Laser in Dermatology
Laser in Dermatology
Laser in Dermatology
Specials
and recommendations
Indian Journal of Dermatology, Venereology, and Leprology | May-June 2011 | Vol 77 | Issue 3 369
Goel, et al. Fractional lasers in dermatology
described for these technologies. It is necessary, al. Fractional photothermolysis: A novel aesthetic laser surgery
modality. Dermatol Surg 2007;33:525-34.
therefore, to examine current available evidence and
make appropriate recommendations based on the
evidence. It is emphasized hereby that this technology PRINCIPLE OF FRACTIONAL PHOTOTHERMOLYSIS
is new and rapidly evolving; therefore, this review
and recommendations made in it are based on the Manstein and colleagues introduced the concept of
evidence available so far and may need to be reviewed fractional photothermolysis (FP) in 2004.[1] Their
periodically as technology evolves. FP device emitted light in a pixilated fashion and
transmitted it to the skin, producing an array of
The laser-resurfacing industry has produced a microthermal zones (MTZs) and creating small
multitude of devices employing ablative, non-ablative microscopic columns of thermal injury to the skin.[1]
and fractional technologies. The three approaches Fractional resurfacing thermally ablates microscopic
largely differ in their method of thermal damage, columns of epidermal and dermal tissue in regularly
degrees of efficacy, downtime and side effect profiles spaced arrays over a fraction of the skin surface; in
against each other. Ablative technologies have been contrast to ablative skin resurfacing, in which a
seen to have higher incidences of side effects, especially confluent, uniform patch of epidermal or dermal injury
in darker skin types. Non-ablative technologies is induced.[2,3] Fractional photothermolysis therefore
generated some interest, but the results were mild and denotes induction of thermal alteration of a fraction or
slow. Recently fractional laser technology is gaining a column of skin, leaving intervening areas of normal
wide popularity because of its favorable side effect skin untouched, which rapidly repopulate the ablated
profile, reduced recovery time and significant clinical columns of tissue.[2,3] The number, depth and size of
outcome.[1] these vertical columns of MTZs are variable and depend
on the type of machine, wavelength of the laser used,
Fractional laser technology represents a major fluence and the number of stackings or applications
advantage over the previous conventional ablative of laser. These zones comprise approximately 15% to
methods (CO2 and erbium:YAG lasers).[2,3] Ablative 25% of the skin surface area per treatment session. The
lasers had the advantages of predictability in the diameter of each MTZ is and ranges from 100 to 160 μ.
depth of tissue ablation and thermal denaturation. At the energies commonly used for facial rejuvenation
Erbium:YAG laser represented an improvement on (8-12 mJ/MTZ), the depth of penetration ranges from
the CO2 laser in producing lesser downtime. However, 300 to 700 μ. The density of MTZs is adjustable,
traditional ablative laser resurfacing suffered and typically, a final density of 2,000 MTZs/cm2 is
from several disadvantages, such as the need for delivered at each treatment, a density corresponding to
effective anesthesia; prolonged downtime; the risk of approximately 20% of the surface area of the skin. The
dyspigmentation and scarring, particularly in darker resulting dermal-epidermal debris are incorporated
skin types; the need for intensive postoperative care; into the columns of microscopic epidermal necrotic
the long-lasting erythema; and the need for prolonged debris (MENDs) and eliminated by the phenomenon
avoidance of sun exposure after treatment. These of transepidermal elimination.[2-4] Subsequently,
drawbacks were sought to be overcome by fractional there is stimulation of re-epithelialization and repair
laser technology.[4,5] mediated by the adjacent columns of intact tissue.
Similar to ablative laser resurfacing, the areas of
REFERENCES thermally ablated tissue are repopulated by fibroblast-
derived neocollagenogenesis and epidermal stem
1. Brightman LA, Brauer JA, Anolik R, Weiss E, Karen J, Chapas cell reproduction. Non-ablative fractional lasers too
A, et al. Ablative and fractional ablative lasers. Dermatol Clin operate through a similar principle of the creation of
2009;27:479-89.
2. Fitzpatrick RE, Goldman MP, Satur NM, Tope WD. Pulsed
microthermal zones of damage to the treated tissue,
carbon dioxide laser resurfacing of photoaged facial skin. Arch but without ablation of epidermis, extrusion of dermal
Dermatol 1996;132:395-402. contents, and rapid resurfacing.
