Ablative Fractional Laser

The charts below show the chances of developing various side effects from laser resurfacing.1,3-25 For some side effects, we currently do not have enough data to provide a percentage.

Certain/Likely Side Effects (% = Incidence)

SHORT TERM Crusting/Scalingup to 100%
SHORT TERM Limitations in activityup to 100%
SHORT TERM Mild to moderate woundsup to 100%
SHORT TERM Redness (erythema)45.5% to 100%
SHORT TERM Skin darkening (post-inflammatory hyperpigmentation)5% to 92.5%
SHORT TERM Skin drynessup to 50%
SHORT TERM Itching (pruritus)up to 40%
SHORT TERM Acne flare-up10% to 30.8%
SHORT TERM Skin lightening (hypopigmentation)18.2% to 27.3%
SHORT TERM Swelling (edema)up to 25%
SHORT TERM Rash (allergic contact dermatitis)up to 15.4%
SHORT TERM Oozing from woundsup to 15%

Possible/Rare Side Effects

SHORT TERM Skin infection7.7% to 14.2%
SHORT TERM Bleedingup to 10%
SHORT TERM Prolonged crusting*up to 3%
LONG TERM Raised (hypertrophic) scars around eyesincidence not known

*Prolonged crusting: Prolonged crusting is crusting that lasts longer than 7 days.20

Studies:

Eleven studies have looked at the side effects of treatment with ablative fractional lasers.

  • Study 1:

    • Authors: Ahmed et al.8
    • Total # of patients: 14
    • # of female patients: (not reported)
    • # of male patients: (not reported)
    • Age of patients: Average: 22.7
    • Laser type: CO2 fractional laser
    • Laser settings: 0.12 mm spot size, 0.9 W, 1.9 ms pulse duration, 99 Hz
    • Duration of treatment and follow-up: 4 treatments, follow-up for 3 months
    • Side effects:
      • Temporary hyperpigmentation (skin darkening): 14.2%
      • Infection: 14.2%
      • No complications: 35.7%
  • Study 2:

    • Authors: Bjorn et al.14
    • Total # of patients: 13
    • # of female patients: (not reported)
    • # of male patients: (not reported)
    • Age of patients: 18-60
    • Laser type: CO2 fractional laser
    • Laser settings: Deep FX handpiece: 17.5–22.5mJ/pulse, 70–90W, 0.25 ms pulse duration, density 3 (15% coverage) and Active FX handpiece: 100mJ/pulse, >125W, <0.8 ms pulse duration, density 3 (82% coverage)
    • Duration of treatment and follow-up:
      • 4 treatments, follow-up for 3 months
        • Side effects:
        • Mild to moderate erythema (redness): 63.6%
        • Mild hypopigmentation (skin lightening): 18.2%
        • Mild post-inflammatory hyperpigmentation (skin darkening): 45.5%
      • 2 treatmetns at 3-month intervals, follow-up at 1 and 6 months
        • Side effects:
          • Mild to moderate erythema (redness): 45.5%
          • Mild hypopigmentation (skin lightening): 27.3%
          • Mild post-inflammatory hyperpigmentation (skin darkening): 45.5%
  • Study 3:

    • Authors: Cho et al.15
    • Total # of patients: 20
    • # of female patients: 13
    • # of male patients: 7
    • Age of patients: 19-33 Average: 27
    • Laser type: CO2 fractional laser
    • Laser settings: Deep FX mode: 10-20 mJ, density 2, 300 Hz and Active FX mode: 50-100 mJ, density 2, <1 ms pulse duration, 75 Hz
    • Duration of treatment and follow-up: 1 treatment, follow-up at 3 months
    • Side effects:
      • Crusting or scaling: 100% (average: 6.3 days)
      • Erythema (redness): 100% (average: 2.8 days)
      • Limitations in activity: 100% (4.9 days)
      • Edema (swelling): 25%
      • Bleeding: 10%
      • Wound exudate (oozing): 15%
      • Post-therapy hyperpigmentation (skin darkening): 5%
      • Aggravation of inflammatory acne: 15%
  • Study 4:

