COMMENTARY

Fractional Laser Photothermolysis: The Best of Both Worlds?

Graeme Lipper, MD

Disclosures

April 11, 2007

The Use of Fractional Laser Photothermolysis for the Treatment of Atrophic Scars

Alster TS, Tanzi EL, Lazarus M
Dermatol Surg. 2007;33:295-299

Summary

The treatment of atrophic scars such as those caused by cystic acne can be challenging, with ablative options (eg, CO2 or erbium laser resurfacing) leading to significant downtime, while nonablative laser options yield variable, subtle improvement. In contrast, Alster and colleagues present data to suggest that a 1550-nm erbium-doped fiber laser (Fraxel, Reliant Technologies Inc, San Diego, Calif) may combine the best of both worlds.

In this prospective analysis, Alster and colleagues treated 53 patients (skin phototypes I-V; 39 women; mean age 39.6 years) with mild to moderate atrophic facial acne with up to 3 monthly laser treatments. Areas of facial acne scarring were treated with the Fraxel laser (15-mm handpiece) and concomitant forced air cooling, using fluences of 8 to 16 J/cm2 at densities of 125-250 microscopic thermal zones applied in 8 to 10 passes. Patients received sequential treatments at monthly intervals. To assess the clinical outcome, 2 treatment-blinded assessors evaluated comparative photographs and graded scar improvement using a quartile grading scale.

Most patients (70%) received 2 or more treatments, and 91% had at least 25% improvement after a single treatment. Nearly 90% of patients receiving 3 laser treatments experienced clinical improvement of at least 51%. Furthermore, clinical responses improved with sequential treatments, and were independent of patient age, gender, or skin phototype. Treatment-related side effects were limited to mild erythema, edema, and transient acne flaring. Transient postinflammatory hyperpigmentation developed in only 1 patient with skin phototype V.

Viewpoint

The Fraxel laser is a nonablative laser that delivers fractional photothermolysis via intradermally focused infrared light. This system generates a pattern of microscopic noncontiguous zones of thermal injury within the dermis -- termed microscopic thermal zones. These localized columns of thermally denatured collagen stimulate collagen remodeling while leaving islands of intact dermal and epidermal cells, which in turn leads to speedy epithelial recovery, thereby minimizing downtime.[1,2]

Fractional photothermolysis has been shown to improve the appearance of photodamaged and dyschromic skin.[3] Adding to earlier smaller reports, the prospective study of Alster and colleagues found impressive acne scar improvement following a series of monthly Fraxel treatments. These results appear to be superior to those of other nonablative laser modalities used to treat acne scarring.[4] Given the expense of the Fraxel device, future studies should compare results from fractional photothermolysis with those achieved using ablative modalities (eg, erbium or CO2 laser skin resurfacing, plasma skin resurfacing). Investigators should also aim to optimize Fraxel treatment parameters, which will likely vary depending on variables such as skin phototype and severity/type of acne scarring.

Abstract

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