Carboxytherapy in Aesthetic Dermatology – Experiences after the Treatment

of 280 Patients

N. Koutná
GHC Clinic Prague

Summary: Carboxytherapy in narrow sense means injectional application of carbon dioxide

(CO2) into the tissue. The method has numerous indications in balneotherapy and
in dermatology and aesthetic medicine. My experiences with the method obtained during
27 months in the treatment of 280 patients are summarised in the article. Also the problems
of the treatment in various indications and pros and cons of its use in aesthetic medicine are
discussed.

Key words: carboxytherapy, needle subcision, neocollagenesis.

My paper Carboxytherapy – a New Method in Aesthetic Medicine was published

in The Journal of Czech Physicians – Cas lek ces, 2006, 145, 11, str. 841-843. Since that time
I had an opportunity to meet several colleagues from abroad devoted to the research
of carboxytherapy and practicing the method for more than 10 years (professor Dr. Roberto
Parmigiani and professor Dr. Cesare Brandi – both from Italy, Dr. Juan Carlos Lopez and
Dr. Julio Cesar Tavares Ferreira – both from Brazil, and others). In treatments of my patients
I have gained certain experiences. Because even nowadays carboxytherapy is rarely used
in Czech Republic, I beg to summarise new knowledge in this survey, which should bring
further practical information to colleagues beginning with the teachnique.
Transcutaneous therapeutical application of carbon dioxide has been used in medicine since
1932 (Dr. Barrieu, Spa Royat, France). In that time it was the use of the gas from local natural
source of 99% clear CO2. Similarly in other areas (Mariánské Lázně, Bad Schonau, locations
in Argentina and Japan) first natural spring gas was used, gradually it was substituted
by standard medical CO2.
At international conference in Freibourg-en-Brisgau (1989) a concensus summarising
the effects of carboxytherapy was formulated (1):
- increase of local blood supply by opening of functionally closed capillaries and by dilatation
of precapillar segments
- improvement of oxygenation by increased release of oxygen from hemoglobin (Bohr´s
effect – in lower pH and higher pCO2 (partial pressure of CO2) hemoglobin´s afinity
to oxygen is decreased)
- increase of erythrocytes´ deformability
- change of the treshold of thermoreceptors
- antiseptic effect
Even nowadays high attention is devoted to to effects of carboxytherapy on
microcirculation, angiogenesis and normalisation of vascular supply in treated area, influence
on lymphatic vessels.
Tradicionally the method is indicated in peripheral vascular disorders (e.g. Reynaud syndrom,
morbus Bürger, diabetical peripheral polyneuropathy), for its analgetic effects also
in the treatment of pains of joints and spine. In the 90ties during the development
of laparoscopy it was found, that instilation even more than 3 litres of CO2 gas into
abdominal cavity in speed even 1 litr per minute is safe and the gas is relatively quickly
eliminated from the organism. Surgeons also noticed reduction of adjacent fatty tissue and
of fibrous edema (2). On the base of these observations gradually developed further
possibilities of use of carboxytherapy in antiaging, in non-ivasive aesthetic medicine and

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in dermatology. While in South America, Italy and in South-Eastern Asia this modification
of the method has become relatively routinal during last 15 years, in many European countries
and in the USA is the method so far used more or less sporadically (probably thanks to small
interest of distributors and physicians, who are used to advertise and treat by lasers and other
methods, already publically well-known and commercially successfull).
In Czech Republic I have been using the method in aesthetic medicine for more than
2 years, the same time as head physician Dr. Ludovit Pinter, PhD in private centre Sanus
in Hradec Kralove. Several other centers have began to use the method later, however, the
final count is not high (till now approximately 5 centers), perhaps because of insufficient
physicians´ trust in the method which they did not try yet.
Carboxytherapy has many indications in aesthetic medicine: treatment of so called cellulite
(fibrolipodystrophy), post-liposuction adhesions, scars and striae, skin rejuvenation, so-called
contouring (gentle non-invasive shaping of facial or body contours coming by soft thinning
of treated area), in dermatology the method can be used for the treatment of stabilised
localised psoriasis, sclerodermias, defluvium and alopecias, and above all in the treatment
of problematic wounds – hence also leg ulcers.