    • Authors: Hedelund et al.16
    • Total # of patients: 13
    • # of female patients: 7
    • # of male patients: 6
    • Age of patients: 22-54 Average: 33
    • Laser type: CO2 fractional laser
    • Laser settings: 0.5 mm spot diameter, 12-14 W, 48-56 mJ/pulse, 100 MTZ/cm2, density 13%, 4 ms pulse duration
    • Duration of treatment and follow-up: 3 treatments, follow-up at 2-3 days and 1, 3, and 6 months
    • Side effects:
      • Mild to moderate erythema (redness): 69.2%
      • Mild to moderate wounds: 100%
      • Post-inflammatory hyperpigmentation (skin darkening): 0%
  • Study 5:

    • Authors: Majid and Imran17
    • Total # of patients: 60
    • # of female patients: 35
    • # of male patients: 25
    • Age of patients: 1 patient under age 20 and 1 patient over 40, the rest between 20 and 40
    • Laser type: CO2 fractional laser
    • Laser settings: 15-25 J/cm2, 100-150 MTZ/cm2, 1.0-1.2 mm ablation depth
    • Duration of treatment and follow-up: 3-4 treatments, follow-up at 6 months
    • Side effects:
      • Transient acneiform (acne-like) lesions: 10%
      • Post-inflammatory hyperpigmentation (skin darkening): 5%
  • Study 6:

    • Authors: Manuskiatti et al.18
    • Total # of patients: 13*
    • # of female patients: 8
    • # of male patients: 5
    • Age of patients: 25-52 Average: 34
    • Laser type: CO2 fractional laser
    • Laser settings: 15 W, 49 MTZ/cm2, 75-105 mJ/MTZ, 9.6% average coverage, 5-7 ms pulse duration
    • Duration of treatment and follow-up: 3 treatments, follow-up at 6 months
    • Side effects:
      • Post-inflammatory hyperpigmentation (skin darkening): 92.3%
      • Acneiform eruption (acne-like lesions): 30.8%
      • Allergic contact dermatitis: 15.4%
      • Herpes simplex infection (cold sores): 7.7%
  • Study 7:

    • Authors: Manuskiatti et al.19
    • Total # of patients: 24*
    • # of female patients: 12
    • # of male patients: 8
    • Age of patients: 22-51 Average: 29.5
    • Laser type: CO2 fractional laser
      • Laser settings: 12.5-15 mJ, 950 ls pulse duration
      • Duration of treatment and follow-up: 2 treatments, follow-up at 6 months
      • Side effects: Post-inflammatory hyperpigmentation (skin darkening): 50%
    • Laser type: Er:YAG fractional laser
      • Laser settings: 14 mJ, 350 ls pulse duration
      • Duration of treatment and follow-up: 2 treatments, follow-up at 6 months
      • Side effects: Post-inflammatory hyperpigmentation (skin darkening): 35%
  • Study 8:

    • Authors: Wang et al.21
    • Total # of patients: 5*
    • # of female patients: 1
    • # of male patients: 4
    • Age of patients: 19-44 Average: 27
    • Laser type: CO2 fractional laser
    • Laser settings: 300 µm spot size, 8 W, 28 J/cm2, 2.5 pulse duration, 500 µm penetration depth, 20% skin coverage
    • Duration of treatment and follow-up: 2 treatments, follow-up at 8 weeks
    • Side effects: Post-treatment erythema (redness): 100%
  • Study 9:

    • Authors: Yuan et al.22
    • Total # of patients: 20*
    • # of female patients: 10
    • # of male patients: 10
    • Age of patients: 22-31
    • Laser type: CO2 fractional laser
    • Laser settings: Deep FX mode: 10 mJ or 20 mJ, 10% or 20% density
    • Duration of treatment and follow-up: 1 treatment, follow-up at 3 days, 1 week, 1 month, and 3 months
    • Side effects:
      • Cutaneous pruritus (skin itching): 40%
      • Skin dryness: 50%
  • Study 10:

    • Authors: Zhang et al.23
    • Total # of patients: 33*
    • # of female patients: 14
    • # of male patients: 19
    • Age of patients: 19-34 Average: 26.4
    • Laser type: CO2 fractional laser
    • Laser settings: Deep FX mode: 20-25 mJ, 10-20% coverage/cm2 per pass, 300 Hz
    • Duration of treatment and follow-up: 3 treatments, follow-up at 5 months
    • Side effects: Post-inflammatory hyperpigmentation (skin darkening): 36.4%
  • Study 11:

    • Authors: Nirmal et al.20
    • Total # of patients: 25
    • # of female patients: 10
    • # of male patients: 15
    • Age of patients: 18-38
    • Laser type: Er:YAG fractional laser
    • Laser settings:
      • Session 1: 9 x 9 tip, 1,200 mJ
      • Session 2: 9 x 9 tip, 1,400 mJ
      • Session 3: 7 x 7 tip, 1,200 mJ
      • Session 4: 7 x 7 tip, 1,400 mJ. 2 Hz for all sessions
    • Duration of treatment and follow-up: 4 treatments, follow-up at 1 month
    • Side effects:
      • Exacerbation of acne lesions: 13%
      • Post-treatment hyperpigmentation (skin darkening): 2%
      • Prolonged crusting: 3%
      • Prolonged erythema (redness): 0%

* All patients were Asian

Study 1: In a study published in 2014 in the Journal of Cosmetic and Laser Therapy, Ahmed and colleagues treated 14 patients with icepick scars with CO2 fractional laser. Patients received 4 treatments at 3-week intervals and were followed up for 3 months. The researchers advised the patients not to use any other scar treatment during the study. Over a third (35.7%) of the patients experienced no side effects.8

Study 2: In a study published in 2014 in the journal Lasers in Surgery and Medicine, Bjorn and colleagues treated 13 patients with moderate to severe atrophic (indented) acne scars with CO2 fractional laser. Patients were given 2 treatments, which were administered at an interval of 1 month on one side of the face and at an interval of 3 months on the other side of the face. The researchers randomly assigned which side of the face received which treatment schedule. Side effects were mild and similar after both treatments.14

Study 3: In a study published in 2009 in the journal Dermatologic Surgery, Cho and colleagues treated 20 patients with mild to severe atrophic (indented) acne scars with 1 session of CO2 fractional laser. Patients were followed up 3 months after treatment. All patients experienced mild side effects in the first 2-3 weeks after treatment. The table below shows the side effects experienced by each patient.15

Study 4: In a study published in 2012 in Lasers in Surgery and Medicine, Hedelund and colleagues treated 13 patients with atrophic (indented) acne scars with CO2 fractional laser. Patients were given 3 sessions of treatment at intervals of 4 to 5 weeks. Patients experienced mild side effects after each treatment. No patients developed post-inflammatory hyperpigmentation (skin darkening).16

Study 5: In a study published in 2014 in the Journal of Cutaneous and Aesthetic Surgery, Majid and Imran treated 60 patients with atrophic (indented) acne scars with CO2 fractional laser. The patients received 3-4 sessions of treatment at 6-week intervals and were followed up 6 months after the last laser session. Most patients experienced erythema (redness) lasting 3-4 days and superficial crusting lasting 4-6 days, as well as mild transient edema (swelling). In addition, 6 patients developed acne-like lesions which, in two cases, had to be treated with oral medication. The only serious side effect was post-inflammatory hyperpigmentation (skin darkening), which occurred in 3 patients and disappeared over 2-3 months with the help of topical therapy.17

Study 6: In a study published in 2010 in the Journal of the American Academy of Dermatology, Manuskiatti and colleagues treated 13 Asian patients with atrophic (indented) acne scars with CO2 fractional laser. The patients received 3 sessions of treatment at 7-week intervals and were followed up 6 months after treatment. The majority of patients experienced post-inflammatory hyperpigmentation (skin darkening), and many also developed acne-like lesions after treatment.18

Study 7: In a study published in 2013 in Dermatologic Surgery, Manuskiatti and colleagues treated 24 Asian patients with shallow or deep boxcar scars with fractional laser. The patients were randomly assigned to receive CO2 fractional laser treatment on one side of the face and Er:YAG fractional laser treatment on the other side of the face. On each side, two laser treatments were administered at an interval of 2 months. The researchers followed up with the patients 6 months after the last treatment. Half of the patients developed post-inflammatory hyperpigmentation (skin darkening) on the side of the face treated with CO2 laser, and 35% of the patients developed post-inflammatory hyperpigmentation on the side of the face treated with Er:YAG laser. Although CO2 laser treatment seemed to result in skin darkening more frequently, this difference was not statistically significant. In other words, the number of patients was too small for the researchers to definitively conclude that CO2 laser treatment is more likely to cause skin darkening than Er:YAG laser treatment.19

