. Dark skin type has high propensity
to acne scarring and is often complicated by persistent
erythema or pigmentation at the base.[4] Initial erythema
may be replaced by purplish base, which may later
pigment. Coexisting active acne may be superimposed[3]
[Figure 3].
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Arsiwala and Desai: Fractional carbon dioxide laser for acne scars
86 86 Journal of Cutaneous and Aesthetic Surgery ¦ Volume 12 ¦ Issue 2 ¦ April-June 2019
Pathogenesis for acne scars
Scientific studies highlight that prolonged inflammation
leads to scarring and if the inflammation is persistent then
scarring may be progressive.[5] High-grade acne leads to high
degree of inflammation as seen with papulonodular and
cystic acne; dermal insult to tissue metalloproteinases is
more long lasting and results in a decrease of tissue leading to
atrophic scars. If the inflammation is nonspecific but robust
and generates early angiogenesis with a quick resolution,
there will be minimal scars. In all those cases, where more
specific, ineffectual, but prolonged inflammatory response
and angiogenesis are seen are the scarrers. Involvement of
epidermis, upper, or deep reticular dermis defines the depth of
acne scars and also the treatment choice.[5] Mild-to-moderate
scars involving epidermis and papillary dermis respond to
resurfacing laser or other technologies [Table 1], whereas the
deep scars involving reticular dermis require more aggressive
or combination modalities.[6]
Clinical characteristics and assessment of pigmented
acne scars
Fitzpatrick skin types 3–6 are predisposed to more inflamed
acne and hence more pigmentation (post-inflammatory
hyperpigmentation [PIH])[3,4,7] than erythema. This results
in pigmented acne and acne scars and has been proven
histologically.[2,7-9] Histological studies in post-acne
pigmented macules revealed epidermal melanin granules
and dermal melanophages infiltration up to the reticular
dermis, along with foreign body granulomas and giant
cells.[9,10] Callender and Davis[4] have postulated that this
heightened inflammatory response may be a major reason
that African Americans with even mild-to-moderate
acne still develop hyperpigmented macules, which were
studied by histopathology, showing dilated, distorted,
keratin-filled follicles consistent with comedones and
patchy chronic inflammation.[1,8] Kligman and Mills[11]
described comedogenicity of cosmetic products applied on
face because of the presence of certain ingredients in their
formulas also called as acne cosmetica. In skin of color
with acne lesions, increased use of cosmetic products may
inadvertently be a causative factor for acne and PIH.[11]
A thick stratum corneum, large melanosomes, and
a thick dermis with abundant fibroblasts constitute
morphological features in a dark skin prototype 4–6.[9]
According to the author, interventional therapies
for skin of color revolve around achieving optimum
outcome, creating no pigmentary sequelae. Aggressive
modalities are hence replaced by less aggressive, safer
options. Repeated treatments are needed to minimize
complications and optimize results; all these must be
achieved through a controlled stage of inflammation as
inflammatory mediators play a large role in progressive
scars. Features that influence choice of therapy and
predictability of outcomes include the presence of active
acne, degree of erythema or pigmentation at base, scar
type and grading, skin stretch test where stretchable scars
have better improvement than adherent ones, which need
subcision.
Principle of fractional photothermolysis
Laser resurfacing delivers monochromatic light into the
scars and subsequent heat initiates collagen injury and
neocollagenesis.[12]
Figure 1: Pigmented macular atrophic acne scars Figure 2: Pigmented atrophic acne scars (grade 2)
Table 1: Interventional modalities for atrophic acne scars
Grade 1 atrophic
acne scars—macular
Peels, microdermabrasion, dermaroller,
nonablative lasers
Grade 1 atrophic
pigmented scars
Peels, dermaroller, nonablative lasers, QS laser
toning with DRT, fractional erbium/
CO2 lasers. Transepidermal delivery of growth
factors, vitamin C
Grade 2 atrophic
scars
Peels and DRT, QSLT and DRT, peels and
fractional erbium/CO2 lasers, QSLT and
fractional lasers, all of the above with PRP
Grade 3 atrophic
scars
Laser combinations ablative and nonablative,
erbium and CO2 fractional, with peels/PRP,
microneedle RF with PRP, with HA
Grade 4 atrophic
scars
Subcision with fractional CO2, with peels/
PRP, microneedle RF with PRP, combination
with transepidermal drug deliveries, with HA
DRT=Dermaroller therapy, RF=Radio Frequency, HA=Hyaluronic
Acid, QSLT=Q- Switched laser toning
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Arsiwala and Desai: Fractional carbon dioxide laser for acnescars
Journal of Cutaneous and Aesthetic Surgery ¦ Volume 12 ¦ Issue 2 ¦ April-June 2019 87
Manstein et al.[13] introduced the concept of fractional
photothermolysis (FP). Their FP device tends to emit
laser beam into pixilated manner, producing array of
microthermal zones (MTZ) and creating microscopic
channels by thermal injury to the skin.[13]
In contrast to ablative devices, which produce uniform and
confluent patch by ablative epidermal and dermal injury,
fractional resurfacing (FR) produces MTZ by ablating
epidermal and dermal tissue in regularly spaced channels on
the skin surface leaving intervened skin untouched, which
leads to faster healing of ablated columns of tissue.[14,15]
The depth, density, and size of microthermal columns
depend on the type of device and parameters used, that
is, fluence, wavelength, density, and stacking of the pulse.