3. Alexiades-Armenakas MR, Dover JS, Arndt KA. The spectrum
of laser skin resurfacing: Nonablative, fractional, and ablative
laser resurfacing. J Am Acad Dermatol 2008;58:719-37. Since a large percentage of intervening skin is
4. Alexiades-Armenakas MR. What is new in lasers and cosmetic unaffected, healing occurs quickly, thereby minimizing
procedures from the 2007 AAD annual meeting. J Drugs
Dermatol 2007;6:464. the downtime. At each subsequent session, such
5. Susan W, Brian ST, James C, Gregory A, Andrei E, Ilya Y, et fractions are treated; and over 2 to 6 sittings, treatment
370 Indian Journal of Dermatology, Venereology, and Leprology | May-June 2011 | Vol 77 | Issue 3
Goel, et al. Fractional lasers in dermatology
Indian Journal of Dermatology, Venereology, and Leprology | May-June 2011 | Vol 77 | Issue 3 371
Goel, et al. Fractional lasers in dermatology
reported the efficacy of ablative fractionated Er:YAG reported the efficacy of a dual-wavelength device
laser (2,940 nm) in treatment of photo-aging.[8] Weiss (1,320 and 1,440 nm), with benefits in the treatment
et al.[9] reported a greater efficacy for fractional CO2 of skin laxity and facial wrinkles.[11]
laser than 1,550-nm erbium laser in a comparative
split-face trial. A comparative split-face trial with REFERENCES
fractional Er:YAG and microfractional CO2 laser
resurfacing showed greater efficacy and patient 1. Rahman Z, Alam M, Dover JS. Fractional laser treatment for
pigmentation and texture improvement. Skin Therapy Lett
satisfaction for the fractional CO2 laser.[10] However,
2006;11:7-11.
the Er:YAG–treated side required a lesser healing time 2. Bass LS. Rejuvenation of the aging face using fraxel laser
and had lesser crusting. Foster and colleagues recently treatment. Aesthet Surg J 2005;25:307-9.
372 Indian Journal of Dermatology, Venereology, and Leprology | May-June 2011 | Vol 77 | Issue 3
Goel, et al. Fractional lasers in dermatology
3. Geronemus R. Fractional photothermolysis: Current and future treated with Fraxel SR (Reliant Technologies, Inc.).[2]
applications. Lasers Surg Med 2006;38:169-76.
4. Jih MH, Goldberg LH, Kimyai-Asadi A. Fractional
After 3 monthly treatments, clinical improvement
photothermolysis for photoaging of hands. Dermatol Surg ranged from 51% to 95%, in 90% of patients. Similar
2008;34:73-8. improvements have been reported in other studies
5. Wanner M, Tanzi EL, Alster TS. Fractional photothermolysis:
Treatment of facial and nonfacial cutaneous photodamage by Lee et al.[7] in Asian patients and by Glaich et al.[8]
with a 1,550-nm erbium-doped fiber laser. Dermatol Surg Glaich reported 2 cases of treatment of marked
2007;33:23-8. atrophic acne scarring and postinflammatory erythema
6. Rahman Z, Alam M, Dover JS. Fractional laser treatment for
pigmentation and texture improvement. Skin Therapy Lett with FP. Marked improvement was noted in the
2006;11:7-11. postinflammatory erythema after 1 treatment session.
7. Mezzana P, Valeriani M. Rejuvenation of the aging face using
Significant improvement in the atrophic acne scars was
fractional photothermolysis and intense pulsed light: A new
technique. Acta Chir Plast 2007;49:47-50. noted 3 months after a series of 5 FP treatments.
8. Lapidoth M, Yagima Odo ME, Odo LM. Novel use of erbium:
YAG (2,940-nm) laser for fractional ablative photothermolysis
in the treatment of photodamaged facial skin: A pilot study.
