Treatment Outcome of Carbon Dioxide (CO2) Laser Skin Resurfacing of Facial Scars and Wrinkles in Skin Type III and IV Patients

BULLETIN FOR MEDICAL PRACTITIONERS

Professor Goh Chee Leok
Senior Consultant and Medical Director
National Skin Centre, Singapore

Introduction

The carbon dioxide (CO2) laser at 10.6 um is recognized as being an effective method for skin resurfacing for wrinkles and scars. It is efficient and provides good control of bleeding during the resurfacing procedure. The laser resurfacing procedure may be associated with prolonged periods of erythema and post-inflammatory hyperpigmentation caused by the associated tissue damage 1,2,3. This is a study on the efficacy and complications of carbon dioxide laser resurfacing performed at the National Skin Centre on skin type III and IV patients.

Objective

The aim of this study was to study the outcome of acne scars and wrinkles in patients with skin type III and IV treated with CO2 laser resurfacing.

Methodology

This was a prospective study of patients with facial scars and wrinkles who opted to be treated with CO2 laser resurfacing. Only patients who were >21 years old, with skin type III or IV were included into the study. Patients with skin type V and VI were excluded.

All patients were instructed to use topical tretinoin 0.025% cream nightly over the affected areas for at least 2 weeks prior to CO2 laser resurfacing. After comprehensive counseling, informed consent was obtained from all patients.

Operatively, the patient’s facial skin was first cleansed thoroughly with normal saline. Facial nerve blocks with 1% lidocaine were administered to the infraorbital nerves and the mental nerves on both sides of the face. Local infiltrations were also delivered to the sides and temples of the face. When the nose was resurfaced, the nasal nerves were also blocked. The supra-orbital nerves were blocked for forehead resurfacing.

Settings for the Unipulse CO2 (Nidek, California) laser scanning system were as follows: the power at tissue was set at 15 watts (fluence = 6.12 J/cm2, spot size=1.02mm, frequency=300Hz), with a 20% overlap. Lesions around the eyes were resurfaced with 1 pass. Those on other parts of the face with 2-3 passes.

Patients were prescribed prophylactic oral erythromycin 500 mg tid post-operatively. Oral acyclovir 200 mg 5x/day or oral valacyclovir 500 mg tid x 5 days was prescribed for patients whose perioral regions were resurfaced or who gave a past history of herpes labialis when the cheeks/forehead were resurfaced. Patients were also prescribed mefenamic acid 500 mg tid to be taken when necessary for post-operative pain relief. All patients had a thin hydrocolloid dressing on the 1st and 2nd post-operative days. From the 3rd post-operative day onwards, they were advised to self-dress their wounds with normal saline wash and aqueous cream. When the resurfaced skin stopped oozing, patients were advised to use sunscreens daily and topical hydroquinone 2% cream nightly.

The resurfaced skin was assessed at day 1 and day 7 post-operatively for any early complications. Patients were subsequently assessed at 6 weeks, 3 months, 6 months and 12 months for treatment response and complications.

Treatment response (assessed by both patient and dermatologist) was graded as “no change”=no improvement, “minimal improvement”= <25% clearance, “moderate improvement”= 25-50% clearance, “good improvement”= 50-75% clearance or “excellent improvement”=>75% clearance. Complications (assessed by dermatologist only) including erythema, hyperpigmentation and hypopigmentation were scored as none, minimal, mild, moderate or severe.

Results

23 (14 females, 9 males) patients participated in the study. 19 patients had acne scars, 3 patients had wrinkles and 1 patient had chicken-pox scars. Their mean age was 30.9 years (SD=9.5 years). 21 patients had skin type IV and 2 had skin type III.

Treatment Response

17 patients were assessed at 6 weeks post-treatment. Both patient’s and dermatologist’s assessments were in concordance on all occasions. 3/17(18%) patients had “minimal improvement, 11/17(65%) patients had “moderate improvement” and 3/17(18%) patients had “good improvement. All 3 patients who experienced “good improvement” at this stage had rhytides (Figs. 1A and 1B). At 6 months, 3/12 (25%) had minimal improvement; 6/12 (50%) had moderate improvement (Figs. 2A and 2B) and 3/12 (25%) had good improvement. At 12 months, 5/6 (83%) had “moderate” improvement and 1 patient had “good improvement”. The patient with “good improvement” was resurfaced for rhytides. Table 1 shows the breakdown of treatment responses according to duration of follow-up.

Complications

Erythema.
All patients experienced moderate to severe erythema at day 1. The erythema gradually faded over 6 months. By 3 months, only 33% had minimal erythema and by 6 months, only 8% (1/12) of patients had erythema. Table 2 shows the severity and frequency of erythema post-operatively.

Hyperpigmentation.
Moderate pigmentation developed in 12% of patients at 6 weeks. At 3 months, 34% had varying degrees of pigmentation. Pigmentation cleared slowly subsequently and by 6 months, only 1 patient had residual pigmentation. Table 3 shows the severity and frequency of post-inflammatory pigmentation after resurfacing.

Hypopigmentation.
1 patient developed mild hypo-pigmentation at 6 months, this cleared at 12 months, but another patient developed delayed hypopigmentation at 12 months.  