Astudy reported that in atrophic acne scars with a density
of 100 spots/cm2, an energy of 100 mJ would reach a
depth of 1236 µm with a coverage of around 8.6%.[14]
Microthermal channels have epidermal and dermal debris,
which get eliminated by transepidermal elimination.[14-16] It
is followed by stimulation of reepithelialization and repair
mediated through adjacent intact tissue, and thermally
ablated channels get repopulated by fibroblast-derived
neocollagenesis. Healing is faster as the large percentage of
intervening area is not affected. Four to six treatments are
performed, each treatment at the interval of 30–45days.
Neocollagenesis is significant after 3months and continue
for 6months.[17]
Advantages of FP include the following:
1. Reduced postprocedural erythema and edema
2. Less chances of PIH as water in collagen is the
chromophore
3. Less downtime
4. Better patient compliance and acceptance
photothermolysis
Ablative fractional resurfacing with CO2 laser
The wavelength of CO2 lasers is 10,600 nm. It has high
affinity for water, which is the chromophore and targets
20–60µm depth of epidermal and papillary dermal layers,
the surrounding zone of thermal damage extends up to
20–50µm.[13] MTZ are formed and are variable according
to the fluence used and the depth of penetration achieved.
Thermal injury generates coagulation and denaturation of
collagen and reepithelialization ensues. Fractional ablation
of epidermis and dermis is enabled thus reepithelisation
is facilitated from the surrounding non ablated skin and
appendages.
Ablative fractional resurfacing with CO2 laser (AFRCL)
is evidenced based for resurfacing atrophic acne scars
of moderate-to-severe variety [Table 2]. Multiple studies
Figure 3: Erythematous acne scars (grade 3) with few active acne lesions. (A and B) before, (C and D) after peels and AFRCL
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Arsiwala and Desai: Fractional carbon dioxide laser for acne scars
88 88 Journal of Cutaneous and Aesthetic Surgery ¦ Volume 12 ¦ Issue 2 ¦ April-June 2019
support the efficacy of AFRCL for atrophic acne scars.
Various parameters, densities and fluence levels, modes,
and the respective outcomes were studied by multiple
authors and are enumerated in Table 2.
Often pigmented scar bases and dark skin types limit the
use of aggressive laser parameters. Long pulse mode is
preferred over short pulse to prevent epidermal damage,
low fluence is chosen versus high fluence and low density
versus high density.[18] Though this becomes safer to prevent
PIH in dark skin, it results in less depth of penetration
and less deeper thermal effects on acne scars.[3] Topical
priming agents are often insufficient to prevent PIH when
optimum parameters need to be used. Fractional lasers do
not correct pigmentation at the base of scars.[3]
According to the author’s experience, while conducting
AFRCL for moderate-to-severe atrophic scars, dual
modes of operation in the same system enable better
treatment outcome where the stack mode enables high-
fluence laser ablation of individual scars, and the dynamic
mode with mosaic pattern of beam delivery enables
textural improvement of the unscarred surrounding skin.
At higher fluence and low average density with a moderate
peak power, one can safely treat deep scars focally in static
mode. With a low fluence and high average density and
larger scan size, one can treat surrounding skin and rest of
the face for textural improvement.
The conclusions drawn on the basis of the various studies
[Table 2] were that ablative fractional resurfacing (AFR)
improved the depth and appearance of acne scars by
as much as 50% after a series of four to five treatments
performed on a monthly basis. All studies reported textural
improvement. Ahigh-fluence, low-density setting has been
shown to be more efficacious than a low-fluence, high-
density setting. For deep scars one can selectively treat
with small spot size and rest of face can be treated with
large spot size and low fluence for textural improvement
thus enabling dual mode treatment pattern to improve
overall outcome for atrophic acne scars.[16,18,22]
Furthermore, FP significantly improved acne scars with
PIH as well as scar volume. Improvement was better
appreciated after 6months of sessions as neocollagenesis
sets in. As with all laser treatments in skin of color,
treatment levels should be increased with caution.[16,18,22]
Special considerations for pigmented acne scars in skin
of color
Priming: Before embarking on laser therapy for atrophic
pigmented acne scars, one must ensure resolution of active
acne and adequate priming [Figures 3–6]. As pigmented
acne scars limit the use of high-fluence parameters, priming
is mandatory, especially in dark-skin prototypes. Priming
reduces wound healing time and decreases the risk of PIH,
it determines patient tolerance and establishes patient
compliance. Added antioxidants/anti-inflammatory
cosmeceuticals are the new focus in priming as are oral
sunscreens, antioxidants as systemic priming agents. All
Table 2: Studies for AFRCL on atrophic acne scars
Fractional laser/
carbon dioxide laser
Type of scar Parameters Outcome
Majid and Imran[19] (60
Indian patients)
Atrophic acne
scars
Fractional carbon dioxide
Laser as monotherapy
Excellent response was observed in 26 patients (43.3%),
whereas 15 (25%) and 19 patients (31.7%) showed a good
and poor response, respectively. Rolling and supercial
boxcar scars responded the best, whereas pitted scars
responded the least to fractional laser monotherapy.
Chapa etal.[20] (13
patients types 1–4)
Moderate-to-severe
atrophic acne scars
Higher pulse and larger microscopic
treatment zones
Signicant improvements of 26%–50% on a quartile scale
and improved scar depths of 66.6%.