Because of its safety profile and greater tolerance,
Dermatol Surg 2008;34:1048-53. fractional laser technology has become an increasingly
9. Weiss R, Weiss M, Beasley K. Prospective split-face trial of a popular treatment modality to treat acne scarring in
fixed spacing array computed scanned fractional CO2 laser
versus hand scanned 1550nm fractional for rhytides. Abstract individuals of darker skin types, including Indian skin,
presented at American Society for Laser Medicine and Surgery in which the conventional ablative laser treatments
Conference, April 2008, Kissimmee, FL. and surgical treatment modalities carry the risk of
10. Lomeo G, Cassuto D, Scrimali L, Sirago P. Er: YAG versus CO2
ablative fractional resurfacing: A split face study. Abstract permanent postinflammatory hyperpigmentation.
presented at American Society for Laser Medicine and Surgery Despite the reported safety of fractional lasers in post-
Conference, April 2008, Kissimmee, FL.
acne scarring, there is still the possibility for transient
11. Foster KW, Kouba DJ, Fincher EE, Glicksman ZS, Hayes J, Valerie
F, et al. Early improvement in rhytides and skin laxity following erythema or edema, dryness, scabbing, milia or acne,
treatment with a combination fractional laser emitting two hyperpigmentation or hypopigmentation, prolonged
wavelengths sequentially. J Drugs Dermatol 2008;7:108-11.
healing, or infection.[13] Hence proper counseling of
patients and appropriate adjuvant medical treatment
2. Post-acne scars and other scars
are essential.
a) Post-acne scars
Management of acne scars presents a challenge for
REFERENCES
any clinician. Treatment of acne scars depends on the
type and severity of scarring. Though several treatment 1. Hasegawa T, Matsukura T, Mizuno Y, Suga Y, Ogawa H, Ikeda S.
options are available, results are not fully satisfactory. Clinical trial of a laser device called fractional photothermolysis
Fractional lasers have been used successfully and system for acne scars. J Dermatol 2006;33:623-7.
2. Alster TS, Tanzi EL, Lazarus M. The use of fractional laser
safely in the treatment of acne scars with good results photothermolysis for the treatment of atrophic scars. Dermatol
in superficial and medium-depth scars, and represent Surg 2007;33:295-9.
a significant advance in the management of this 3. Gold M, Gold MH, Heath AD, Biron JA. Clinical evaluation of
the SmartSkin fractional laser for the treatment of photodamage
challenging condition.[1-10] Improvement has also been and acne scars. J Drugs Dermatol 2009;8:s4-8.
reported in pores, an otherwise difficult condition to 4. Hu S, Chen MC, Lee MC, Yang LC, Keoprasom N. Fractional
treat.[11] While macular, superficial and medium-depth resurfacing for the treatment of atrophic facial acne scars in
asian skin. Dermatol Surg 2009;35:826-32.
scars respond well, deep scars and ice-pick scars may 5. Rahman Z, Tanner H, Jiang K. Treatment of atrophic scars with
improve only marginally. In cases with severe scarring, the 1550nm erbium-fiber fractional laser. Lasers Surg Med
combination with other approaches such as chemical 2006;38:24.
6. Geronemus R. Fractional photothermolysis: current and future
peels, subcision, surgical dermabrasion, dermaroller applications. Lasers Surg Med 2006;38:169-76.
and trichloroacetic acid CROSS technique[12] may 7. Lee HS, Lee JH, Ahn GY, Lee DH, Shin JW, Kim DH, et al.
be needed. In a case series, Chapas and colleagues[9] Fractional photothermolysis for the treatment of acne scars: A
report of 27 Korean patients. J Dermatolog Treat 2008;19:45-9.
demonstrated improvements of 26% to 50% in texture 8. Glaich AS, Goldberg LH, Friedman RH, Friedman PM. Fractional
and atrophy, as well as overall improvement, in photothermolysis for the treatment of postinflammatory
moderate-to-severe acne scarring with fractionated erythema resulting from acne vulgaris. Dermatol Surg
2007;33:842-6.
CO2 laser. Fractional non-ablative lasers too have been 9. Chapas AM, Brightman L, Sukal S, Hale E, Daniel D, Bernstein
found to be effective in acne scarring. Geronemus LJ, et al. Successful treatment of acneiform scarring with CO2
reported initially on the treatment of acne scarring with ablative fractional resurfacing. Lasers Surg Med 2008;40:381-6.
10. Kim S. Clinical trial of a pinpoint irradiation technique with
non-ablative fractional lasers.[6] Alster and colleagues the CO2 laser for the treatment of atrophic acne scars. J Cosmet
reported a study on 53 patients with atrophic acne scars Laser Ther 2008;29:1-4.
