Use of CO 2. laser for the treatment of acne and burn scars in Indian skin - case studies. Dr. Aditya Shah Aura Laser and Cosmetic Clinic Gujarat

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Patients with darker skin types are at a higher risk of developing post-laser-treatment pigmentary changes, most notably post-inflammatory hyperpigmentation (PIH), requiring special risk-mitigating

1 Use of CO 2 laser for the treatment of acne and burn scars in Indian skin - case studies Dr. Aditya Shah Aura Laser and Cosmetic Clinic Gujarat Background: Burn as well as acne scars are challenging to treat particularly for darker Fitzpatrick skin types such as Indian skin. Patients with darker skin types are at a higher risk of developing post-laser-treatment pigmentary changes, most notably post-inflammatory hyperpigmentation (PIH), requiring special risk-mitigating measures including specific treatment settings and bleaching creams. Aim: To improve scar appearance in two cases of burn and acne scars. Methods: Two case studies of healthy male and female Indian patients aged 24 & 45 years with Fitzpatrick skin types IV-V and moderate-to-severe acne and burn scar lesions received 1 3 treatments with a fractional CO 2 laser (AcuPulse) at baseline and at 4 to 6 week intervals and were evaluated with photographs at each treatment visit and up to 6 months after the final treatment session. Patients reported on their satisfaction with the treatment. The safety of treatments was evaluated by the frequency, severity, and type of adverse events. Results: Both patients achieved improvement in the appearance of their acne and burn scar lesions. Overall patient satisfaction from treatment at the 6-months follow-up visit was very high. post-operative adverse events were mild and transient. Conclusion: The results presented here support the efficacy of fractional CO 2 laser for the cosmetic improvement of acne scars and burn lesions in Indian skin type. Moreover, the favorable adverse event profile witnessed in this trial underscores the safety of this technology for the treatments such as facial acne scar lesion therapy or burn scars in darker Fitzpatrick skin types.

2 Introduction Acne Scars Acne is one of the most frequent inflammatory chronic dermatoses affects approximately 85% of adolescents 1. Acne scars have always been very challenging to treat. Traditional treatments offer some improvement of the appearance of acne scars, but do not provide complete or permanent repair 2 4. Treatment or treatment-combination choice is affected by objective aspects such as type, subtype, age, color, distensibility of scars, and Fitzpatrick skin type; as well as patient-subjective ones such as concerns, expectations and expected compliance. Scars are divided into two major groups, atrophic and hypertrophic scars depending on whether there is a net loss or gain of collagen. Most post-acne scars are associated with a loss of collagen (atrophic scars) compared to a minority of hypertrophic scars and keloids 2 (table 1). Table 1 Classification of acne scars as their morphology Acne Scars Subtype Ice pick Ice Clinical Features Pick scars are narrow (<2 mm), deep, sharply emarginated epithelial tracts that extend vertically to the deep dermis or subcutaneous tissue. Boxcar Shallow Deep Boxcar scars are round and oval depressions with sharply demarcated vertical edges similar to varicella scars. They are clinically wider at the surface than ice pick scars and do not taper to a point at the base. They may be shallow ( mm) or deep (>0.5 mm) and are most often 1.5 to 4.0 mm in diameter Rolling Rolling scars occur from dermal tethering of otherwise relatively normal-appearing skin and are usually wider than 4 to 5 mm. Abnormal fibrous anchoring of the dermis to the subcuits leads to superficial shadowing and a rolling of undulating appearance to the overlying skin. The qualitative scarring grading system proposed by Goodman and Baron 6 is simple and universally applicable (Table 2). According to this classification, four different grades (based on the visibility of the scars at the social distance of 50 cm) can be used to identify different clinical frameworks (Table 2).