Drawback: erythema, which resolved within 1month in
most patients
Jung etal.[18] (10 Korean
patients)
Atrophic acne
scars
Split face, Evaluator blinded, lower
uence, high density vs. higher uence,
low density
A high-uence, low-density setting has been shown to be
more efcacious than a low-uence, high-density setting
Manuskiatti etal.[21] (13
Asian patients) with
Fitzpatrick skin type 4
Atrophic scars in
Asian patients
Four treatment sessions over a 7-week
duration
Scar smoothness and volume improved, 25% and 50%
improvement 6months after treatment
Cho etal.[22] (20 Korean
patients)
Atrophic acne
scars
Selected deep scars, small spot size,
coagulation, and larger spot size for rest
of face for rejuvenation, 3months
Moderate-to-good improvement in deep scars and
improved rejuvenation
Hedelund etal.[23] (13
patients)
Atrophic acne
scars
Low-pulse energies of 48–56 mJ
accounted for the modest results
Modest improvement in scar texture and scar atrophy
Trelles etal.[16] (40
patients types 2–4)
Atrophic acne
scars
Single session, medium settings (2 Hz,
30 W, 60 mJ) were used, and two passes
were made for dark skins and degree
1 wrinkles. High settings (2 Hz, 60 W,
120mJ) were used, and three passes
were made
Treatment improved, wrinkle aspect and scar condition,
and no patient reported adverse effects or complications,
irrespective of skin type
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Arsiwala and Desai: Fractional carbon dioxide laser for acnescars
Journal of Cutaneous and Aesthetic Surgery ¦ Volume 12 ¦ Issue 2 ¦ April-June 2019 89
these enable ultraviolet damage protection and prevent
pigment darkening and hence prepare theskin.
In cases of pigmented acne scars, as pigment at base of
scar is a limitation for high-fluence laser therapy and often
only topical priming agents are insufficient to alleviate
pigmentation adjuvant therapies (such as chemical
peeling) [Figure 3A–D, Figure 5A–D], low-fluence QS
laser toning acts as interventional priming, the concept
being to make the scars as skin colored as possible.[2,7,24]
Optimizing outcomes, advantages of peels/laser toning as
priming agents:
1. Adjunctive therapy
2. Pigment elimination, textural improvements, and
photodamage correction
3. Improve compliance and tolerance
4. Adherence to therapy and enables acne and squeal
monitoring
5. Synergistic to fractional ablative lasers in treating
atrophic scars
6. Enhances outcome to laser resurfacing
7. Used for acne and scars in males as skin is more
seborrheic and thicker
Combinations rationale for combination therapies
Achieving synergism with multiple adjunctive therapies
when combined shortens time interval to achieve results
with albeit safer parameters [Figures 3–6]. Combination
of technologies when used sequentially or rotationally
improves outcome, thus minimizes side effects. The results
are better lasting. The evidence from multiple recent
literature validates combinations to optimize outcomes in
atrophic acne scars. Table 3 shows the possible combinations.
Subcision
Adherence of rolling acne scars can be addressed
with subcision before laser resurfacing sequentially or
rotationally. It is less suited for ice pick and deep boxcar
scars.[26] An 18- or 20-gauge needle breaks fibrous strands,
holding the scar down, and elevates the scar and subcision
also stimulates and produces neocollagen formation.[26,28]
Multiple treatments may be required to achieve an
optimal outcome.[25-30] Combination of ablative fractional
and nonablative lasers is another rationale for reducing
complications and optimizing outcomes in skin of color
as studied by Kim and Cho[31] who combined it in a series
of 20 Asian patients (skin prototypes 4–6) with atrophic
facial acne scars. Good outcome was reported in scars and
texture and pigment compared to stand-alone AFR.[31]
Combination with Quality- Switched (QS) neodymium-doped
yttrium aluminum garnet (Nd:YAG) quasi-pulse nonablative
and/or QS Nd:YAG low-fluence laser toning[24] is another
combination with good synergism with AFRCL and is widely
used for pigmented atrophic acne scars [Figure 4A–D].The
Figure 4: (A, B) Pigmented erythematous acne scars before. (C, D) Pigmented erythematous acne scars after nonablative quasi pulse Nd:YAG laser
with AFRCL
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Arsiwala and Desai: Fractional carbon dioxide laser for acne scars
90 90 Journal of Cutaneous and Aesthetic Surgery ¦ Volume 12 ¦ Issue 2 ¦ April-June 2019
Figure 5: (A, B) Erythematous acne scars grade 3, with few active acne lesions. (C, D) Erythematous acne scars grade 3 after peels and AFRCL
Figure 6: (A, B) Pigmented acne scars grade 3. (C, D) Pigmented acne scars after AFRCL with PRP
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Arsiwala and Desai: Fractional carbon dioxide laser for acnescars
Journal of Cutaneous and Aesthetic Surgery ¦ Volume 12 ¦ Issue 2 ¦ April-June 2019 91
author uses the low-fluence laser toning before AFRCL as
an interventional priming method.
Safety and efficacy of AFR with CO2 laser are well
documented, a few studies also elaborate longevity of
the results from 1–2years. Ortiz et al. reported clinical
maintenance of the improvement in up to 74% among
10 patients.[32] The presence of inflammatory mediators
and heat shock protein 47 in first 3 months after FR
may attribute better appearance of improvement initially
compared to that in long term, according to this study as
shown by certain histologic studies.
Platelet-rich plasma
Autologous platelet-rich plasma (PRP) injected or
delivered into the scars after laser treatment enriches
the skin with potential bioactive growth factors and
chemokines released on platelet activation and enables
faster wound repair.[33] Studies indicate faster reduction
of post-laser edema, erythema, and PIH.[34] Synergizing
AFR with PRP is also known to actively reduce atrophic
acne scarring[33] [Table 4] [Figure 6A–D].