Indian Journal of Dermatology, Venereology, and Leprology | May-June 2011 | Vol 77 | Issue 3 373
Goel, et al. Fractional lasers in dermatology
11. Cho SB, Lee JH, Choi MJ, Lee KY, Oh SH. Efficacy of the 6. Tierney E, Mahmoud BH, Srivastava D, Ozog D, Kouba DJ.
fractional photothermolysis system with dynamic operating Treatment of surgical scars with fractional photothermolysis
mode on acne scars and enlarged facial pores. Dermatol Surg versus pulse dye laser: Randomized control trial. Dermatol
2009;35:108-14. Surg 2009;35:1172-80.
12. Kim HJ, Kim TG, Kwon YS, Park JM, Lee JH. Comparison of 7. Waibel J, Beer K. Fractional laser resurfacing for thermal burns.
a 1,550 nm Erbium: Glass fractional laser and a chemical J Drugs Dermatol 2008;7:59-61.
reconstruction of skin scars (CROSS) method in the treatment
of acne scars: a simultaneous split-face trial. Lasers Surg Med
2009;41:545-9. 3. Stretch marks (Striae)
13. Rivera AE. Acne scarring: A review and current treatment Management of striae has remained a challenge, and
modalities. J Am Acad Dermatol 2008;59:659-76. hitherto no satisfactory treatment has been reported.
Recent reports suggest that fractional photothermolysis
b) Surgical scars may improve striae, with improvement in texture,
Surgical, post-traumatic and burn scars can also and dyschromia[1,2]; however, these findings are
be treated with fractional lasers.[1-3] Multiple preliminary and need to be reproduced in larger and
treatments lead to improvement in texture, quality controlled studies.
and pigmentation of the scars in both atrophic and
hypertrophic types. However, atrophic and pigmented REFERENCES
scars tend to improve better than the hypertrophic
scars. 1. Stotland M, Chapas AM, Brightman L, Sukal S, Hale E, Karen J,
et al. The safety and efficacy of fractional photothermolysis
for the correction of striae distensae. J Drugs Dermatol 2008;7:
In a case report, Behroozan and colleagues noted 857-61.
75% overall improvement in a surgical scar on the 2. Kim BJ, Lee DH, Kim MN, Song KY, Cho WI, Lee CK, et al.
Fractional photothermolysis for the treatment of striae
chin after a single treatment with the 1,550-nm
distensae in Asian skin. Am J Clin Dermatol 2008;9:33-7.
Fraxel SR.[4] Glaich et al.[5] demonstrated 51% to 75%
improvement in hypopigmented facial scars in 6 of 4. Pigmentary disorders
the 7 treated patients, by using 1,550-nm Fraxel SR. a) Melasma
In a study performed by Tierney et al.,[6] fractional Fractional lasers have been used successfully in the
photothermolysis (using 1,550-nm fractionated management of melasma and postinflammatory
erbium laser - Fraxel SR, Reliant Technologies, Inc.) pigmentation in a number of studies.[1-3] Rokhsar and
was found to be more effective than pulse dye laser Fitzpatrick published an initial report on the efficacy
(Candela Corporation Inc., Wayland, MA) for the of FP for the treatment of melasma.[2] After 4 to 6
cosmetic improvement of surgical scars. treatment sessions, 60% of treated patients (n= 10)
achieved 75% to 100% clearance, with only 30% of
c) Burn scar patients demonstrating less than 25% improvement.
A single report on the efficacy of FP in burn scar has Only 1 of the 10 patients reported postinflammatory
been published, and this indication therefore needs hyperpigmentation (which resolved within 3 months
further study.[7] of treatment). Goldberg and colleagues[3] treated 10
melasma patients (skin types III-IV), with a total of 4
REFERENCES treatments at 2-week intervals, using a non-ablative
fractional photothermolysis (FP) device (Fraxel SR 750).
1. Haedersdal M, Moreau KE, Beyer DM, Nymann P, Alsbjørn B.
Fractional nonablative 1540 nm laser resurfacing for thermal By both light microscopy and electron microscopy,
burn scars: A randomized controlled trial. Lasers Surg Med post-treatment specimens demonstrated a relative
2009;41:189-95.
decrease in melanocytes. Six patients with skin type
2. Lee Y. Combination treatment of surgical, post-traumatic and
post-herpetic scars with ablative lasers followed by fractional III had good improvement, whereas 4 patients with
laser and non-ablative laser in Asians. Lasers Surg Med skin type IV had only fair improvement.
2009;41:131-40.
