Fractional CO2 laser safe for facial rejuvenation in Brazilian skin

Results from two years of follow-up indicate deep fractional CO2 laser treatment (TotalFX, Lumenis) is safe and effective in treating photoaging and acne scars in patients with darker skin types, according to Guilherme Almeida, M.D., who spoke at the 2010 annual meeting of the American Society for Laser Medicine and Surgery (ASLMS).

Outcomes were analyzed for a series of 45 Brazilian patients who underwent fractional photothermolysis using the 10,600 nm UltraPulse laser (Lumenis). All patients had Fitzpatrick skin types ranging from III to V, and the treatments were performed using the manufacturer's standard protocol. Outcomes were assessed subjectively by the patients and by four physicians who compared pre- and post-treatment 3-D, high-resolution photographic images (VECTRA 3D, Canfield).

The results from the patient and physician assessments showed all patients achieved at least greater than 50 percent improvement, and the majority improved greater than 75 percent. While all patients developed postinflammatory hyperpigmentation (PIH), it was generally mild and transient, and even patients who had more persistent PIH or other complications were highly satisfied with the results of their treatment. Another 40 patients have been treated with similarly favorable results, says Dr. Almeida, Sirio-Libanes Hospital, São Paulo, Brazil.

"Developed to address the shortcomings of previous ablative and nonablative skin rejuvenation, fractional CO2 laser treatment has become a new gold standard for resurfacing procedures because it is highly effective, but associated with less morbidity and a low risk of complications. The technology we used has been approved for use by the FDA (Food and Drug Administration) in 34 indications, and our study reaffirms its efficacy in improving acne scars and photodamage," Dr. Almeida says.

"Although all of our patients developed PIH, it was generally mild and in no case persisted longer than four months," he says. "However, further studies may be warranted investigating lower energy and density settings to see if pigmentary changes can be avoided, and at this meeting (ASLMS) we are also reporting a new method using only DeepFX with low densities without a single case of PIH."

PIH AND DARKER SKIN Photodamage is a common problem among Brazilians where sun exposure is high year-round, but dark skin types are also prevalent within the population, raising the concern of post-treatment pigmentary changes following laser rejuvenation. Researching the literature, Dr. Almeida and colleagues found that previous studies reported a lower incidence of PIH in patients with darker skin types treated with fractional CO2 lasers, ranging between 0 and 37 percent.

"However, the risk may be greater in our geographic region due to higher proportions of patients with darker skin types and the high sun exposure at our tropical latitude," Dr. Almeida says.

The fractional laser procedures were performed under IV anesthesia/sedation using propofol, in most cases. All patients were treated with antimicrobial drugs to prevent viral, fungal and bacterial infections, and with topical hydroquinone to minimize PIH. Patients were excluded from treatment if they had any active infection, history of keloid scar formation, were pregnant, had undergone chemical peeling or other cosmetic surgical procedures within the previous six months, or had used isotretinoin within the previous 12 months. Patients were also asked to withhold any medications or supplements with anticoagulant properties for one week prior to the laser treatment in order to minimize pinpoint bleeding.

TREATMENT PROTOCOL The treatment protocol consisted of a single pass over scars and rhytids using the DeepFX mode at an energy level of 5 mJ to 25 mJ, pattern 1-4, size 2, and density 2-3, followed by a full-face single pass with the less aggressive ActiveFX mode at an energy level of 70 mJ to 125 mJ, 150 Hz, pattern 3, size 2-5, density 2-3 in a vectorial fashion over the lax skin.

All patients developed erythema, edema, oozing and crusting post-treatment, but these sequelae all resolved within seven to 10 days post-treatment.

Post-treatment improvement was assessed at one and three months using a quartile rating scale where 1 = minor improvement (1 percent to 25 percent) and 4 = very significant improvement (76 percent to 100 percent). The physicians' assessments showed 36 (80 percent) of the 45 patients achieved very significant improvement, while the remaining nine (20 percent) achieved marked improvement from baseline.

The patient ratings showed they were even more pleased with their outcomes than were the physicians. Forty patients (89 percent) rated their improvement as very significant, and the other five (11 percent) felt it was in the marked range.

A severity rating scale of 0 (none) to 4 (severe) was used to assess PIH. Forty-two patients were seen seven days post-treatment; 30 patients had a PIH score of 1, six patients had a score of 2, five were rated 3 and only one patient had a severity score of 4. PIH had resolved in all patients by four months.

Other complications included late-onset hypopigmentation and hypertrophic scarring on the neck, each affecting only one patient. Both events were categorized as mild.