Autologous growth factors and secretory proteins,
chemokines, and cytokines released on platelet
activation facilitate wound repair and rejuvenation
in cosmetic dermatology, they act by stimulation of
dermal fibroblast proliferation and increase type
Icollagen synthesis.[8,13,35] Both topical and intradermal
PRP injections have been studied with variable results
for acne scars.[9,36,37] Fractional CO2 laser creates thermal
wounds on the skin and also facilitates absorption
gradient by a damaged epidermis and PRP is known
to aid in wound healing, combining the two increases
therapeutic outcome.[9,36,38-40]
Tips for treating pigmented acne scars with AFRCL are
as follows:
Use the fluence judiciously in darker skin (Fitzpatrick
skin types 3–6). Parameters to be chosen with caution
as chances of post-inflammatory pigmentation are
very high.
• Priming with lightening agents and sunscreen should
be started at least 3–4 weeks before first treatment, oral
sunscreens can be added.
Table 3: Synergistic possibilities in combination therapies
for pigmented acne scars
Study Method Outcome
Split-face trail
of 16patients by
Faghihi etal.[37],
two sessions
One side treated with
fractional CO2 laser alone
and the other side treated
with a combination of
fractional CO2 laser with
intradermal PRP
Better results and
lesser side effects
with combination
Gawdat etal.,[41]
30patients, split
face, 3sessions,
6months
PRP injected and applied
after AFRCL vs. AFRCL
alone
Combination
better score with
less pain after
therapy
Abdel Aal etal.,[39]
20patients
AFRCL vs. AFRCL with
topical PRP
Better results
with combination
Table 4: Studies of AFRCL combined with PRP
Interventional
modality Atrophic scar response
Peels Improves acne, seborrhea, pigmentation,
texture, and grade 1–2 acne scars
Microdermabrasion Improves texture, grade 1 scars
Subcision Adherent scars—boxcar scars
Microneedling Types 1 and 2 scars
Lasers—nonablative Types 1–3 rolling scars
Lasers fractional
erbium
Types 1 and 2 scars
Lasers fractional CO2Types 1–4 scars
Lasers—QS Nd:YAG Pigmentation in QS mode and types 1 and 2
scars in quasi pulse mode
Microneedle RF Types 2–4 scars
PRP Adjuvant for better healing and
neocollagenesis
Transepidermal drug
delivery
For hydration, pigmentation, repair, and
textural improvement
RF = Radio frequency
Chart 1: Algorithm for treating pigmented acne scars
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Arsiwala and Desai: Fractional carbon dioxide laser for acne scars
92 92 Journal of Cutaneous and Aesthetic Surgery ¦ Volume 12 ¦ Issue 2 ¦ April-June 2019
• Interventional priming with chemical peels and laser
toning before AFR helps to reduce photodamage,
recent tan, and pigment at scar base, thus minimizing
risk of PIH after AFR.
Low-fluence, high-density treatments are safer for
pigmented acne scars.
History of oral isotretinoin and keloids formation to
be elicited.
1. Oral isotretinoin should be discontinued at least
6–12 months before resurfacing procedures.[42]
This is recommended based on earlier reports of
keloid formation and atypical scar formation after
treatment with argon lasers and dermabrasion,
which are more invasive and ablative procedures.[42,43]
Some of the recent studies suggest the safety of
different procedures such as laser hair removal and
dermabrasion in patients recently treated with oral
isotretinoin.[44]
2. Postprocedural delivery of vitamin C, antioxidants
and emollients, and PRP acts to facilitate better
healing, rejuvenation.
3. Postprocedural emollients and sunscreen with
antiviral and antibacterial prophylaxis when
indicated minimize side effects.
Combinations with subcision, topical drug delivery, PRP,
nonablative, and QS Nd:YAG lasers act by synergism and
facilitate safer treatments and better outcomes. Charts1–3
show the algorithm of combination treatments.
Chart 2: Algorithm for acne scars with AFRCL and PRP
Chart 3: Algorithm for combining with subcision and PRP
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Arsiwala and Desai: Fractional carbon dioxide laser for acnescars
Journal of Cutaneous and Aesthetic Surgery ¦ Volume 12 ¦ Issue 2 ¦ April-June 2019 93
conclusIon
The management of acne vulgaris and consequent scarring
is a long-term process that must be individualized to each
patient. Often we are dealing with patients who have coexisting
active acne with acne scars. Problems while handling skin of
color need great consideration while choosing aggressive
modalities of treatment to avoid complications. For Indian
patients, the current trends revolve around less aggressive
and combination of various treatment modalities.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal.
The patients understand that their names and initials will
not be published and due efforts will be made to conceal
their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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... zones (MTZs) [38]. Ultimately, this laser targets these MTZs with high-intensity energy, inducing controlled thermal damage to the skin's layers. ...
... Ultimately, this laser targets these MTZs with high-intensity energy, inducing controlled thermal damage to the skin's layers. This process stimulates the skin's physiologic healing response, increasing the production of new collagen and elastin fibers [38,39]. Although it is primarily known for its applications in dermatology, the FRCO2 laser has also piqued interest in the context of AA and AGA. ...
... The FRCO2 laser is an advanced laser system designed for various dermatological procedures and is notably recognized for its efficacy in skin resurfacing and rejuvenation. It functions primarily via fractional photothermolysis, which divides the laser beam into numerous minuscule, closely positioned microthermal zones [38]. These microthermal zones are then delivered to the skin's surface, creating microscopic injuries known as microthermal treatment of 20% per treatment. ...