3. Niwa AB, Mello AP, Torezan LA, Osprio N. Fractional
Photothermolysis for the Treatment of Hypertrophic Scars: Manstein et al.[4] established the possible mechanism
Clinical Experience of Eight Cases. Dermatol Surg 2009;35: for the above-reported efficacy of fractional
773-8.
4. Behroozan DS, Goldberg LH, Dai T, Geronemus RG, Friedman photothermolysis in melasma — that MTZ creation
PM. Fractional photothermolysis for the treatment of surgical and tissue destruction by FP results in elimination of
scars: A case report. J Cosmet Laser Ther 2006;8:35-8. melanocytes- and keratinocytes-containing melanin
5. Glaich AS, Rahman Z, Goldberg LH, Friedman PM. Fractional
resurfacing for the treatment of hypopigmented scars: A pilot granules through a “melanin shuttle.” This melanin
study. Dermatol Surg 2007;33:289-94. shuttle formation results in significant improvement
374 Indian Journal of Dermatology, Venereology, and Leprology | May-June 2011 | Vol 77 | Issue 3
Goel, et al. Fractional lasers in dermatology
in epidermal and dermal pigmentation associated 4. Rokhsar CK, Ciocon DH. Fractional Photothermolysis for
the Treatment of Postinflammatory Hyperpigmentation after
with conditions such as melasma and dyschromia of
Carbon Dioxide Laser Resurfacing. Dermatol Surg 2009;35:
photoageing. 535-7.
Indian Journal of Dermatology, Venereology, and Leprology | May-June 2011 | Vol 77 | Issue 3 375
Goel, et al. Fractional lasers in dermatology
be used with caution in patients with tendency 4. Katz BE, Mac Farlane DF. Atypical facial scarring after
isotretinoin therapy in a patient with previous dermabrasion. J
for pigmentation and/ or keloid formation. Proper Am Acad Dermatol 1994;30:852-3.
counseling, priming with depigmenting agents and 5. Peteiro C, Toribio J. Keloid formation induced by isotretinoin
sunscreens, and initiation of treatment at lower therapy. Int J Dermatol 1999;38:228-9.
6. Cassano N, Arpaia N, Vena GA. Diode laser hair removal and
fluences are advised in such patients. isotretinoin therapy. Dermatol Surg 2005;31:380-1.
b) All patients for facial resurfacing, with previous 7. Khatri KA, Garcia V. Light-assisted hair removal in patients
history of herpes labialis, should receive undergoing isotretinoin therapy. Dermatol Surg 2006;32:875-7.
8. Khatri KA. Diode laser hair removal in patients undergoing
prophylactic oral antivirals such as acyclovir, isotretinoin therapy. Dermatol Surg 2004;30:1205-7.
famciclovir or valacyclovir, starting 1 day before 9. Khatri KA. The safety of long-pulsed Nd:YAG laser hair removal
fractional resurfacing and continuing for 5 days in skin types III-V patients during concomitant isotretinoin
therapy. J Cosmet Laser Ther 2009;11:56-60.
postoperatively. 10. Roenigk HH Jr, Pinski JB, Robinson JK, Hanke CW. Acne,
c) Oral antibiotics, such as cloxacillin or azithromycin, retinoids, and dermabrasion. J Dermatol Surg Oncol
may be prescribed to patients with a history of 1985;11:396-8.
11. Bagatin E, Guadanhim LR, Yarak S, Kamamoto CS, De Almeida
bacterial infections of the facial skin to reduce the FA. Dermabrasion for Acne Scars during Treatment with Oral
chance of secondary bacterial infection. Isotretinoin. Dermatol Surg 2010;36:483-9.
d) While treating patients with melasma and
postinflammatory pigmentation, prior priming Contraindications for fractional lasers
with sunscreens and depigmenting agents for about History of immunocompromised status or active
2 to 4 weeks is advised. systemic disease that might interfere with wound
e) Pregnancy and lactation: Laser resurfacing healing, any active local or systemic infection,
in women who are pregnant or lactating, is connective tissue disorders, lactation, history of
contraindicated. allergy to any medication necessary for treatment,
f) Isotretinoin and fractional lasers: Care should active psoriasis or vitiligo, unrealistic expectations
be exercised in patients with a history of recent and body dismorphic disorder — all constitute relative
isotretinoin use. A 6- to 12-month waiting period contraindications.[1]
following discontinuation of isotretinoin has
been recommended before performing resurfacing REFERENCE
procedures.[1] This recommendation is based on
earlier reports of keloid formation and atypical 1. Tannous Z. Fractional resurfacing. Clin Dermatol 2007;25:
scar formation after use of dermabrasion and 480-6.