Study 8: In a study published in 2010 in the Journal of Cosmetic and Laser Therapy, Wang and colleagues treated 5 Asian patients with moderate to severe acne scarring with CO2 fractional laser. The patients received 2 treatment sessions at an interval of 6-8 weeks and were followed up 8 weeks after the second treatment. All patients experienced skin redness after the treatment which lasted 5-7 days. No other side effects occurred.21

Study 9: In a study published in 2014 in Dermatologic Surgery, Yuan and colleagues treated 20 Chinese patients with atrophic (indented) acne scars with CO2 fractional laser. All patients received a single treatment with the laser, but the laser settings differed between patients. For instance, some patients were treated with the fluence set to 10 mJ on one side of the face and 20 mJ on the other side of the face. While the side effects were very similar on both sides of the face, they lasted slightly longer on the side of the face treated with the higher fluence. None of the patients experienced infection, scarring, acne flare-ups, or hypopigmentation (skin lightening) as a result of the treatment.22

Side effectAverage duration of side effect (days)22
10 mJ20 mJ
Pain4.394.98
Edema (swelling)2.503.50
Crusting4.004.80
Post-inflammatory hyperpigmentation (skin darkening)46.8056.80

Study 10: In a study published in 2013 in Dermatologic Surgery, Zhang and colleagues treated 33 Chinese patients with atrophic acne scars with CO2 fractional laser on one side of the face. The patients received 3 treatments at intervals of 6-12 weeks (8 weeks on average) and were followed up 6 months after the last treatment. Over a third of patients developed post-inflammatory hyperpigmentation (skin darkening).23

Side effectAverage duration of side effect (days)23
Erythema (redness)12.3
Crusting and scaling10.2

Study 11: In a study published in 2013 in the Indian Journal of Dermatology, Venereology and Leprology, Nirmal and colleagues treated 25 patients with atrophic acne scars with Er:YAG fractional laser. The patients were given 4 treatment sessions at 1-month intervals and were followed up 1 month after the last treatment. Most patients experienced short-term redness, which lasted less than 2 days, and crusting, which lasted around 5 days. A few patients (3%) experienced prolonged crusting lasting more than 7 days, but none developed prolonged redness lasting over 4 days. The most common side effect was exacerbation of acne lesions, which was treated with oral antibiotics.20