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Alopecia, also known as hair loss, is a highly prevalent condition affecting millions of men and women in the United States and worldwide, making it one of the most common complaints by patients presenting to a dermatologist. The symptomology on the presentation of alopecia can be highly variable, ranging from diffuse thinning of hair, discrete and localized patches completely absent of hair, or noticing significant shedding when brushing and showering. Although alopecia does not have a direct negative health impact on patients, it is nonetheless a debilitating disease as it can profoundly impact an individual’s self-image and psychosocial well-being. There are multiple treatment options available to patients with alopecia, and they are typically tailored to the patient’s needs and preferences. The most common of these is the Food and Drug Administration-approved drugs for alopecia, minoxidil, and finasteride. However, both of these are known to be partially efficacious for all patients, so clinicians often use different modalities in conjunction with them, in particular laser-based therapies. This review article will provide a comprehensive assessment of lasers and other light therapies that may be used to manage the two most common types of alopecia: androgenetic alopecia and alopecia areata.
... The choice between fractional CO 2 laser and microneedle radiofrequency for treating acne scars hinges on various factors, including patient demographics and skin characteristics. Evidence suggests that microneedling may be more appropriate for individuals with darker skin tones, as it is deemed more effective, better tolerated, and relatively safer for this demographic [41]. Conversely, the fractional CO 2 laser has demonstrated greater efficacy in patients with atrophic acne scars, with the potential for notable improvement in certain scar types, albeit with a heightened risk of post-inflammatory hyperpigmentation in individuals with darker skin tones [41]. ...
... Evidence suggests that microneedling may be more appropriate for individuals with darker skin tones, as it is deemed more effective, better tolerated, and relatively safer for this demographic [41]. Conversely, the fractional CO 2 laser has demonstrated greater efficacy in patients with atrophic acne scars, with the potential for notable improvement in certain scar types, albeit with a heightened risk of post-inflammatory hyperpigmentation in individuals with darker skin tones [41]. Furthermore, a randomised study underscored the superior therapeutic efficacy of fractional CO 2 laser compared to microneedling in post-acne scarring [25]. ...
... Individuals with darker skin types may face an elevated risk of post-inflammatory hyperpigmentation (PIH). They, thus, should undergo priming with chemical peels and laser toning before receiving ablative fractional CO 2 laser treatment to diminish recent tan and pigment at the scar base [41]. ...
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Acne scarring is a prevalent issue affecting millions worldwide, with significant psychological and social implications. Microneedling and CO2 laser therapy have emerged as promising modalities for acne scar remodelling. Microneedling induces controlled micro-injuries to stimulate collagen production, while CO2 laser therapy precisely ablates scar tissue. This comprehensive review evaluates the efficacy, safety, and comparative benefits of microneedling and CO2 laser therapy. Literature synthesis reveals both modalities to improve acne scars, albeit with different mechanisms and risks. Factors influencing treatment selection and the role of combination therapy are discussed. Future directions include optimising protocols and exploring novel techniques. Overall, microneedling and CO2 laser therapy offer valuable options for acne scar management, empowering individuals to address the physical and emotional burden of scarring.
... Obviously, this device is limited in its efficacy in sculpting the edges of scars with sharp angles or highly irregular surface [1], especially for deeper scars [28]. Some studies have reported that combining fractional laser with injectable permanent fillers, peels, or subcision can yield effective results, suggesting that combination approaches may be more effective than single therapeutic modalities [29][30][31][32][33]. To provide more effective option, we have produced a three-step treatment approach combining ultrapulse CO 2 with fractional CO 2 laser treatments for atrophic scars, which has not been previously mentioned. ...
... Patients are advised to use broad-spectrum sunscreens and avoid sun exposure. Topical application of hydroquinone or tranexamic acid pre-and post-treatment can help reduce the incidence of PIH [38,39], and interventional priming with chemical peels and laser toning before ablative fractional CO 2 laser helps to minimize the risk of PIH [32]. ...
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Various treatment modalities have been applied to atrophic scars. Fractional CO2 laser treatment has attracted increasingly more attention because of its quicker recovery time and fewer side effects. However, its limitation of sculpting the edge is an urgent shortcoming. In order to achieve a more effective result with fewer complications, we have integrated ultrapulse CO2 and fractional CO2 lasers to for the treatment of facial atrophic scars. The study included 25 patients (10 males and 15 females) diagnosed with moderate to severe atrophic scars between August 2020 and July 2022. All subjects underwent the same surgical treatment. The effects were assessed at baseline, 1 week, 1 month, and 3 months using photographic evidence. Objective evaluation of the results was conducted using a quartile grading scale, while the subjects’ satisfaction and any adverse events were also recorded. The patients in the study underwent more than two laser sessions (2–5), resulting in substantial improvement in their appearance. The time interval between each session was 3–6 months. The majority of the patients (19/25, 76%) had a significant or even excellent improvement. Any adverse events observed, such as erythema, superficial crusting, and PIH, were of a mild nature and temporary in duration. This treatment combined two CO2 lasers is an effective and safe choice for atrophic scars in Asians.
... Among the various methods, fractional CO2 laser resurfacing has emerged as the golden standard for treating atrophic acne scars. This laser technology works by ablating microcolumns of damaged skin while tightening underlying collagen, allowing for faster healing and fewer complications due to untreated surrounding tissue 5 . ...
