Fractional Co2 Laser for Acne Scars on Asian Skin?

Question

I'm a Filipina woman with deep acne scars.  A dermatologist recommended a light Fractional CO2. I was told new CO2s are safer.  I was classified as Type 4 and I'm afraid of hyperpigmentation. What can I expect from Fractional CO2 treatments?

Johnny Mao, MD, FACS · Answer

I believe the dermatologist recommended light Fractional CO2 because Asian skin has more pigment producing cells (that's why Asians are darker), and when you laser you are causing inflammation which can turn your skin even darker.  The thing is when you turn the laser down to a lighter setting you are compromising potential result for safety.  In the world of resurfacing, the "stronger" the treatment which = more downtime = more result = potentially more risk of hyperpigmentation/complications.  It's a real balancing act, if you would.  You can expect the treated area to be more red initially, then brown, then fading hopefully to your own skin color.  Your skin may or may not peel, depending on the setting.  You may also require multiple sessions.  The best way to judge is to perform a test spot using the treatment setting and then tailor to your individual needs.  There are ways to "pretreat" the skin and prime the skin ready for resurfacing.  These options should be throughly discussed with your provider.

Matthew Richardson, MD · Answer

Fractional CO2 laser treatments are possible in patients with darker skin, but certain precautions need to be taken. As others have mentioned, keeping the power/intensity settings lower and also decreasing the density of the treatments can be helpful to prevent post-inflammatory hyperpigmentation (PIH). Additionally, prepping the skin with pigment-blocking agents prior to treatment and employing them after treatment as well can be beneficial. Finally, prevention in the post-laser setting (SPF sunscreen) is critical.Keep in mind that acne scars are a tough problem regardless of skin type, and skin that tends to hyperpigment makes treating these scars even more challenging. Be sure to see an expert specializing in facial aesthetic treatments to review all of the options in detail.All the best,

Farhan Taghizadeh, MD · Answer

Fractional CO2 laser resurfacing is a very good treatment for acne scarring. The small columns made in the skin are very good at stimulating collagen production, which can help with smoothing out old acne scarring. The issue with long wavelength lasers like Co2 is the potential for darkening skin in patients who have Type 4 skin like yourself. In New Mexico I have done a lot of fractional Co2 laser resurfacing on darker skinned patients, and for the most part we have had success in avoiding hyper pigmentation. Of course all patients are different, but here are a few strategies we employ to help prevent this complication.1. First, we select settings on the machine that tend to have reduced density and reduced energy. This is combined with phasing of the treatments to get the total energy into the skin we desire, but doing that over time instead of all at one time. Phasing allows us to get the total energy into darker skin with less risk. In patients who are very anxious about this issue, we can also do a test spot on a first phase of treatment to gauge response to the laser.2. The second part of treating patients at risk for hyper pigmentation is to selectively pre-treat with hydroquinone starting a week or two before the laser treatment. We do this less now but it is still an effective way both before or even after to manage this situation.3. Third, we are very selective about the products used in the post laser recovery process in darker patients. We have seen very excellent results with the Aminoplex/Bio2 line of laser recovery products. I feel the faster one heals and the better the post laser care, the lower risk of hyper pigmentation.4. Finally, the latest addition to our laser treatments in darker pigmented patients is combined use of PRP (TruPrp) with the fractional laser. Here we have noticed a trend to faster recovery, less hyper pigmentation, and better overall acne scarring response to the laser energy, allowing us to reduce settings even further.In summary, darker patients can be layered with CO2 as long as long as the practitioner has good experience with the procedure.

Raffy Karamanoukian, MD, FACS · Answer

Fractional CO2 and chemical peels work wonders for acne scarring in patients of all colors. In my practice in Santa Monica and Beverly Hills, I recommend the fractional CO2 laser for acne scars and for deep wrinkles. Patients who have darker skin types, including Filipino and Hispanic skin can benefit from the Fractional CO2 laser, but I would recommend a regimen of Melaquin AM and Melaquin PM before and after the laser session. Melaquin helps control the post laser hyperpigmentation and allows for a more controlled recovery. If you have acne scars, you can also benefit from chemical peels and other types of acne surgery, including subcision, punch grafts, and acne excision. Dr. Karamanoukian.