3 Table 2 Goodman and Baron qualitative scar grading Grades of Post Level of Clinical Features Acne Scarring disease 1 Macular These scars can be erythematous, hyper or hypopigmented flat marks. They do not represent a problem of contour like other scar grades but of color. 2 Mild Mild atrophy or hypertrophy scars that may not be obvious at social distances of 50 cm or greater and may be covered adequately by makeup or the normal shadow of shaved beard hair in men or normal body hair if extra facial 3 Moderate Moderate atrophic or hypertrophic scarring that is obvious social distances of 50 cm or greater and is not covered easily by makeup or the normal shadow of shaved beard hair in men or body hair if extra facial, but is still able to be flattened by manual stretching of the skin (if atrophic) 4 Severe Severe atrophic or hypertrophic scarring that is evident at social distances greater than cm and is not covered easily by makeup or the normal shadow of the shaved beard hair in men or body hair if extra facial and is not able to be flattened by manual stretching of the skin Treatments A variety of modalities have been proposed for the treatment of atrophic acne scars including: punch excision, punch elevation, punch autografting, subcision, dermabrasion, chemical peels, TCA CROSS technique, fillers and fat transplantation, radiofrequency, microneedling radiofrequency, traditional ablative and non-ablative lasers, fractional ablative and non-ablative lasers. Each has varying degrees of success and adverse reactions 5,7. Burn Scarring Burn scars can be classified by their pigmentation, erythema, texture, and thickness. Scars can be either hyper- or hypo-pigmented compared to the patient s unaffected skin, and many burn scars are erythematous. Burn scar textures are commonly irregular many times due to meshing of skin grafts. Most burn scars are hypertrophic, form within weeks to months of the burn insult and peak in thickness at 6 12 months. Thereafter, scar thickness decreases, and at 24-months post-burn injury, less than 30% of scars are hypertrophic. This hypertrophic tissue, along with altered pigmentation, erythema, and irregular texture, is a target of interventions 9. Treatments According to current guidelines for the treatment of pathological scarring, silicone gel preparations are recommended as a first-line therapy, and the use of pressure garments, as well as onion extract-based products may be advisable too, even though data on their efficacy is not as robust 8.

4 CO 2 Laser Therapy in Scar Patients with Fitzpatrick skin types V and VI Dark skin types have a few characteristics that are specifically relevant to laser aesthetic procedures: increased epidermal melanin, larger melanosomes that are more singly dispersed and widely distributed within epidermal keratinocytes, labile melanocyte responses and reactive fibroblasts. Most importantly, dark skin types react to injury or inflammation with changes in pigment production. Thus, laser procedures are associated with a greater risk for post-procedure hyper- or hypopigmentation in individuals with IV VI. It therefore highly important to select treatment modality and settings as well as to use pre- and post-treatment precautions with the aim of minimizing epidermal and dermal injuries. 21 As darker skin types have relatively large quantities of melanin in the basal layer of the epidermis, there is a higher risk for nonspecific thermal injury and untoward effects, including permanent dyspigmentation, textural changes, focal atrophy, and scarring. Moreover, the required degree of tissue destruction may be difficult to achieve due to competitive absorption by epidermal melanin decreasing the total amount of energy that can reach deeper dermal lesions. 22 The development of nonablative and ablative fractional lasers has broadened the scope of safe and effective treatment options for patients with darkly pigmented skin, however, this patient population requires precautions to mitigate the risk of pigmentary abnormalities. In a recent review of the literature, post-inflammatory hyperpigmentation (PIH) was observed in up to 92% of ablative fractional laser-treated patients. Published studies in East Asian subjects (SPT III and IV) report favourable efficacy in the treatment of acne scarring, surgical scars and photoageing, with a considerable risk for PIH 11,12,17. A retrospective study of 82 Saudi Arabian patients (SPT II V) treated with ablative fractional CO 2 (n = 37) lasers for acne scarring demonstrated at least 50% improvement in scar severity in 37% of patients. PIH was observed in 44% of patients who did not receive pretreatment with topical bleaching agents. 21 Studies have shown that high-density settings are the most important determinant of PIH 23,24. A recent review of the literature noted that most cases resolved within 6 weeks, with only one case lasting more than 6 months 25. A study that treated Middle Eastern subjects with a darker complexion noted a 14% PIH rate. The density was considerably high, with a mean total coverage of 30%. Subjects were given bleaching cream, and all cases resolved within 6 8 weeks 26. Chan et al. employed a similar density setting of 35% total coverage. 56% of their subjects experienced PIH, but all cases except one had resolved by 6 months 11. No permanent side effects were reported 25.

