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ORIGINAL ARTICLE
Year : 2022 | Volume
: 42
| Issue : 2 | Page : 103-109
A prospective study on the efficacy and safety of fractional carbon dioxide laser in the treatment of post-acne scars
Gayathri Sundaram, Seethalakshmi G Vellaisamy, Kannan Gopalan, Navakumar Manickam
Department of Skin & STD, Vinayaka Mission KirupanandhaVariyar Medical College & Hospital, Vinayaka Mission’s Research Foundation (deemed to be University), Salem, Tamil Nadu, India
Correspondence Address:
MD Seethalakshmi G Vellaisamy
11, Mullai Nagar, Near Chandra Mahal, Seelanaickenpatty, Salem 636201, Tamil Nadu
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ejdv.ejdv_17_21
Introduction Acne scars can play havoc with the social functioning of the patient leading to severe depression with reduced quality of life. Fractional CO2 laser provides a fine balance between the undesirable side effects of ablative lasers and the limited efficacy of nonablative lasers.
Objective The present study was conducted to evaluate the efficacy and safety of fractional CO2 laser in the treatment of acne scars.
Patients and methods Fractional CO2 laser treatment performed on 30 patients with atrophic acne scar by different protocols depending on the type and its depth. Results were assessed based on serial photographs, clinical improvement, and physician’s global assessment scale.
Results Of the 30 participants, 27 completed all three sessions. Out of the 27 patients in the final follow-up, three (10%) had excellent improvement of which two had mild acne scar and one had moderate scar before treatment; 16 (59.2%) had good response of which 13 had moderate acne scar and three had mild scar and eight (29.7%) had fair response of which six had moderate scars and two had mild scars.
Conclusion Fractional CO2 laser as monotherapy in the treatment of mild-to-moderate post-acne scars seems to be effective with good patient satisfaction and reduced side effect profile. In case of severe acne scars, fractional CO2 laser can be used as a combined procedure along with other therapeutic modalities like subcision, platelet-rich plasma, and TCA CROSS (chemical reconstruction of skin scars using trichloroacetic acid) techniques.
Keywords: acne vulgaris, fractional CO2 laser, fractional photothermolysis, post-acne scars
Acne scarring is one of the most feared and long-lasting complications of inflammatory acne [1]. It can play havoc with the social functioning of the patient leading to severe psychological depression, low self-esteem, and social phobia. Acne scars can be categorized as either due to increased or lack of tissue formation or due to tissue damage. In 80–90%, the scars are due to loss of collagen, whereas 10–20% comprise hypertrophic scars and keloids [2]. Depending on the shape and depth, atrophic facial scars are classified into various morphological types [3]. The four significant types of atrophic scars are ice-pick pitted scars, superficial or deep boxcar scars, rolling scars, and linear scars [4].
The evaluation and treatment of post-acne scar always remains a challenge to the dermatologists. A variety of modalities have been used to treat atrophic acne scars including punch excision, dermabrasion, chemical peels, fillers and traditional ablative and nonablative lasers, each with varying degrees of success and adverse reactions [3],[5]. Ablative skin resurfacing with CO2 and erbium: YAG lasers was previously considered the gold standard for laser treatment of atrophic acne scars [6]. However, while effective in recontouring the skin and improving the appearance of scar texture, these are limited by significant downtime, prolonged erythema, and adverse effects such as postinflammatory pigmentary changes and scarring [7].
Fractional photothermolysis or fractional CO2 laser is a newer technology in which only a fraction of skin is removed instead of wiping away the entire skin [8]. It unites the idea of fractional photothermolysis with an ablative 10 600 nm wavelength. It creates microscopic treatment zones to stimulate a wound healing response. The tissue surrounding each column is spared, resulting in rapid epidermal regeneration with reduced downtime and adverse reactions compared with traditional ablative lasers. This provides a fine balance between the undesirable side effects of ablative lasers and the limited efficacy of nonablative ones. In this backdrop, this study attempts to throw light on the efficacy and safety of fractional CO2 laser in the treatment of post-acne scars.
ObjectivesThe objective of the study was to evaluate the efficacy and safety of fractional CO2 laser in the treatment of post-acne scars.
Patients and methodsThis was a prospective study conducted in our Skin and STD Outpatient Department after getting approval from the ethics committee of our institution. The study population included 30 patients from the age group of 17 years, who attended our outpatient department during from February 2019 to August 2020 with facial acne scars (atrophic scars) and with Fitzpatrick’s skin types III–V. Exclusion criteria included patients with active acne, those who are on anticoagulant therapy, pregnant and lactating females, active bacterial or viral infection, history of isotretinoin treatment in the past 6 months, and patients with unrealistic expectations.