On the world market there are many devices for performing aesthetic carboxytherapy.
The aim is good control of the gas flow, there should be also mechanical and microbial filter,
the gas coming out should be sterile. With use of the device without warming the gas
the patient feels various sensations during the gas instilation – „as cold water flows there“,
afterwards tingling, burning, in the end warmth. Some of these sensations can be individually
quite unpleasant. Paradoxically they tend to be more intensive e.g. during the treatment of so-
called cellulite or post-liposuctional adhesions or striae, application in the face is born better.
Topical anesthesia by Emla cream (lidocain, prilocain) cannot be used meaningfully, its
effect is only superficial and here we have sensations mainly „under the skin“, next, Emla
makes vasoconstriction and it is questionable if it could influence success of the treatment or
not). However, nowadays many machines use prewarmed gas, which significantly improves
the comfort of the patient during the application.
On Czech market currently is Evolution device (manufacturer Carbossiterapia Italiana,
distributor Planmed company), the device has European certification. I use the older machine
Carbomed (Carbossiterapia Italiana), which unfortunately does not prewarm the gas. It is
important not to underestimate the change of instilation tubing for single use, there occured
a case of hepatitis tranfer in one European country, when the sets were not changed after
every patient.

Up to now I have used carboxytherapy in my praxis in the treatment of 280 patients

(25 men, 255 women, age 16-74 years, mean age 40,1 years). The patients passed from 1 to
32 treatments (according to the indication, their interest and success of the therapy).
The indications and usual effects are summarised in Table 1.
The most frequent indication in the group was skin rejuvenation (face of 196 subjects, neck
and decolleté of 80, hands of 9 subjects – many patients prefered the treatment of several
locations). Application is performed by gentle punctures (needle 30G) on the periphery
of the face, around the eyes and mouth, I use modificated technique of Dr. Juan C. Lopez
(Brazil), when we apply small amount of gas into every injectional point – approximately
1 cm3. The puctures are done intradermally. In the study of Dr. Ferreira (2) it was
demonstrated that intradermal application of CO2 results in bigger reaction of the collagen
than in subdermal or deeper application. Exact mechanism of collagen reaction is not known,
besides stimulation coming with improvement of local metabolism and blood supply we
speculate about mechanical stimulation of fibroblasts by the gas flow, about possible effect