$Lumenis CO 2 Laser AcuPulse Treatment for Scarring Acne Scarring Treatment Using Lumenis CO 2 laser AcuPulse Ablative fractional resurfacing creates microscopic treatment zones (MTZ) to stimulate a$ With this technique, the tissue surrounding each column is spared, ultimately resulting in rapid epidermal regeneration with reduced downtime and adverse reactions compared to treatment with

With this technique, the tissue surrounding each column is spared, ultimately resulting in rapid epidermal regeneration with reduced downtime and adverse reactions compared to treatment with

$3 mm spots, in fractional patterns: The smaller diameter microbeams are used when deep skin penetration is required. While the larger spots affect the skin more superficially.$ Acne scar case report A 24-year-old male patient with skin type V presented with acne scars (boxscar and rolling type).

Acne scar case report A 24-year-old male patient with skin type V presented with acne scars (boxscar and rolling type).

5 Lumenis CO 2 Laser AcuPulse Treatment for Scarring Acne Scarring Treatment Using Lumenis CO 2 laser AcuPulse Ablative fractional resurfacing creates microscopic treatment zones (MTZ) to stimulate a wound healing response. With this technique, the tissue surrounding each column is spared, ultimately resulting in rapid epidermal regeneration with reduced downtime and adverse reactions compared to treatment with traditional full ablative techniques. AcuPulse AcuScan120 scanner is capable of generating 0.12 mm microbeams, as well as 1.3 mm spots, in fractional patterns: The smaller diameter microbeams are used when deep skin penetration is required. While the larger spots affect the skin more superficially. A combination mode delivers the 0.12 mm and 1.3 mm beams sequentially on the same area, such that deeper and more superficial pathologies can be treated in the same pass. Acne scar case report A 24-year-old male patient with skin type V presented with acne scars (boxscar and rolling type). He had acne scars for the past 4 years, without active acne in the year prior to laser treatment. The patient reported sun exposure. We advised him to apply sunscreen on daylight and glycolic acid 6% cream at night for a month before starting CO 2 laser treatments. He had not undergone any dermaroller or micro needling treatments in the past. The patient was counselled not to apply the glycolic acid 6% cream two nights before the session. Treatment session were done using AcuPulse DEEP mode. 1. Energy 15mJ, Shape size 6, Density 5% 2. Second treatment, 2 months following the 1st: Energy of 20mJ, Shape size 7, Density 5% 3. Third treatment, 2 months following the 2nd: Energy 20mJ, Shape size 6, Density 5% Treatment was assessed using a photograph of post procedure taken on one month following the sessions. Downtime following treatments was between 3 and 6 days. Post-treatment instructions: patient was instructed to apply hyaluronic acid cream to be used at night for 5 days, and sunscreen for use at daytime. After 5 days, the patient was advised to use face wash and we advised him to continue the glycolic acid cream. There were no complains post treatment. After the third session, the patient had hyperpigmented spots which lasted for 10 to 12 days which was resolved by applying topical Kojic acid. Acne scar case (3 sessions) Before After Before After

Burn scar case report A 45-year-old female, skin type IV, with a history of hot-water scalding burns that occurred 5 years prior to laser treatment.

$Prior to treatment with the AcuPulse system, the patient was treated with a different CO 2 fractional laser system, for 8 sessions with hardly any difference in the lesion.$ In contrast, treatment with the AcuPulse system provided visible difference and she was very satisfied. Pre-operative local anesthetic cream (lidocaine 2.50 % and prilocaine 2.

In contrast, treatment with the AcuPulse system provided visible difference and she was very satisfied. Pre-operative local anesthetic cream (lidocaine 2.50 % and prilocaine 2.