After getting informed consent each patient was interviewed for age, sex, occupation, sun exposure, duration of disease, family history, previous treatment history, use of cosmetics, and any precipitating factors. Patients were subjected to a proper general, systemic, and dermatological examination. The acne scars were graded using Goodman and Baron’s qualitative global acne grading system [9]. The first grade consists of macular hyperpigmented or hypopigmented flat marks that are visible. The second grade includes mild atrophy or hypertrophic scars that may not be visible at a distance of 50 cm, which can be concealed with cosmetics. The third grade consists of moderate atrophic or hypertrophic scars, visible at a social distance of 50 cm or greater, cannot easily be concealed with makeup, but still can be flattened by manual pressure of the skin. The most severe grade is highly atrophic or hypertrophic scar, visible at a distance greater than 50 cm that are not flattened with pressure of the skin around the scars.
Before procedure, all treatment areas were gently cleansed using a mild cleanser followed by application of a topical anesthetic cream. After 1 h, the anesthetic cream was gently removed and then alcohol was used to degrease the skin. The fractional CO2 laser treatment was carried out for the atrophic scar by different protocols depending on the type of scar and its depth. The laser system was a CO2 laser (DermaIndia, Subashree Industrial Park, Plot No. 2, Venkateswara Nagar Main Road, Venkateswara Nagar, Off. IT Corridor, Perungudi, Chennai, Tamil Nadu, India, www.dermaindia.in) developed specifically for fractional treatments. The laser procedure was performed in a single pass with a spot diameter of 1.0 mm, pulse duration of 10 ms, laser power of 10–15 W, microbeam energy of 100–150 mJ per pulse and 100 microscopic treatment zones/cm2. The lowest energy level was used for first treatment and increased with subsequent treatments. The procedure was repeated every 3 weeks and a total of three sessions were performed on each patient. Photographic documentation using identical camera settings, lighting, and patient positioning was obtained at first visit, before each treatment session, and 1 month after the final treatment session.
Efficacy was assessed based on serial photographs, clinical improvement and physician’s global assessment scale. The following grading scale was used for assessing the improvement: excellent (76–100%), good (51–75%), fair (26–50%), and poor (0–25%) [10]. Level of patient satisfaction (based on subjective evaluation) was assessed at the final visit and they were grouped into very satisfied, only satisfied, slightly satisfied, or completely unsatisfied [11]. Pain assessment was also done for each one of them immediately after treatment using a numerical scale ranging from 0 (no pain) to 10 (worst imaginable pain) [12]. Moreover, side effects were monitored and recorded. Clinical findings and results were recorded in a predesigned proforma for analysis and interpretation of data. Data were entered using IBM SPSS, version 23.0 (IBM). Descriptive statistics were done in the form of mean and SD. The Kendall test was done to correlate the percentage of improvement between the three follow-ups. Values were considered significant when P values were less than or equal to 0.05.
ResultsA total of 30 patients participated in the study of whom 27 completed all four sessions. Three cases were lost to follow-up, one during the second follow-up and the other two during the third follow-up. Of the 30 patients, 22 (73.3%) patients were 18–25 years old and the mean age was 24.4 years; 18 (60%) were males and 12 (40%) were females and the male to female ratio was 1.5 : 1. Basic demographic features are shown in [Table 1]. Duration, site, and grading of acne scars are shown in [Table 2]. Based on Goodman and Baron’s qualitative scale [9] for acne scars, seven (23.3%) patients were graded as grade 2 or mild, 22 (73.3%) patients as grade 3 or moderate, and one (3.3%) patient as grade 4 or severe. In our study, majority of the population had grade 3 or moderate post-acne scars.
Table 1 Age, sex, occupation, precipitating factors, and associated conditions of the patients
Table 2 Duration, site, and grading of post-acne scars in the study populationRegarding the morphology of post-acne scars, most of the patients (30%) had a combination of ice pick and boxcar scars ([Table 3]). Percentage of improvement was assessed based on physician’s global assessment scale at each follow-up [10]. Regarding pain assessment as per the visual analog scale, all the patients in our study experienced mild pain. During the first follow-up, 10 (33.3%) patients had good (51–75%) improvement and 20 (66.7%) patients had fair (26–50%) improvement. During the second follow-up of the 29 patients, 16 (55.1%) had good (51–75%) improvement and 13 (44.9%) had fair (26–50%) improvement. Out of the 27 patients in the final follow-up, three (10%) had excellent improvement, 16 (59.2%) had good response, and eight (29.7%) had fair response ([Table 4]). With fractional CO2 laser as monotherapy, good improvement was observed in patients with grade 2 and grade 3 acne scars after three sittings.