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of acidosis (3, 4), however explanation requires further research. Stimulation is rather strong,
because in many cases we observe distinct improvement of skin tightening or scar smoothness
as soon as after one treatment.
Ideally during superficial application we see during the gas instilation whitening of the skin
resulting from the gas flow, afterwards comes the redness signaling vasodilatation in the area.
Some physicians apply bigger amounts of the gas, however, it is important to watch and avoid
unwanted gas diffusion into deeper tissues, as CO2 has also lipolytic effect (5) – but,
in the face, especially e.g. in medial cheeks area, it is not desirable to initiate its loss. It is
advisable also to notice skin tonus, if the complexion is lax and unwanted, even slight
lipolysis occurs, the effect does not need to be aestheticaly nice, even if the patient herself
values her complexion as better. In rejuvenation I use the gas flow 30-40 ml/min and
recommend the treatment approximately once in a month, it is possible to apply more often,
however, although we reach better momentary results, longlasting effect coming with
neocollagenesis does not tend to be bigger. Collagen rebuilding lasts, similarly like with other
techniques (e.g. photorejuvenation) for 3-4 weeks or more, even this speaks for intervals
1 month between the sessions. Final number of the treatments is usually from 3 to 7, it
depends on the level of the effect – it seems that the best effect comes on subjects between
35- 60 years old, but is apparently considerably dependent on biologic age. Improvement is
best visible on the forehead, jawlines, around the eyes and on the neck, according to its level
and the style of living lasts for about 4-6 months, in further process usually less sessions are
need to reach the same improvement.
Combinations with other methods are possible, some companies in the world even offer
devices for simultaneous application of CO2 gas and e.g. hyaluronic acid with vitamins
for rejuvenation or phosphatidylcholin/deoxychoate for lipolysis. However, because
of to distinguish what is more effective in particular patient, I tend to devide the applications,
e.g. the patient tries carrboxytherapy 1-4 sessions, if she is not satisfied, we choose another
technique. Carboxytherapy gives usually overall improvement of the skin and the result is
usually better if the whole face is treated as a complex. Mesotherapy by hyaluronic acid
injections tends to give more visible improvement of problematic area, however there are
usually some 3 days of healing. In the case of clinical ptosis of cheeks or eyelids plastic
surgery approach is indicated (or e.g. radiofrequency techniques).
Concerning to combinations with botulotoxin, usually it is not a problem, however we
apply in separate sessions. Very rarely decrease of the effect of botulotoxin can occur, if
carboxytherapy is applied in very short interval after botulotoxin (e.g. 14 days afterwards),
however it is very rare. Opinions on combinations with fillers vary, some colleagues hold
an opinion that the gas is potentionally able to destruct the filler, therefore also in combination
with hayluronic acid we apply the gas very superficially (however the gas is very „vivid“,
slight amount maybe always can get deeper) . Generally, with neocollagenesis and superficial
application, destruction of the filler is not clinically observable at all, in my praxis I do these
combinations normally, according to the indication and the patient´s interest. In the case
of long-lasting and permanent fillers some colleagues principally never apply carboxytherapy,
surely it is necessary to be careful and apply the gas superficially, but I do not regard such
fillers as strict contraindication of carboxytherapy, depends on the type of the filler and state.
Combinations with lasers and other light techniques do not matter.
In combination with so-called „threads“ (APTOS – anti-ptosis-threads and others)
carboxytherapy is performed normally, again it is advisable to stay with the gas as much
superficially as possible.
Another frequent indication of carboxytherapy in my group were scars. Reached
improvement , if the evoking moment doesn´t last (e.g. in acné) is longlasting or permanent.
Posttraumatic scars were treated in 31 pacients, post-acné scars in 18 pacients. The oldest

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scar was nearly 65 years old (from the time of the World War II), the age of the youngest
scars was around 2 months. Even in cases of demanding patients, insisting on very early
treatment (psychological, social reasons) I try not to begin with carboxytherapy too soon,
the method accelerates the wounds´ healing process indeed, but in just healed scars the
pressure of the gas does not need to influence necessarily well, in extreme case it could lead
even to widening still not firm scar. Therefore it is better in scars younger than 2 months
to use rather other approaches, biolaser or outer tools like silicagel. On more mature scars
carboxytherapy acts generally positively, however, depends on the type of the scar. The
treatment is performed usually once in 3-4 weeks (again because of the collagene rebuilding),
only on keloids more often.
We apply the gas by needle 30G (in keloids even 27,5G) according to the appearance of the
scar either very superficially into the scar in its direction (gas flow according to the location
and toughness of the skins from 30 to 60 ml/min), we observe immediate whitening of the
scar or its part, signaling that the amount of the gas in the part is sufficient. Sometimes
(on atrophic scars) it is desirable to reach rebuilding of the tissue under the scar, where often
pathological fibrosis is found, resulting in tightening of the bottom of the scar downwards.
Then we use the gas flow as mechanical „needle subcision“ (6,7) – (technique, when we cut
this fibrosis by the special needle with triangle edge, subsequent healing leads to
improvement of the shape – the surface lifts, however, further improvement often needs
repeating of the procedure). Mechanical subcision by the gas flow is more gentle, but is more
spread to the area, therefore on tough, deep fibroses it does not need to be fully efficient.
In so-called „normal“ scars (in the level of surrounding skin, 12 pacients) and atrophic
scars (decreased, 8 pacients) we can expect smoothing of the surface, often also thinning
of the scar, especially of scars of with less than cca 4 mm. On wider scars improvement does
not tend to be so visible. Especially on certain locations – e.g. forehead, nose – reached
improvement can very important for the patient (Fig. 1, 2).
In hypetrophic scars (upon the level of the surrounding skin, 5 pacients) reaction of the scar
is usually very good, even after one treatment bleaching and decrease of the surface is
visible, also the feeling of tightening which the patients sometimes refer before the therapy
diminishes or fades. Final number of the treatments is usually around 5.
In keloid scars (5 pacients) the application of the gas can be thanks to the toughness
of the scar unpleasant for the patient, however the effect is not high. The feeling of tightening
in the scar fades, the patient who was not able to touch the scar before now does not mind
the touch etc, however, improvement of scar appearance is not significant even after repetitive
treatments and therefore it is better to use other techniques (like traditional application
of corticoid injection in loco, eventually possibility discussed in the literature during last years
– surgical ablation of keloid with subsequet application of immunomodulator imiquimod 5%
into the wound (8,9)).
In acné scars (19 patients) again depends on the scar type. Superficial soft flat scars after
excoriations (3 patients) improves very well, however this type of laesions would improve
in time even itself, just with effective acné therapy, these are not scars in the proper meaning.
For patients it is usually stressful to wait during time when the scars are visible as red-purple
or pigmented patches, they demand the treatment and it is possible to use carboxytherapy.
In so-called. „saucer shape“ scars (8 patients), „ice pick“ scars (8 patients) and large pores
reached improvement was individual and let us say limited. Patients always saw at least slight
improvement though, however, this was generally not so significant for to be able to
recommend the treatment for general use. The therapy by ablative lasers (nowadays fractional
lasers more often) can reach better results. However, on certain ice pick scars and large pores
improvement was often visible very well and for the patient it was very satisfying.
Anecdotally it was shown that this improvement was usually less, if the patient used a make-