For post-treatment home care, she was provided with hyaluronic acid-based moisturizer, anti-histamines (loratidine 5mg) and analgesics (aceclofenac 100 mg and paracetamol 325 mg); twice a day for 5

6 Burn scar case report A 45-year-old female, skin type IV, with a history of hot-water scalding burns that occurred 5 years prior to laser treatment. She was rushed to plastic surgery and was given primary care. She recovered within a few months but developed severe scarring on her shoulders, arms, back and buttocks. The patient was treated with scar creams but saw no response. Prior to treatment with the AcuPulse system, the patient was treated with a different CO 2 fractional laser system, for 8 sessions with hardly any difference in the lesion. In contrast, treatment with the AcuPulse system provided visible difference and she was very satisfied. Pre-operative local anesthetic cream (lidocaine 2.50 % and prilocaine 2.50%) was applied for 45 minutes. The patient reported experiencing minor heat sensation during the laser treatment. For post-treatment home care, she was provided with hyaluronic acid-based moisturizer, anti-histamines (loratidine 5mg) and analgesics (aceclofenac 100 mg and paracetamol 325 mg); twice a day for 5 days. Treatment sessions were done using AcuPulse DEEP mode. 1. Energy 12.5mJ, Shape size 10, Density 5% 2. Second treatment, 2 months following the 1st: Energy 15mJ, Shape size 10, Density 5% 3. Third treatment, 2 months following the 2nd: Energy 17.5mJ, Shape size 10, Density 10% The patient reported experiencing mild pain at home, during the post-treatment period. In addition, when off anti-histamines, the patient experienced severe itching. Post-treatment adverse events lasted for 15 days. The patient reported high satisfaction following the treatments. Burn scar case (3 sessions) Before Treatment After 1 st treatment After 2 nd treatment After 3 rd treatment Conclusion Literature as well as recent cases show that fractional ablative CO 2 laser treatment of acne and burn scars is effective and causes mild and transient adverse effects. While effective in a very wide range of skin types, special care should be taken when treating patients with skin types IV and V.

7 References 1. Yentzer BA, Hick J, Reese EL, Uhas A, Feldman SR, Balkrishnan R. Acne vulgaris in the United States: a descriptive epidemiology. Cutis. 2010;86(2): Fabbrocini G, Vita VD, Cozzolino A, Marasca C, Mazzella C, Monfrecola A. The Management of Atrophic Acne Scars: Overview and New Tools. J Clin Exp Dermatol Res. April doi: / s Goodman GJ, Baron JA. The management of postacne scarring. Dermatol Surg Off Publ Am Soc Dermatol Surg Al. 2007;33(10): doi: /j x. 4. Basta-Juzbašić A. Current therapeutic approach to acne scars. Acta Dermatovenerol Croat ADC. 2010;18(3): Jacob CI, Dover JS, Kaminer MS. Acne scarring: a classification system and review of treatment options. J Am Acad Dermatol. 2001;45(1): doi: /mjd Goodman GJ, Baron JA. Postacne scarring a quantitative global scarring grading system. J Cosmet Dermatol. 2006;5(1): doi: /j x. 7. Goodman G. Post acne scarring: a review. J Cosmet Laser Ther Off Publ Eur Soc Laser Dermatol. 2003;5(2): Poetschke J, Dornseifer U, Clementoni MT, Reinholz M, Schwaiger H, Steckmeier S, Ruzicka T, Gauglitz GG. Ultrapulsed fractional ablative carbon dioxide laser treatment of hypertrophic burn scars: evaluation of an in-patient controlled, standardized treatment approach. Lasers Med Sci. 2017;32(5): doi: /s z. 9. Lee S-J, Suh D-H, Lee JM, Song K-Y, Ryu HJ. Dermal Remodeling of Burn Scar by Fractional CO 2 Laser. Aesthetic Plast Surg. 2016;40(5): doi: /s x. 10. Huang L. A new modality for fractional CO 2 laser resurfacing for acne scars in Asians. Lasers Med Sci. 2013;28(2): Chan NP, Ho SG, Yeung CK, Shek SY, Chan HH. Fractional ablative carbon dioxide laser resurfacing for skin rejuvenation and acne scars in Asians. Lasers Surg Med. 2010;42(9): Manuskiatti W, Triwongwaranat D, Varothai S, Eimpunth S, Wanitphakdeedecha R. Efficacy and safety of a carbon-dioxide ablative fractional resurfacing device for treatment of atrophic acne scars in Asians. J Am Acad Dermatol. 2010;63(2): Waibel J, Beer K. Ablative fractional laser resurfacing for the treatment of a third-degree burn. J Drugs Dermatol JDD. 2009;8(3): Haedersdal M. Fractional ablative CO 2 laser resurfacing improves a thermal burn scar. J Eur Acad Dermatol Venereol. 2009;23(11): Qu L, Liu A, Zhou L, He C, Grossman PH, Moy RL, Mi Q-S, Ozog D. Clinical and molecular effects on mature burn scars after treatment with a fractional CO 2 laser. Lasers Surg Med. 2012;44(7): Avram MM, Tope WD, Yu T, Szachowicz E, Nelson JS. Hypertrophic scarring of the neck following ablative fractional carbon dioxide laser resurfacing. Lasers Surg Med. 2009;41(3): Lee SJ, Kim JH, Lee SE, Chung WS, Oh SH, Cho SB. Hypertrophic Scarring After Burn Scar Treatment with a 10,600-nm Carbon Dioxide Fractional Laser. Dermatol Surg. 2011;37(8): Chapas AM, Brightman L, Sukal S, Hale E, Daniel D, Bernstein LJ, Geronemus RG. Successful treatment of acneiform scarring with CO 2 ablative fractional resurfacing. Lasers Surg Med. 2008;40(6):