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Background: Acne vulgaris is a chronic inflammatory skin condition that often results in atrophic scarring, impacting physical appearance and mental health. This study aims to evaluating the potential effect of combining punch elevation with fractional CO2 laser resurfacing versus laser treatment alone for moderate to severe atrophic acne scars. Patients and Methods: A split-face comparative study involved 20 adults aged 18 to 55 with moderate to severe atrophic acne scars. One side received punch elevation followed by fractional CO2 laser resurfacing, while the other side received fractional CO2 laser treatment alone. Clinical assessments included Goodman and Baron’s grading scale and patient satisfaction ratings. Histopathological evaluations analyzed fibroblast activity, epidermal thickness, and collagen composition. Results: The combined treatment significantly improved scar severity, with a mean reduction of 44.40% compared to 18.89% for the laser-only group (p < 0.001). Histopathological analysis showed increases in fibroblast activity (5.87% to 19.14%, p < 0.003) and epidermal thickness (635.65 µm to 1497.35 µm, p < 0.001). Patient satisfaction was higher for the combined approach (6.80 ± 1.2) versus laser-only treatment (5.65 ± 1.3, p < 0.001). Conclusion: Combining punch elevation technique with fractional CO2 laser resurfacing enhances treatment outcomes for atrophic acne scars
... While this subtype has been identified as being linked to the risk of skin cancer, it is important to note that it cannot provide a quantitative measure of that risk. Individuals with Fitzpatrick skin types III-VI are more susceptible to acne and may experience excessive postinflammatory pigmentation (PIH) as a result (Arsiwala and Desai 2019). ...
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The collection of big data on skin and appendage phenotypes has revolutionized the field of personalized diagnosis and treatment by enabling the evaluation of individual characteristics and early detection of abnormalities. To establish a standardized system for collecting and measuring big data on phenotypes, a systematic categorization of measurement entries has been undertaken, accompanied by recommendations on measurement entries, environmental equipment requirements, and collection processes, tailored to the needs of different usage scenarios. Specific collection sites have also been recommended based on different index characteristics. A multi-center, multi-regional collaboration has been initiated to collect big date on phenotypes of healthy and diseased skin in the Chinese population. This data will be correlated with patient disease information, exploring the factors influencing skin phenotype, analyzing the phenotypic data features that can predict prognosis, and ultimately promoting the exploration of the pathophysiology and pathogenesis of skin diseases and therapeutic approaches. Non-invasive skin measurement robots are also in development. This consensus aims to provide a reference for the study of phenomics and the standardization of phenotypic measurements of skin and appendages in China.
... Fractional laser primarily forms minimally invasive pores through thermal coagulation and thermal exfoliation, creating thermal bridges between these pores and normal tissues. This stimulates the skin's repair process, producing a substantial amount of collagen for reconstructing the dermal framework structure, ultimately achieving scar remediation [13,14]. Some studies have suggested that fractional laser stimulates skin renewal by creating small, uniform holes in the patient's skin, resulting in skin resurfacing. ...
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Purpose: To assess the feasibility and safety of a combination therapy involving fractional laser treatment and recombinant bovine basic fibroblast growth factor (rb-bFGF) in acne scar patients.Methods: 90 patients with acne scar admitted at Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology from September 2020 to December 2022 were enrolled in retrospective study. Patients were divided into control group (n = 41), treated with rb-bFGF alone and study group (n = 49), which underwent fractional laser treatment using Lutronic fractional laser device involving 40 days per session for three sessions, with additional application of rb-bFGF in the affected area at a dose of 300 IU/cm2 , three times daily, for seven consecutive days following the completion of each laser treatment session. Treatment effect, skin physiological indices, lactic acid stinging test (LAST) scores, stratum corneum integrity, and incidence of adverse reactions were determined.Results: Study group demonstrated superior efficacy with a total effectiveness of 97.96 %, significantly outperforming control group at 85.3 % (p < 0.05). Pre-treatment, both groups exhibited comparable values in trans-epidermal water loss (TEWL), pH, stratum corneum hydration, and erythema (a-value) (p> 0.05). Post-treatment, both groups exhibited significant improvements, with reduced TEWL, pH, and a-value, along with increased stratum corneum hydration (p < 0.05). Compared to control group, study group showed significantly lower TEWL, pH, and a-value, coupled with higher stratum corneum hydration (p < 0.05). Post-treatment, study group demonstrated lower total LAST scores, improved stratum corneum integrity, and a significantly lower incidence of adverse reactions.Conclusion: The combination of fractional laser and rb-bFGF in patients with acne scar improves skin barrier function, reduces lactic acid-induced stinging, and enhances stratum corneum integrity. Further research and clinical trials are needed to optimize the treatment protocols.
... Acne scars come in a variety of shapes and depths and can be treated with a combination of treatments to achieve the satisfying result. The gold standard for the treatment of atrophic scars is the ablative fractional carbon dioxide (FCO 2 ) laser [8]. It induces the reepithelialization of keratinocytes and the production and rearrangement of collagen in the dermal tissue by creating micro-columnar vaporization zones and thermally coagulated necrotic zones in the tissue [9]. ...
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Fractional carbon dioxide (CO2) laser combined with subcision has been widely used for the clinical treatment, but the efficacy of the combined therapy on three types of atrophic acne scars remains unreported. This retrospective study analyzed the clinical data of 413 patients with atrophic acne scars, treated with fractional CO2 laser combined with subcision in the combined group and with fractional CO2 laser in the control group. The treatment efficacy was evaluated by the Investigator's Global Assessment (IGA) and the Échelle d'évaluation clinique des cicatrices d'acné (ECCA). We reported adverse reactions such as erythema, lump, skin sensitivity, acne recurrence, and hyperpigmentation that occurred in both treatment groups. The treatment efficiency of the combined group was significantly higher than that of the control group (P < 0.001). Among the three subtypes of atrophic acne scars, the ECCA scores in the combined group of boxcar-type and rolling-type scars after treatment were lower than those in the control group (P = 0.041, P < 0.001, respectively), and no statistical difference in scores between the two groups for icepick-type scars was seen (P = 0.062). There was no statistical difference in adverse reactions between the two groups (P = 0.361). Fractional CO2 laser combined with subcision is more effective than fractional CO2 laser in the treatment of boxcar-type and rolling-type scars, but there is no significant difference in the treatment of icepick-type scars.