References
  1. Sobanko JF, and Alster TS. Management of acne scarring, part I: a comparative review of laser surgical approaches. Am J Clin Dermatol. 13(5), 319-30 (2012)
  2. Preissig J, Hamilton K, and Markus R. Current laser resurfacing technologies: A review that delves beneath the surface. Semin Plast Surg. 26(3), 109–116 (2012).
  3. Uptodate.com. Management of acne scars. Available from: https://www.uptodate.com/contents/management-of-acne-scars?source=search_result&search=subcision&selectedTitle=1~4. Last retrieved on 30 June, 2017.
  4. Alexis AF, et al. Nonablative Fractional Laser Resurfacing for Acne Scarring in Patients With Fitzpatrick Skin Phototypes IV-VI. Dermatol Surg. 42(3), 392-402 (2016).
  5. Alster TS, and West TB. Resurfacing of atrophic facial acne scars with a high-energy, pulsed carbon dioxide laser. Dermatol Surg. 22(2), 151-4 (1996).
  6. Bhatia AC, Dover JS, Arndt KA, Stewart B, and Alam M. Patient satisfaction and reported long-term therapeutic efficacy associated with 1,320 nm Nd:YAG laser treatment of acne scarring and photoaging. Dermatol Surg. 32(3), 346-52 (2006).
  7. Chae WS, et al. Comparative study on efficacy and safety of 1550 nm Er:Glass fractional laser and fractional radiofrequency microneedle device for facial atrophic acne scar. J Cosmet Dermatol. 14(2), 100-6 (2015).
  8. Ahmed R, Mohammed G, Ismail N, and Elakhras A. Randomized clinical trial of CO₂ LASER pinpoint irradiation technique versus chemical reconstruction of skin scars (CROSS) in treating ice pick acne scars. J Cosmet Laser Ther. 16(1), 8-13 (2014).
  9. Engın B, et al. Evaluation of effectiveness of erbium:yttrium-aluminum-garnet laser on atrophic facial acne scars with 22-MHz digital ultrasonography in a Turkish population. J Dermatol. 39(12), 982-8 (2012).
  10. Jeong JT, and Kye YC. Resurfacing of pitted facial acne scars with a long-pulsed Er:YAG laser. Dermatol Surg. 27(2), 107-10 (2001).
  11. Lee SJ, Kang JM, Chung WS, Kim YK, and Kim HS. Ablative non-fractional lasers for atrophic facial acne scars: a new modality of erbium:YAG laser resurfacing in Asians. Lasers Med Sci. 29(2), 615-9 (2014).
  12. Wanitphakdeedecha R, Manuskiatti W, Siriphukpong S, and Chen TM. Treatment of punched-out atrophic and rolling acne scars in skin phototypes III, IV, and V with variable square pulse erbium:yttrium-aluminum-garnet laser resurfacing. Dermatol Surg. 35(9), 1376-83 (2009).
  13. Tanzi EL, and Alster TS. Treatment of atrophic facial acne scars with a dual-mode Er:YAG laser. Dermatol Surg. 28(7), 551-5 (2002).
  14. Bjørn M, Stausbøl-Grøn B, Braae Olesen A, and Hedelund L. Treatment of acne scars with fractional CO2 laser at 1-month versus 3-month intervals: an intra-individual randomized controlled trial. Lasers Surg Med. 46(2), 89-93 (2014).
  15. Cho SB, Lee SJ, Kang JM, Kim YK, Chung WS, and Oh SH. The efficacy and safety of 10,600-nm carbon dioxide fractional laser for acne scars in Asian patients. Dermatol Surg. 35(12),1955-61 (2009).
  16. Hedelund L, Haak CS, Togsverd-Bo K, Bogh MK, Bjerring P, and Haedersdal M. Fractional CO2 laser resurfacing for atrophic acne scars: a randomized controlled trial with blinded response evaluation. Lasers Surg Med. 44(6), 447-52 (2012).
  17. Majid I, and Imran S. Fractional CO2 Laser Resurfacing as Monotherapy in the Treatment of Atrophic Facial Acne Scars. J Cutan Aesthet Surg. 7(2), 87-92 (2014).
  18. Manuskiatti W, Triwongwaranat D, Varothai S, Eimpunth S, and 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. 63(2), 274-83 (2010).
  19. Manuskiatti W, Iamphonrat T, Wanitphakdeedecha R, Eimpunth S. Comparison of fractional erbium-doped yttrium aluminum garnet and carbon dioxide lasers in resurfacing of atrophic acne scars in Asians. Dermatol Surg. 39(1 Pt 1), 111-20 (2013).
  20. Nirmal B, et al. Efficacy and safety of erbium-doped yttrium aluminium garnet fractional resurfacing laser for treatment of facial acne scars. Indian J Dermatol Venereol Leprol. 79(2), 193-8 (2013).
  21. Wang YS, Tay YK, and Kwok C. Fractional ablative carbon dioxide laser in the treatment of atrophic acne scarring in Asian patients: a pilot study. J Cosmet Laser Ther. 12(2), 61-4. (2010).
  22. Yuan XH, Zhong SX, and Li SS. Comparison study of fractional carbon dioxide laser resurfacing using different fluences and densities for acne scars in Asians: a randomized split-face trial. Dermatol Surg. 40(5), 545-52 (2014).
  23. Zhang Z, Fei Y, Chen X, Lu W, and Chen J. Comparison of a fractional microplasma radio frequency technology and carbon dioxide fractional laser for the treatment of atrophic acne scars: a randomized split-face clinical study. Dermatol Surg. 39(4), 559-66 (2013)
  24. Cachafeiro T, Escobar G, Maldonado G, Cestari T, and Corleta O. Comparison of Nonablative Fractional Erbium Laser 1,340 nm and Microneedling for the Treatment of Atrophic Acne Scars: A Randomized Clinical Trial. Dermatol Surg. 42(2), 232-41 (2016).
  25. Isarría MJ1, Cornejo P, Muñoz E, Royo de la Torre J, and Moraga JM. Evaluation of clinical improvement in acne scars and active acne in patients treated with the 1540-nm non-ablative fractional laser. J Drugs Dermatol.10(8), 907-12 (2011).