argon lasers, which are more invasive and
ablative procedures.[2-5] However, several recent Anesthesia
publications have documented the safety of This is patient specific and dosage specific. Lower
different procedures such as laser hair removal fluences are tolerated well by most patients; but at
and dermabrasion in patients recently treated with higher fluence levels, topical anesthesia with mixture
isotretinoin.[6-10] A paper by Bagatin[11] suggested of lidocaine and prilocaine for 60 minutes prior to the
that “The current recommendation to wait 6 to procedure may be needed. As an alternative, cold air
12 months after treatment with oral isotretinoin or ice may be used to minimize discomfort.[1]
for acne scar revision using dermabrasion should
be re-evaluated. Abrasion of a small test area may REFERENCE
be a useful predictor of wound healing, enabling
earlier acne scar treatment using this procedure.” 1. Fisher GH, Kim KH, Bernst®ein LJ, Geronemus RG. Concurent
use of a handheld forced cold air device minimizes patient
Therefore, studies and published data on Indian discomfort during fractional photothermolysis. Dermatol Surg
skin are needed to make proper recommendations 2005;31:1242-3.
in this matter.
Postoperative care
REFERENCES Minimal care is needed after the procedure.
Sunscreens, avoidance of sun, moisturizers are started
1. Rivera AE. Acne scarring: A review and current treatment soon after the procedure, and diligently used daily.
modalities. J Am Acad Dermatol 2008;59:659-76.
2. Dogan G. Possible isotretinoin-induced keloids in a patient Mild topical steroid may be prescribed if erythema and
with Behçet’s disease. Clin Exp Dermatol 2006;31:535-7. edema persist. Postoperative antibiotics are usually
3. Rubenstein R, Roenigk HH Jr, Stegman SJ, Hanke CW. A typical
keloids after dermabrasion of patients taking isotretinoin. J Am not necessary. Avoidance of rubbing and scratching is
Acad Dermatol 1986;15:280-5. advised.
376 Indian Journal of Dermatology, Venereology, and Leprology | May-June 2011 | Vol 77 | Issue 3
Goel, et al. Fractional lasers in dermatology
Side effects or complications of fractional lasers considerably less than that with ablative lasers, it
In general, the side effects of fractional lasers are may be seen in darker skin patients, particularly
minimal and transient. Mild erythema, edema and in those patients with history of post inflammatory
peeling are common and can be managed by use of hypopigmentation (PIH) or melasma.[5] Caution
sunscreens and moisturizers. However, side effects should be exercised while using higher fluences or
do occur, particularly when aggressive doses / higher multiple stackings in such patients. Precautionary
stackings are used, particularly in patients with darker 2 weeks of pretreatment with depigmenting agents
skin.[1] Fractional ablative lasers are more likely to and a strict sun protection scheme are advisable
produce side effects than fractional non-ablative
while treating such patients. Hypopigmentation is
lasers.[1] The complications observed are shown in
rare.
Table 3.
5. Bacterial infection
Bacterial infection is rare but has been reported in
1. Erythema
0.1% of cases.[6]
This is usually mild and stays for 2 to 3 days but
6. Transient acneiform eruptions and milia may
can persist up to 1 week. However, more prolonged
occur.[7-9] Antibiotics can be used to prevent flareups
erythema and linear abrasions, often persisting up
of acneiform eruptions.
to 3-4 weeks, have been observed when fractional
7. Cicatricial ectropion is a rare but potentially serious
laser treatments with higher fluences and multiple
complication and has been reported after fractional
stackings are used.[1-3]
CO2 laser treatment.[10]
2. Post-treatment edema
8. Hypertrophic scarring, though rare, has been
Post-treatment edema is patient-dependent. The
reported after fractional CO2 laser use for neck
average patient experiences edema for 1 to 3 days;
though in some patients, it may last up to 1 week. rejuvenation.[11] Focal areas of erythema and
The risk of edema also increases with higher induration, 2 to 4 weeks after treatment, are the
fluence levels. It can be treated easily by applying first signs of potential scar formation. Neck is an
ice at 10-minute intervals for the first 24 hours area prone to such scarring. Postoperative wound
after treatment. Some physicians advocate the use infection, contact dermatitis and tendency for
of topical or short-course systemic corticosteroids keloidal scarring are other potential risk factors.
following treatment.
