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

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.

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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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