Take conservative approach to enjoy CO2 's plentiful benefits

Scottsdale, Ariz. - Although it remains the gold standard for skin rejuvenation, CO₂ laser resurfacing is paradoxically losing favor due to drawbacks ranging from the risk of complications to increasing patient reluctance over downtime and concerns about the complications.

Yet with dramatic results reported to last, in some cases, for at least 10 years, it may still be well worth the effort to work to prevent CO₂'s common complications in order to enjoy its benefits, said Edgar F. Fincher, M.D., Ph.D., at a recent meeting of the Skin Disease Education Foundation.

"This can be a highly effective treatment to offer your patients, and complications can be avoided with experience and a conservative approach," says Dr. Fincher, a clinical instructor at the University of California, Los Angeles' David Geffen School of Medicine.

To use as much caution as possible, patients who should absolutely not be candidates for CO₂ laser resurfacing include those with a history of keloids or hypertrophic scars and those who have been on Accutane (Roche) at any time in the past six months.

Dr. Fincher says he prefers not to resurface people with skin types IV through VI, although some doctors do opt to treat such patients.

Patients to approach with caution include those with psoriasis, collagen vascular disease and immunodeficiencies, or those who are smokers, because of concerns about causing flares in their disease or compromising wound healing.

And while patients who have had previous resurfacing or dermabrasion needn't be ruled out, Dr. Fincher says he takes the precaution of treating these patients conservatively.

"I play it safe by turning down the energy and lowering the number of passes," he says. "There is the possibility of getting some focal scarring, and you need to talk to your patients about that."

All patients should be made well aware of the potential for an extended period of erythema, and Dr. Fincher tells patients to expect at least three to four weeks of the redness.

As part of his preoperative regimen, Dr. Fincher starts patients on daily skin hydration two weeks prior to the procedure, not necessarily to make a difference in the laser treatment, but to prepare them for the hydration regimen necessary postoperatively.

One of the biggest concerns about CO₂ lasers among patients and doctors is hyperpigmentation, and steps that can be taken to prevent the post-inflammatory hyperpigmentation, as well as to help accelerate healing, are to use tretinoin and hydroquinone preoperatively.

Most importantly, however, is the need to put patients on an antibiotic prophylaxis, Dr. Fincher says. Beginning the day before the procedure, Dr. Fincher puts his patients on antibiotics.

At the very minimum, laser resurfacing patients should be given an antistaphylococcal and antiviral prophylaxis medication for one week. Some physicians may opt to add further coverage with antipseudomonal or antifungal prophylaxis.

Dr. Fincher says he has also started putting all patients on short doses of prednisone to accelerate the resolution of the edema.

Finally, anesthesia is important, not just for the patient's comfort but for the successful outcome of the treatment.

"For full-face patients, the IV sedation is especially important, because if they are uncomfortable and they are moving you're not going to get an even treatment and could get some overlap and scarring," Dr. Fincher says.

Treatment

During the treatment itself, the number of passes to use depends not only on the type of system being used, but also on the area being treated. Factors that can contribute to hypertrophic scars or hypopigmentation include prolonged dwell time and too many passes going too deep, so extreme care should be used.

Edges should be feathered in a transition zone, and especially along the neck, to prevent a straight line of demarcation.

Closed dressings may increase comfort, but some studies have shown that they may delay the diagnosis of an infection.