3. Petechiae REFERENCES
Occasional petechiae can be seen, especially in
1. Metelitsa AI, Alster TS. Fractionated laser skin resurfacing
periorbital area, following use of higher fluences.[4] treatment complications: A review. Dermatol Surg 2010;36:299-
Often such petechiae are delayed, occurring after 3 306.
2. Ross RB, Spencer J. Scarring and persistent erythema after
days. Avoidance of nonsteroidal anti-inflammatory fractionated ablative CO2 laser resurfacing. J Drugs Dermatol
drugs, aspirin and other blood thinners in the 2008;7:1072-3.
immediate postoperative period is recommended to 3. Rokhsar CK, Fitzpatrick RE. The treatment of melasma with
fractional photothermolysis: A pilot study. Dermatol Surg
decrease the risk of such purpura in these patients. 2005;31:1645-50.
Patients should also be advised to avoid rubbing 4. Fife DJ, Zachary CB. Delayed pinpoint purpura after fractionated
carbon dioxide treatment in a patient taking ibuprofen in the
or scratching of treated skin, because of increased postoperative period. Dermatol Surg 2009;35:553.
skin fragility during the immediate post-treatment 5. Chan HH, Manstein D, Yu CS. The prevalence and risk factors
period. of post-inflammatory hyperpigmentation after fractional
resurfacing in Asians. Lasers Surg Med 2007;39:381-5.
4. Postinflammatory hypopigmentation and 6. Setyadi HG, Jacobs AA, Markus RF. Infectious complications
hyperpigmentation after nonablative fractional resurfacing treatment. Dermatol
Surg 2008;34:1595-8.
Though incidence of hyperpigmentation is
7. Fisher GH, Geronemus RG. Short-term side effects of fractional
photothermolysis. Dermatol Surg 2005;31:1245-9.
8. Graber EM, Tanzi EL, Alster TS. Side effects and complications
Table 3: Complications of fractional laser resurfacing of fractional laser photothermolysis: Experience with 961
Mild complications Moderate Severe treatments. Dermatol Surg 2008;34:301-5.
complications complications 9. Wanner M, Tanzi EL, Alster TS. Fractional photothermolysis:
Treatment of facial and nonfacial cutaneous photodamage
Erythema and edema Persistent erythema Hypertrophic scarring with a 1,550-nm erbium-doped fiber laser. Dermatol Surg
Acneiform eruptions Bacterial infection Ectropion formation 2007;33:23-8.
Milia Activation of herpes 10. Fife DJ, Fitzpatrick RE, Zachary CB. Complications of fractional
Delayed purpura simplex CO2 laser resurfacing: Four cases. Lasers Surg Med 2009;41:
Superficial erosions Hyperpigmentation 179-84.
Indian Journal of Dermatology, Venereology, and Leprology | May-June 2011 | Vol 77 | Issue 3 377
Goel, et al. Fractional lasers in dermatology
DISCLAIMER
The contents/recommendations of all articles prepared by IADVL Taskforce on dermatosurgery are recommendatory only,
and are not absolute or binding on members. The principles outlined in the IADVL Taskforce articles/recommendations are of
general nature, based on current evidence and as in any aesthetic treatment or surgery, individual variations may occur from
patient to patient, and hence, appropriate modifications may be needed depending on the needs of the given patient, as per
the discretion of the physician and as per emerging evidence in future. Each patient has to be treated on his/her merit and
the ultimate judgment regarding the choice of a procedure should be made by the physician, keeping in view the individual
378 Indian Journal of Dermatology, Venereology, and Leprology | May-June 2011 | Vol 77 | Issue 3
Goel, et al. Fractional lasers in dermatology
patient and training and experience of the treating physician. As in the correct and ethical practice of any surgical procedure,
the physician must exercise his judgment in light of all the circumstances of the individual patient.
These guidelines/articles have been prepared with the sole purpose of establishing minimum standards of care, and as a
service to the members of IADVL; Neither the taskforce members nor IADVL will be held responsible either directly or
indirectly for any legal claims.
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Indian Journal of Dermatology, Venereology, and Leprology | May-June 2011 | Vol 77 | Issue 3 379
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