Bruce Katz
Department of Dermatology, Mt. Sinai School of Medicine, Juva Skin & Laser Center, New York, New York
INTRODUCTION
A variety of fractional CO2 laser devices are available for the treatment of photodamage and acne scarring. Early studies of these “microablative” devices show that parts of both the epidermis and dermis are ablated1,2 and that tissue tightening occurs initially due to collateral heating and later during the 3 to 6 months after treatment due to collapse of the tiny vaporized columns.1-3 Efficacy of the fractional CO2 technique has been reported for the treatment of wrinkles, acne scars, striae, lentigines, solar elastoses, and other manifestations of photodamage.4-7 This study evaluates the efficacy and safety of a novel fractional CO2 laser device for improving facial rhytids, hyperpigmentation, enlarged pores, skin laxity, and acne scarring.
METHODS
Subjects (n=15) aged 31 to 81 years with facial rhytids, hyperpigmentation, enlarged pores, and skin laxity were treated 3 to 5 times at 3-week intervals. One subject had acne scars. Subjects received two passes with a microablative fractional CO2 laser device (Affirm CO2, Cynosure, Inc., Westford, MA). Treated areas included the entire face (n=7), perioccular areas (n=5), perioral areas (n=2), and cheeks (n=1). Target areas were cleaned and makeup was removed just before treatment. Lidocaine (30%) topical anesthetic was applied 20 to 30 minutes before treatment. All subjects provided signed informed consent to treatment and the study protocol was approved by the Independent Investigational Review Board, Inc., Plantation, Florida.
Clinical improvement was rated on a quartile rating scale (Mild = 0%-25%, moderate = 26%-50%, good = 51%-75%, and excellent = 76%-100%) from digital photographs obtained at baseline, and 1 and 3 months after the final treatment. Subject discomfort during treatment was evaluated on a scale of 0 to 5. Biopsy specimens were obtained before treatment and at 3, 7, and 14 days after treatment to evaluate healing response and neocollagenesis.
Multiple low-level treatments with cooling and reduced downtime were the preferred approach to treatment. Power settings varied from 15 to 25 W with incremental increases with each treatment. Dwell times were 0.5 to 0.8 ms and spot pitches were between 300 and 600 mm, most frequently at 500 μm. Gel (Aquaphor) and ice packs were applied to the target areas immediately after treatment. Subjects were instructed to gently clean treated areas and apply Aquaphor 3 to 4 times during the first 24 hours after each treatment.
RESULTS AND DISCUSSION
The 14 subjects who completed the study achieved good to excellent improvement in overall appearance, with 60% rated excellent. Subjects received an average of 3.5 treatments. One subject was lost to follow-up. Improvements three months after the final treatment are shown in Figure 1. Improvement in photodamage was good to excellent in 92% of subjects and reduction in rhytids was good to excellent in 85%. A total of 79% of subjects achieved good to excellent improvement in pore sizes and skin laxity. For the single subject treated for acne scaring, improvement was graded “good” in overall improvement and in pore size reduction. Subjects tolerated the procedure well. On average, subjects rated discomfort during treatment at 3.0 ± 0.7 on a scale of 0 to 5. Erythema and edema persisted 2 to 3 days and subjects applied make-up and resumed normal activities 1 to 2 days after the procedure. One subject complained of itching, which resolved in a few days after treatment with oral acetaminophen. Scars and dyschromia were not observed. Histological slides after a single treatment showed new collagen formation (Figure 2). Clinical examples are shown in Figures 3 through 6.
In the present study, treatment parameters were selected on the basis of the subject’s age and severity of photodamage. This is consistent with the suggestions of Groff and coworkers (2008),3 who selected settings on the basis of the number and depth of wrinkles and the degrees of textural irregularity, dyschromia, capillary telangiectasia, and tissue laxity.
A summary of all the reports on the use of the fractional CO2 laser devices for the treatment of photodamage is beyond the scope of this paper. However, our results confirm those of Gold and colleagues,8 who showed improvement in photodamage parameters with minimal adverse effects after two treatments with the Affirm CO2 device used in the present study. Physician and subject evaluations were favorable, discomfort during treatment was 2.0 (compared to our 3.0) on a scale of 0 to 5, and 11 of the 12 subjects would recommend the treatment to others. Our results are also similar to those of Gotkin and colleagues,7 who treated 32 subjects once with a device and scanner similar to the Affirm CO2. Their improvements in wrinkles, scars, striae, lentigines, and skin texture and color were supported by histological evidence of neocollagenesis.
Our single patient with acne scarring showed noticeable improvement. This finding agrees with that of Gold and colleagues,8 who noted improvement in the acne scars of two subjects after two treatments with the Affirm CO2 laser device.
As suggested by earlier studies, a single treatment at higher power and longer dwell time settings may achieve similar results as those of the present study, providing the patient is willing to accept the longer downtime. The design of the Affirm CO2 laser device permits the user to customize outcomes by selecting power, dwell time, and spot pitch settings, and by adjusting the scanner.
CONCLUSION
The Affirm fractional CO2 system provides substantial improvement for the treatment of facial wrinkles, hyperpigmentation, pore size, and skin laxity associated with photodamage. Adverse effects were minimal and transitory.
REFERENCES
1. Hantash BM, Bedi VP, Kapadia B, et al. In vivo histological evaluation of a novel ablative fractional resurfacing device. Lasers Surg Med 2007; 39: 96-107.
2. Hantash BM, Bedi VP, Chan KF, Zachary CB. Ex vivo histological characterization of a novel ablative fractional resurfacing device. Lasers Surg Med 2007; 39: 87-95.
3. Groff WF, Fitzpatrick RE, Uebelhoer NS. Fractional carbon dioxide laser and plasmakinetic skin resurfacing. Semin Cutan Med Surg 2008; 27: 239-251.
4. Rahman Z, Tanner H, Tournas J, et al. Ablative fractional resurfacing for the treatment of photodamage and laxity. Laser Surg Med 2007; 39(s19): 15.
5. Weiss RA, Weiss MA, Beasley KL. Prospective clinical trial of a fixed spacing array computer scanned fractional CO2 laser for rhytids. Laser Surg Med 2007; 39(s19): 16.
6. Chapas AM, Brightman L, Sukal S, et al. Successful treatment of acneiform scarring with CO2 ablative fractional resurfacing. Lasers Surg Med 2008; 40: 381-386.
7. Gotkin RH, Sarnoff DS, Cannarozzo G, Sadick NS, Alexiades-Armenakas M. Ablative skin resurfacing with a novel microablative CO2 laser. J Drugs Dermatol 2009; 8: 138-144.
8. Gold MH, Heath AD, Biron JA. Clinical evaluation of the Affirm CO2 fractional laser for the treatment of photodamage and acne scars. J Drugs Dermatol in press.
The above mentioned was published in Therapeutic Hotline. Dermatologic Therapy, Vol 23,2010, 403-406. 2010 Wiley Periodicals, Inc. ISSN 1396-0296