The Kendall test was used to correlate the percentage of improvement between the three follow-ups and a P value of 0.001 was obtained and it was statistically significant. Using the physician’s global assessment scale [10], the percentage of improvement for different grades of acne scars was noted as follows, among the 27 patients, three (76–100%) patients had excellent response of which two had mild acne scar ([Figure 1]a and b) and one had moderate scar before treatment. Sixteen (51–75%) patients had good response of which 13 had moderate acne scars ([Figure 2]a and b) and three had mild scars ([Figure 3]a and b). Eight (26–50%) patients had fair response of which six had moderate scars and two had mild scars ([Table 5]). For the subjective evaluation, each patient’s level of satisfaction was assessed at the final visit ([Figure 4]). In our study, the most commonly observed side effect was erythema in 12 (7.4%) patients, burning sensation and erythema in five (18.5%) patients, erythema and edema in three (11.1%) patients ([Figure 5]) and burning, erythema, and edema in three (11.1%) patients. Only one patient developed postinflammatory hyperpigmentation (PIH). All the side effects were transient and resolved spontaneously.
Figure 1 (a) Baseline photograph of a patient with mild acne scar and (b) more than 75% improvement after three sittings of fractional CO2.
Figure 2 (a) Baseline photograph of a patient with moderate acne scar and (b) 51–75% improvement after three sittings of fractional CO2.
Figure 3 (a) Baseline photograph of a patient with mild acne scars and (b) 51–75% improvement after three sittings of fractional CO2.
Figure 5 Transient erythema and edema seen immediately posttreatment in a female patient. Discussion The evaluation and treatment of acne scar always remains a challenge. A typical patient has scars of different morphological types and grades, and it is difficult to treat all these scar types satisfactorily with a single treatment option making the assessment of efficacy of any therapeutic option difficult to judge [13]. Fractional CO2 laser evades a significant number of unwanted results as just a fraction of the skin is dealt with, without disrupting the integrity of the epidermis [14]. Of the treatment options available to treat post-acne scars, fractional photothermolysis may offer the highest degree of scar amelioration and patient satisfaction [13].
The results obtained with the fractional laser resurfacing technique lack the uniform objective assessment of satisfaction [11]. Numerous clinical investigations on the use of fractional laser innovation have utilized quartile reviewing frameworks or patient fulfilment as the measures to survey the restorative outcomes. Both of these criteria are fraught with subjective bias and there is an urgent need for a proper objective tool that can be used across the whole spectrum of post-acne scars to assess any therapeutic benefits [15].
Age group and sex preponderance
In our study, most of the patients were between the age group of 18 and 25 years, with a mean age of 24.6 years. It could be due to the fact that acne is a condition prevalent among the adolescents; the scars are of great cosmetic concern among youngsters. This was in concurrence with the study by Saeed and Alsaiari [11] in which the mean age was 26.4 years, whereas in the study by Majid and Imran [13] majority of the study group belonged to the age group of 31–40 years.
In the study by Saeed and Alsaiari [11] and Majid and Imran [13] females outnumbered males, whereas in our study male patients outnumbered the female patients, which is in contrast to the belief that females were more concerned about their physical appearance.
Grading of post-acne scars
On the basis of Goodman and Barons qualitative grading scale [9], in our study 73.3% of patients had moderate or grade 3 acne scars; 23.3% had mild or grade 2 scars; and 3.3% had severe acne scars. In the study by Saeed and Alsaiari [11], 31% had moderate acne scars and 9% had severe acne scars. In the study by Majid and Imran [13], majority of patients had moderate to severe atrophic post-acne scars whereas in the study by Alster et al. [16] post-acne scars were not graded and only photographs of the patients were used to assess the severity of scars.
Site of post-acne scars
On the basis of the site of involvement, in our study cheek was the most common affected site, with all 30 (100%) patients having involvement of cheeks. This was in concurrence with the study by Saeed and Alsaiari [11] in which 95% of patients had involvement of cheeks.
Morphology of post-acne scars
On the basis of the morphology of post-acne scars, 30% of patients had ice-pick and boxcar scars, 23.3% patients had a mixture of all the three types of atrophic acne scars, and 13.3% patients had predominantly rolling type of scars. In the study by Layton et al. [17], majority of the patients had ice-pick scars whereas in the study by Saeed and Alsaiari [11], 40% patients had predominantly rolling scars; 37.5% had a mixture of various morphologic types and 22.5% had predominant pitting scars.
Efficacy of treatment
In our study, out of the 27 patients who completed three sessions of treatment, 11.1% had excellent response of more than 75%; 59.2% patients had a good response with 51–75% improvement; and 29.7% had a fair response of 26–50%. Of the seven (25.9%) with mild or grade 2 acne scars, two (7.4%) had excellent response, three (11.1%) had good response, and two (7.4%) had a fair response. Of the 20 patients who had moderate or grade 3 acne scars, one (3.7%) had excellent response, 13 (48.1%) had good response, and six (22.2%) had a fair response. With fractional CO2 laser as monotherapy, good improvement was observed in patients with grade 2 and grade 3 acne scars after three sittings.