Discussion

Cutaneous laser resurfacing with the new generation carbon dioxide, erbium:YAG and combined erbium:YAG/CO2 lasers have recently been put to good use in the treatment of facial scars and wrinkles 1,2,3,4,5 . Acne scars and rhytides were the common indications for laser resurfacing at the National Skin Centre.

Acne scars generally do not respond as well as rhytides 2. Our findings confirmed that the CO2 laser resurfacing outcome is variable and usually does not result in complete clearance of the rhytides and scars. The patient’s expectations should be assessed carefully before beginning surgery. Surgical scar revision e.g. excision of fibrotic scars preceding the laser resurfacing may help improve the outcome of laser resurfacing on acne scars.

CO2 laser resurfacing provided mild to moderate improvements for acne scars in our study. Improvement continued to occur progressively after CO2 laser resurfacing over 12 months. At 6 weeks post-operatively, 50% of patient had moderate improvement. At 12 months, 83% of our patients had moderate improvement.

Erythema is a common post-operative complication 1. Erythema was experienced by all our patients in the initial 6 weeks post-treatment (Fig. 3). The erythema cleared completely over 6 months.

Hyperpigmentation has been reported to occur in 5% to 83% of patients after CO2 laser resurfacing and is principally related to the patient’s skin type 8,9,10. Post-inflammatory pigmentation is a common problem amongst the darker skinned Asians post-operatively. About 30% of our patients experienced post-inflammatory pigmentation at 6 weeks post-operatively. From our study, it appears that post-inflammatory pigmentation following laser resurfacing (Fig. 4) amongst the darker skinned Asians may not be as frequent as reported. But the pigmentation may be severe in those affected. The pigmentation cleared slowly over the next 6 to 12 months. Vigilant sun protection and the use of lightening agents e.g. hydroquinone 2-4%, may help reduce the severity and frequency of pigmentation 10,11 .

Hypopigmentation appeared to be less common in our patients. It has been reported to occur after carbon dioxide laser resurfacing in patients with skin type I to IV, most commonly in patients with extensive photodamaged skin 12. One of our patients developed hypopigmentation at 12 months post-treatment; it is a late complication even amongst skin type IV patients.

From our studies, it appears that patients with skin type III or IV can be resurfaced with the CO2 laser with improvement. However, the expected treatment outcome and complications should be clearly made known to the patient before the procedure as the final outcome may be lower than that expected by patients.

Conclusion

CO2 laser resurfacing can provide up to moderate improvement for scars amongst Asians with skin types III and IV. Post-CO2 laser resurfacing erythema is to be expected but generally fades over 6 months. Post-inflammatory pigmentation is common but tends to clear over 6-12 months.

References

1. Lask G, Keller G, Lowe N, Gormley D. Laser skin resurfacing with the silktouch flashscanner for facial rhytides. Dermatol Surg 1995;21:1021-4.
2. Ratner D, Tse Y, Marchell N et al. Cutaneous laser resurfacing. J Am Acad Dermatol 1999;41: 365-89
3. Fitzpatrick RE, Goldman MP: Resurfacing of photodamage of the neck using the ultrapulse CO2 laser. Lasers Surg Med 1997; 21:33.
4. McDaniel DH, Ash K, I Loar, Newman I. The erbium:YAG laser. A review and preliminary report on resurfacing the face, neck and hand. Aestht Plast Surg 1997;17:157-64.
5. Trelles M, Garcia-Solana L, Calderhead RG. Skin resurfacing improved with a new dual wavelenght Er:YAG/ CO2 laser system: A comparative study. J Clin Laser Med Surg 1999;17:99-04.
6. Goodman GJ. Carbon dioxide laser resurfacing. Dermatol Surg 1998;24:331-4.
7. Trelles Mam Mordon S, Svaasand LO, Mellow TK, Rigau J, Garcia L. The origin and role of erythema after carbon dioxide laser resurfacing: a clinical and histological study. Dermatol Surg 1998;24:25-9.
8. Alster TS, Garg S. Treatment of facial rhytides with the ultrapulse high energy carbon dioxide laser. Plast Reconstru Surg 1996;98:791-4.
9. Ross EV, Grossman MC, Duke D, Grevelink JM. Long term results after CO2 laser resurfacing: a comparison of scanned and pulsed systems. J Am Acad Dermatol 1997; 37:709-18.
10. Weinstein C, Ramirez O, Pozner J. Postoperative care following carbon dioxide laser resurfacing: avoiding pitfalls. Dermatol Surg 1998;24:51-6.
11. Ho C, Nguyen Q, Lowe NJ Griffin ME, Lask G. Laser resurfacing in pigmented skin. Dermatol Surg 1995; 21:1035-7.
12. Laws RA, Finley EM, McCollough ML, Grabski WJ. Alabaster skin after carbon dioxide laser resurfacing with histologic correlation. Dermatol Surg 1998;24:633-8. 

DEDICATED TO EXCELLENCE IN DERMATOLOGY
By National Skin Centre (Singapore)
Copyright (C) 1995 - National Skin Centre (Singapore) 
 

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