8 19. Cho S, Jung JY, Shin JU, Lee JH. Non-ablative 1550 nm erbium-glass and ablative 10,600 nm carbon dioxide fractional lasers for various types of scars in Asian people: evaluation of 100 patients. Photomed Laser Surg. 2014;32(1): Manstein D, Herron GS, Sink RK, Tanner H, Anderson R. Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med. 2004;34(5): Alexis AF. Lasers and light-based therapies in ethnic skin: treatment options and recommendations for Fitzpatrick skin types V and VI. Br J Dermatol. 2013;169 Suppl 3: doi: /bjd Shah S, Alster TS. Laser treatment of dark skin: an updated review. Am J Clin Dermatol. 2010;11(6): doi: / Chan HH, Manstein D, Yu CS, Shek S, Kono T, Wei WI. The prevalence and risk factors of post-inflammatory hyperpigmentation after fractional resurfacing in Asians. Lasers Surg Med. 2007;39(5): Kono T, Chan HH, Groff WF, Manstein D, Sakurai H, Takeuchi M, Yamaki T, Soejima K, Nozaki M. Prospective direct comparison study of fractional resurfacing using different fluences and densities for skin rejuvenation in Asians. Lasers Surg Med. 2007;39(4): Magnani LR, Schweiger ES. Fractional CO 2 lasers for the treatment of atrophic acne scars: a review of the literature. J Cosmet Laser Ther Off Publ Eur Soc Laser Dermatol. 2014;16(2): doi: / Alajlan AM, Alsuwaidan SN. Acne scars in ethnic skin treated with both non-ablative fractional 1,550 nm and ablative fractional CO 2 lasers: Comparative retrospective analysis with recommended guidelines. Lasers Surg Med. 2011;43(8): Warnings and risks CO 2 lasers are intended solely for use by physicians trained in the use of the Carbon Dioxide laser (10.6 μm) wavelength. Incorrect treatment settings or misuse of the technology can present risk of serious injury to patient and operating personnel. Risks that may be associated with any CO 2 laser procedure may include change of pigmentation, infection, erythema, skin induration or scarring. Read and understand the CO 2 systems and accessories operator manuals for a complete list of intended use, contraindications and risks. The use of Lumenis CO 2 laser is contraindicated where a patient has taken Accutane (Isotretinoin) within the past 6-12 months, has a history of keloid formation and demonstrate excessive or unusually prolonged erythema LASER CLASS 4/IV CO 2: 10.6 m, 40W Max, CW Max Pulse Width: 290 s Max Pulse Energy: 30mJ LASER CLASS 3R/IIIa Diode Laser: 635nm, 5mW Max, CW VISIBLE AND INVISIBLE LASER RADIATION AVOID EYE OR SKIN EXPOSURE TO DIRECT OR SCATTERED RADIATION CLASS 4 LASER PRODUCT per EN /2007 CLASS IV LASER PRODUCT per 21 CFR & except for deviations pursuant to Notice 50, Dated June 24, 2007 LB _A Lumenis Ltd. Yokneam Industrial Park 6 Hakidma Street P.O.B. 240 Yokneam , Israel Tel: PB Rev A

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