In the study by Saeed and Alsaiari [11], good or excellent results were documented in 30 (75%) patients. Of these 30 patients, seven (17.5%) patients had more than 75% improvement, while seven patients had 51–75% improvement. Thus, excellent response was achieved in 14 (37.5%) patients. Sixteen (40%) patients showed a good response and 10 patients showed less than 25% improvement.
Majid and Imran [13] demonstrated a good to excellent response in about 67% patients on the quartile grading scale. While about 40% patients achieved more than 50% improvement, additional 27% patients were seen to have 25–50% improvement in scar morphology and texture in the study group. Chapas et al. [18] in their study on facial acne scars recorded an improvement of 26–50% in skin topography. The investigators additionally utilized an imaging framework (Primos) to dissect the adjustment in the morphology of scars. Moreover, this imaging framework additionally recorded a target improvement in the profundity of individual scars going from 43 to 79.9% with a mean improvement of 66.8%.
Alster et al. [16] in a study on 53 patients documented a clinical improvement in the range of 51–75% in about 87% of their patients, who received three treatments at 4-week intervals with fractional erbium-doped fiber laser. Hedelund et al. [12] in his study on 13 patients demonstrated a statistically significant improvement in skin texture and atrophy in comparison with placebo after 3 monthly laser sessions with a fractional CO2 device. Cho et al. [19] demonstrated the efficacy as well as safety of fractional CO2 laser resurfacing in Asian patients with acne scars. Half of the 20 patients enrolled in this study achieved a clinical improvement of more than 50% while another seven patients achieved 26–50% improvement ([Table 6]).
Table 6 Comparison of overall percentage of improvement with other studiesIn general, patients were comfortable with fractional CO2 laser and it is insufficient to assess the outcome with only three sittings as a favorable outcome in the morphology of scars with full collagen remodeling may take up to 6–12 months. The difference in the results obtained with overall percentage of improvement among the comparative studies could be attributed to the fact that there is a lack of uniform criteria or objective assessment tool to measure the outcome of the procedure.
Patients’ level of satisfaction
In the study by Saeed and Alsaiari [11], patient satisfaction study demonstrated that about 77.5% (31 cases out of 40) were happy with the results achieved. For the remaining nine patients, the improvement accomplished was not up to their desires. In the study by Majid and Imran [13], patient satisfaction study demonstrated that about 73% (44 cases out of 60) were happy with the results achieved. For the remaining 16 patients, the improvement accomplished was not up to their desires.
In all other studies, only an overall measure of patient satisfaction is mentioned and only our study has graded the level of satisfaction in each patient. Hence to evaluate the outcome of the procedure, it is emphasized that the level of patient satisfaction should also be assayed.
Safety profile
Adverse effects were noted in almost all the patients but they were transient and none of the patients had any long-term or permanent side effects. This could be attributed to the use of sunscreens before and after treatment and that only a fraction of the skin is treated, so that the normal epithelium from the surrounding skin aids in the faster regeneration of the damaged tissue. Superficial crusting occurred in a few patients, which resolved in 2–3 days. PIH was noted in one (3.7%) patient and it resolved with topical therapy over 2 months. In our study, there were no major adverse effects like persistence of erythema, flare-up of herpes labialis, scarring, and keloid formation.
In Saeed and Alsaiari study [11] 95% had mild erythema; 77.5% had superficial crusting; and 67.5% had transient edema and two patients developed PIH. Majid and Imran [13] also demonstrated adverse effects like mild transient erythema, edema, superficial crusting, transient acneiform eruptions, and PIH that resolved over a period of time. The adverse effects seen in our study is in concurrence with the other studies. As all the effects were only transient, it did not cause any hindrance in the day-to-day activities of the patients. Hence, fractional CO2 laser is a safer modality of treatment due to its reduced downtime, when compared with other procedures like TCA CROSS (chemical reconstruction of skin scars using trichloroacetic acid) and subcision that causes the patients to endure prolonged adverse effects.
Limitations of the study
The smaller sample size.The number of laser sessions was limited to 3.Lack of uniform criteria to assess the outcome.Limited duration of follow-up (only 3 months) as the time for maximum benefit takes at least 6 months. ConclusionPatients with grade 2 and grade 3 acne scars showed an overall good improvement with fractional CO2 as monotherapy in our study. Majority of the patients were satisfied with the treatment and it did not cause any hindrance to the day-to-day activities of the patients. On the basis of the results of our study, fractional CO2 laser as monotherapy in the treatment of mild-to-moderate post-acne scars seems to be effective with good patient satisfaction and reduced side effect profiles.
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Conflicts of interest
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References
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