Article
Background Acne scars are commonly seen in the young population affecting quality of life. Treatment requires different modalities which can span over few months to years. A multimodal approach is required to treat various types of scars in a single session. Aims and Objectives The aim of this study was to assess the efficacy and safety of multimodal approach for acne scars using blunt subcision, fractional CO 2 laser, and stromal vascular fraction (SVF) injection. Materials and Methods The study included 20 patients with atrophic scars. All the patients were treated with subcision using Taylor Acne Liberator™ after injection of tumescent anesthesia, CO 2 laser, and SVF injection. Patients were followed up at intervals of 5 days, 1 month, and 3 months. Side effects of the procedure were noted. Results The mean improvement in acne scars was 3.2 after 3 months of procedure. This indicates the role of multimodal approach in treating various types of scars in single sessions. Seventy percent of patients were extremely satisfied with the procedure. Conclusion The multimodal approach gives excellent results in the management of acne scars and can be used when patients cannot visit frequently for treatment.
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Skin diseases pose challenges in treatment due to the skin’s complex structure and protective functions. Topical drug delivery has emerged as a preferred method for treating these conditions, offering localized therapy with minimal systemic side effects. However, the skin’s barrier properties frequently limit topical treatments’ efficacy by preventing drug penetration into deeper skin layers. In recent years, laser-assisted drug delivery (LADD) has gained attention as a promising strategy to overcome these limitations. LADD involves using lasers to create microchannels in the skin, facilitating the deposition of drugs and enhancing their penetration into the target tissue. Several lasers, such as fractional CO2, have been tested to see how well they work at delivering drugs. Despite the promising outcomes demonstrated in preclinical and clinical studies, several challenges persist in implementing LADD, including limited penetration depth, potential tissue damage, and the cost of LADD systems. Furthermore, selecting appropriate laser parameters and drug formulations is crucial to ensuring optimal therapeutic outcomes. Nevertheless, LADD holds significant potential for improving treatment efficacy for various skin conditions, including skin cancers, scars, and dermatological disorders. Future research efforts should focus on optimizing LADD techniques, addressing safety concerns, and exploring novel drug formulations to maximize the therapeutic benefits of this innovative approach. With continued advancements in laser technology and pharmaceutical science, LADD has the potential to revolutionize the field of dermatology and enhance patient care.
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Background Acne‐induced hyperpigmentation (AIH) may accompany acne vulgaris (AV) inflammation in all skin phototypes. Trifarotene has shown depigmenting properties in vivo. This study evaluated trifarotene plus skincare because it is increasingly recognized that holistic AV management should include skincare and treatments. Methods This is a phase IV double‐blind, parallel‐group study of patients (13–35 years) with moderate AV and AIH treated with trifarotene ( N = 60) or vehicle ( N = 63) plus skincare regimen (moisturizer, cleanser, and sunscreen) for 24 weeks. Assessments included the AIH overall disease severity (ODS) score, post‐AV hyperpigmentation index (PAHPI), exit interviews, photography, and acne assessments. Standard safety assessments were included. Results Trifarotene 50 μg/g cream improved significantly from baseline in ODS score versus vehicle (−1.6 vs. −1.1, P = 0.03) at Week 12, but scores were comparable between groups at Week 24 (primary endpoint). Trifarotene had a better reduction in PAHPI score at Week 24 (−18.9% vs. −11.3% vehicle, P < 0.01). Lesion count reductions were higher with trifarotene at Week 12 versus vehicle ( P < 0.001) and at Week 24 ( P < 0.05), as were IGA success rates versus vehicle at Weeks 12 ( P < 0.05) and 24 ( P < 0.05). Patients agreed that the skincare regimen contributed to less irritation, making treatment adherence easier. Photography showed improvements in pigmentation and erythema across all skin types. AEs were more common in the vehicle group versus trifarotene (30.2 vs. 16.7%, respectively). Conclusions In all skin phototypes, there was more rapid improvement in the ODS and PAHPI scores with trifarotene by Weeks 12 and 24, respectively. The combination of trifarotene and skincare correlated with high patient satisfaction and adherence to the treatment protocol.
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Background: Currently, the standard protocol regarding the performance of procedures on patients receiving or having recently received isotretinoin (13-cis-retinoic acid) states that the procedures should not be performed. The recommendations in standard books and drug insert require discontinuation of isotretinoin for 6 months before performing cosmetic procedures, including waxing, dermabrasion, chemical peels, laser procedures, or incisional and excisional cold-steel surgery. These recommendations have been followed for over two decades despite little evidence for the stated increased risk of scarring. Objective: The Association of Cutaneous Surgeons (I) constituted a task force to review the evidence and to recommend consensus guidelines regarding the safety of skin procedures, including resurfacing, energy-device treatments, and dermatosurgical procedures in patients with concurrent or recent isotretinoin administration. Materials and methods: Data were extracted from the literature through a PubMed search using the keywords "isotretinoin," "safety," "scarring," "keloids," "hypertrophic scarring," and "pigmentation." The evidence was then labeled and circulated to all members of task force for review. Results: The task force is of the opinion that there is insufficient evidence to support the current protocol of avoiding and delaying treatments in the patient group under consideration and recommends that the current practice should be discontinued. The task force concludes that performing procedures such as laser hair removal, fractional lasers for aging and acne scarring, lasers for pigmented skin lesions, fractional radio-frequency microneedling, superficial and medium-depth peels, microdermabrasion, dermaroller, biopsies, radio-frequency ablation, and superficial excisions is safe in patients with concurrent or recent isotretinoin administration.
