Fractional CO₂ Resurfacing Improves Acne Scarring in Middle Eastern Patients

Acne vulgaris is a highly prevalent chronic inflammatory disorder, affecting an estimated 50 million individuals annually. While active acne can often be controlled, residual scarring remains a persistent therapeutic challenge. Postacne scars may have lasting psychosocial consequences, including negative effects on self-esteem and mental health, underscoring the need for safe and effective treatment strategies, particularly in patients with darker skin phototypes.¹

A wide range of interventions are currently used to treat acne scarring, such as subcision, microneedling, chemical peels, fillers, punch techniques, radiofrequency devices, and fat transfer. Over the past 2 decades, laser-based resurfacing has become a cornerstone of scar management due to its ability to induce controlled dermal injury, stimulate neocollagenesis, and remodel scar architecture. Among these options, fractional CO₂ laser resurfacing has demonstrated particular utility for atrophic acne scars.² However, concerns remain regarding pigmentary complications, especially in Fitzpatrick skin types IV–VI, which are common in Middle Eastern populations.

The recently published retrospective study summarized here evaluated the efficacy and safety of a customized dual-mode fractional CO₂ laser protocol for acne scarring in Middle Eastern patients. The investigators aimed to address the gap in optimized treatment protocols for darker skin tones by combining targeted high-fluence treatment of individual scars with lower-fluence resurfacing of the surrounding skin.³

Study Design and Patient Population

This retrospective chart review included 57 adults treated between 2015 and 2018. All patients were older than 18 years and had Fitzpatrick skin types IV or V with clinically evident postacne scarring. Patients with active inflammatory skin disease, recent cosmetic procedures, isotretinoin use, pregnancy, or systemic conditions affecting wound healing were excluded.

Treatment Protocol

All patients underwent 4 sessions of fractional CO₂ laser treatment using the eCO₂ system (Lutronic), spaced 6 to 8 weeks apart. A dual-mode approach was employed:

• Targeted scar treatment: A 120-μm tip was applied directly to individual scars at high fluence (120 mJ/cm²) and moderate density (100 spots/cm²).
• Field resurfacing: A 300-μm tip was used over the entire treatment area at lower fluence (40 mJ/cm²) with the same density.

Postprocedure care included topical antibiotic ointment, strict photoprotection, avoidance of mechanical trauma during healing, and antiviral prophylaxis when indicated. Follow-up photography was obtained 3 months after the final session.

Outcome Assessment

Treatment response was assessed using both subjective and objective measures. Subjective evaluation relied on the Goodman and Baron Global Acne Scarring Grading System (GASS), performed by an evaluator-blinded dermatologist. Objective assessment was conducted using the VISIA complexion analysis system, which quantified changes in skin texture and spot characteristics using percentile, score, and count metrics.

Key Findings

Overall, GASS scores demonstrated a statistically significant improvement following treatment, decreasing from a mean of 10.12 at baseline to 8.04 posttreatment. Improvement was most pronounced in patients with moderate atrophic scars, while mild macular scars showed nonsignificant change. Interestingly, patients with higher baseline severity tended to experience greater improvement, consistent with prior laser resurfacing literature.

VISIA analysis showed a statistically significant improvement only in spot percentile scores, while other individual texture and spot parameters did not reach significance. However, regression modeling revealed that VISIA metrics collectively explained more than one-third of the variance in GASS scores, supporting their role as a supplementary assessment tool rather than a standalone outcome measure.

Importantly, no clinically significant postinflammatory hyperpigmentation was observed, suggesting that the customized fluence-and-density strategy was effective in mitigating pigmentary risk in darker skin types.

Clinical Implications

This study reinforces the role of fractional CO₂ laser resurfacing as an effective option for atrophic acne scars in Middle Eastern patients when treatment parameters are carefully tailored. The dual-mode approach—combining high-fluence focal treatment with lower-fluence field resurfacing—appears to balance efficacy and safety, particularly in skin types at higher risk for dyschromia. Consistent with prior reports, boxcar and rolling scars responded better than ice-pick scars, which often require adjunctive techniques.

Limitations and Future Directions

As a retrospective study without a control group, the findings should be interpreted cautiously. The sample size was modest, follow-up was relatively short, and acute adverse effects could not be systematically assessed. Nevertheless, the use of both validated subjective grading and objective imaging strengthens the conclusions.

Overall, this study provides clinically relevant evidence supporting customized fractional CO₂ laser protocols for acne scarring in darker skin phototypes. While subjective grading systems remain the most sensitive indicators of clinical improvement, objective tools such as VISIA may offer valuable complementary insights. Larger prospective, controlled trials are warranted to refine protocols and confirm long-term outcomes.

References

1. Vasam M, Korutla S, Bohara RA. Acne vulgaris: A review of the pathophysiology, treatment, and recent nanotechnology based advances. Biochem Biophys Rep. 2023;36:101578. doi:10.1016/j.bbrep.2023.101578
2. Majid I, Imran S. Fractional CO2 laser resurfacing as monotherapy in the treatment of atrophic facial acne scars. J Cutan Aesthet Surg. 2014;7(2):87-92. doi:10.4103/0974-2077.138326
3. Al-Haddab M, AbuDujain NM, Alanazi A, Al Muqarrab FJ. Fractionated ablative CO2 laser treatment of acne scars in Middle Eastern patients. Dermatol Ther. 2026. doi:0.1155/dth/7247864