Paul L. Hester, MD · Answer

Thank you for the question.  Resurfacing lasers have been used to improve the appearance of acne scars for many years.  Some side effects of the traditional CO2 laser treatments have been reduced by applying the energy to the skin in through newer variable density methods called fractional or micro fractional  resurfacing.  Mixto&trade; SX Micro Fractional CO2 Laser is an example of a resurfacing machine with this new technology.  In experience hands, it is a proven skin rejuvenation treatment that makes it possible to promote healthy, younger looking skin with minimal treatment sessions, rapid healing and thereby less post-treatment down time. A single treatment can show significant improvement in skin texture and color while softening wrinkles.  With your skin type, even the new micro fractional lasers could cause some hyperpigmentation as the darker cells (melanin) is recruited to the skin layers heated by the laser. Due to the fact that CO2 reaches the shallow layers, reduced power settings could still stimulate pigmentation in your skin and would surely decrease the intended effect on the acne scars.  The best method of resurfacing for your skin type will be use of a technique that delivers less heat near the surface and more heat at the deeper levels of collagen production.  You may want to discuss the use of deep micro fractional radiofrequency device such as Fractora&trade; with your Doctor. Some of these can be effective at reaching the layers important for skin remodeling and sparing the levels that stimulate pigmentation. Unlike the Mixto&trade; CO2  fractional  laser that delivers results in a single 40-minute treatment , the microfractional radiofrequency  technique might require several sessions. The good news is that there is virtually no social down time following a  Fractora treatment, so it is easy to schedule and maintain your result. 
  
Health and Happiness, Dr. Hester

Michael H. Gold, MD · Answer

Any CO2 laser, even fractional, can be associated with side effects. In Asians, we usually are most concerned with post-inflammatory hyper pigmentation which can last for several months if not treated appropriately. All patients should be treated with the appropriate topicals prior to the procedure, and the provider should be familiar with the device and the expectations. There is no such thing as a light fractional CO2 - the depth is determined by the energy used and all devices can be superficial or deep. Most importantly, make sure the provider performing the procedure is skilled and knowledgable.

Daniel Shapiro, MD · Answer

Thank you for your question. At my practice, I have gotten excellent results for scarring with Fraxel. This treatment eliminates irregular skin discoloration, and stimulates new collagen production, tightening the skin without prolonged recovery. After a series of 2 to 4 Fraxel treatments, the cumulative cosmetic improvement is near more aggressive lasers, but unlike more aggressive lasers, redness and swelling eliminated within 2 to 4 days after each treatment. Fraxel is outstanding for fine wrinkles, mild skin laxity, irregular pigmentation, acne scars, surgical scars, enlarged pores, stretch marks, age spots and Rosacea. It can be used safely on the face, neck, hands, arms, and chest.

Ben Behnam, MD · Answer

Hello, I am Dr. Behnam and I am a fractional CO2 specialist. I treat a lot of patients that are darker skin (including type 4), including Asians. One of the most common side effects is pigmentation. It is very important that an experienced physician treats you. The setting have to be lowered. In addition, I have developed a regimen where it minimizes the pigmentation as much as possible. Patients use Bleaching cream for at least one month, then immediately after the procedure they use a special non-hydroquinone bleaching cream for a week, then start the hydroquinone again after a week and add on tretinoin cream 2 weeks later. This regimen in combination with lower setting has practically eliminated pigmentation changes in my practice. You can see some before and after images of darker skin individuals on my website . Remember, a lot of technicians may do CO2 but you want to trust your face to a physician who is experienced and does it all the time. Overall,I think it will work but you may need 2 or more sessions. Dr. Behnam

Gregory J. Vipond, MD, FRCSC · Answer

I have treated a large number of non-Caucasian patients with the fractional CO2 laser, including several with very dark skin. It is very important to find a physician with experience in treating darker skin. In any patient where I may be concerned about the possibility of changing the skin pigmentation, I always perform a test spot with the laser and wait 4 weeks to see how the skin responds. If there are no side effects, then I proceed with the laser treatment. In terms of acne scarring, you will likely want to have more than one treatment. Acne scarring can be improved with fractional CO2 laser resurfacing, but because of your darker skin, your treatment should be more conservative to reduce the risk of side effects.

Jacob D. Steiger, MD · Answer

Fractional CO2 laser can be an excellent tool to treat acne scars. However, it is important to visit with a doctor experienced in treating acne scarring as laser is not always the best solution and certainly not the only one.
Since acne scars come in differents shapes and sizes, the treatment must be directed at the type of scarring you have.  While a laser may be good for certain types of acne scarring, you may need a different treatment for other types.
Depending on the laser settings used, the fractional laser can be very safe and effective for darker skinned patients.  you do however have a higher risk for increased pigementation after the procedure which can be treated with topical medication.

Fractional Co2 Laser for Acne Scars on Asian Skin?

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