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Platelet-rich plasma (PRP) is currently used in different medical fields. The interest in the application of PRP in dermatology has recently increased. It is being used in several different applications as in tissue regeneration, wound healing, scar revision, skin rejuvenating effects, and alopecia. PRP is a biological product defined as a portion of the plasma fraction of autologous blood with a platelet concentration above the baseline. It is obtained from the blood of patients collected before centrifugation. The knowledge of the biology, mechanism of action, and classification of the PRP should help clinicians better understand this new therapy and to easily sort and interpret the data available in the literature regarding PRP. In this review, we try to provide useful information for a better understanding of what should and should not be treated with PRP.
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Background: Autologous platelet-rich plasma has recently attracted significant attention throughout the medical field for its wound-healing ability. Aims: This study was conducted to investigate the potential of platelet-rich plasma combined with fractional laser therapy in the treatment of acne scarring. Methods: Sixteen patients (12 women and 4 men) who underwent split-face therapy were analyzed in this study. They received ablative fractional carbon dioxide laser combined with intradermal platelet-rich plasma treatment on one half of their face and ablative fractional carbon dioxide laser with intradermal normal saline on the other half. The injections were administered immediately after laser therapy. The treatment sessions were repeated after an interval of one month. The clinical response was assessed based on patient satisfaction and the objective evaluation of serial photographs by two blinded dermatologists at baseline, 1 month after the first treatment session and 4 months after the second. The adverse effects including erythema and edema were scored by participants on days 0, 2, 4, 6, 8, 15 and 30 after each session. Results: Overall clinical improvement of acne scars was higher on the platelet-rich plasma-fractional carbon dioxide laser treated side but the difference was not statistically significant either 1 month after the first treatment session (P = 0.15) or 4 months after the second (P = 0.23). In addition, adverse effects (erythema and edema) on the platelet-rich plasma-fractional carbon dioxide laser-treated side were more severe and of longer duration. Limitations: Small sample size, absence of all skin phototypes within the study group and lack of objective methods for the evaluation of response to treatment and adverse effects were the limitations. Conclusion: This study demonstrated that adding platelet-rich plasma to fractional carbon dioxide laser treatment did not produce any statistically significant synergistic effects and also resulted in more severe side effects and longer downtime.
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BACKGROUND AND OBJECTIVES: Most people who experience the acne suffer from damage under the surface of their skin which causes saucer-like depressions or pits on their skin. Sometimes the skin loses its underlying support and develops fibrous bands of tissue between the skin and subcutaneous layer, which pull on the epidermis and cause a wavy texture called as rolling scar. Treatment of acne scars is a therapeutic challenge that may require multiple modalities. Subcision is a procedure that has been reported as a beneficial method in the treatment of rolling acne scars. Although Subcision is a valuable method, its efficacy is mild to moderate because of the high recurrence rate and patients dissatisfaction due to some side effects include post procedure inflammation.
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Background: While laser resurfacing remains the most effective treatment option for atrophic acne scars, the high incidence of post-treatment adverse effects limits its use. Fractional laser photothermolysis attempts to overcome these limitations of laser resurfacing by creating microscopic zones of injury to the dermis with skip areas in between. Aim: The aim of the present study is to assess the efficacy and safety of fractional CO 2 laser resurfacing in atrophic facial acne scars. Materials and Methods: Sixty patients with moderate to severe atrophic facial acne scars were treated with 3-4 sessions of fractional CO 2 laser resurfacing at 6-week intervals. The therapeutic response to treatment was assessed at each follow up visit and then finally 6 months after the last laser session using a quartile grading scale. Response to treatment was labelled as ′excellent′ if there was >50% improvement in scar appearance and texture of skin on the grading scale while 25-50% response and
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Atrophic acne scars are difficult to treat. The demand for less invasive but highly effective treatment for scars is growing. To assess the efficacy of combination therapy using subcision, microneedling and 15% trichloroacetic acid (TCA) peel in the management of atrophic scars. Fifty patients with atrophic acne scars were graded using Goodman and Baron Qualitative grading. After subcision, dermaroller and 15% TCA peel were performed alternatively at 2-weeks interval for a total of 6 sessions of each. Grading of acne scar photographs was done pretreatment and 1 month after last procedure. Patients own evaluation of improvement was assessed. Out of 16 patients with Grade 4 scars, 10 (62.5%) patients improved to Grade 2 and 6 (37.5%) patients improved to Grade 3 scars. Out of 22 patients with Grade 3 scars, 5 (22.7%) patients were left with no scars, 2 (9.1%) patients improved to Grade 1and 15 (68.2%) patients improved to Grade 2. All 11 (100%) patients with Grade 2 scars were left with no scars. There was high level of patient satisfaction. This combination has shown good results in treating not only Grade 2 but also severe Grade 4 and 3 scars.
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Introduction: Acne scar is a common distressing complication of acne vulgaris. CO2 laser resurfacing proved effective for treatment of such 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 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 patient`s satisfaction. Result: The right side of the face (PRP treated side) achieved excellent improvement in 13.3% of 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.
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