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up (collagen rebuilding lasts around 3 weeks, if there is a mass of make-up in the scar or in
the pore, probably it cannot be so easily shrung).
Striae (7 patients) we are not able to remove of course, however by collagen rebuilding
gradual smoothing and hardening of the surface is obtained, so also improvement of the area
appearance, although the stripe itself does not fade. The application is performed once in 3-4
weeks by the gas flow 50-70 ml/min, in numerous, fast, superficial puctures into stria. During
the application we observe „inflation“ of stria and its shortlasting bleaching. The method can
be used very well also on the breasts. Caution is necessary on lax, soft area – e.g. abdominal
area after repetitive pregnancies, here the tissue need not be able of desired reaction yet and
the effect can be minimal.
In  soft contouring of the body (27 patients) or of the face (13 patients) the application is
usually performend once in a week or 2 weeks depending on the size of the area and
toughness of the fat, coming reduction should be visible during 3-5 sessions, later it continues
depending on the state and the interest of the patient. Effect in this indication is less
predictable, in some persons it is excellent, on others minimal and does not depend directly
just on the subjects´ style of living or on the toughness of the fat. In era, when we have many
other techniques for facial and body contouring (electrolipolysis, many devices on ultrasound
or radiofrequency base, eventually injectional lipolysis and liposuctions) it is suitable to
indicate consciously and to inform frankly to avoid patient´s disillusion.
On the other hand in the treatment of so-called cellulite (fibrolipodystrophy) and
postliposuctional adhesions in despite of accessibility of numerous other methods (wrapping
techniques, mesotherapy or no-needle mesotherapy, endermology, radiofrequency)
carboxytherapy can be very appreciated. The gas flow (50-80 ml/min) not only improves
metabolism and local blood circulation, but has also mechanical influence leading
to demaging of thickened fibrous septae. It is necessary to do more sessions, because septae
have a tendency to fibrotize again. Mostly I perform one session per week, total number
of the sessions varies around 10, then the frequency goes down to once in 2 weeks and
gradually even less. Because cellulite is a secondary sexual character, improvement is not
lasting for long, approximately after half a year it is according to the state and patient´s
satisfaction useful to think either of repetition of the course (usually in less number of
sessions) or to try other method.
In treatment of postliposuctional adhesions depends on the level of fibrotisation, sometimes
also on the interval after the liposuction. The treatment of large superficial fibrotisation e.g.
in abdominal area can be quite unpleasant for the patient – the gas has no space to spread and
presses on fibrotic septae and adhesions, effect can be minimal. However, if the intensity
of fibrosis is not so massive and we reach instilation of bigger gas amounts, the effects can be
very nice and such improvement is real reward for the patient (Fig.3,4). It proves good here
to use rather the flow 70-80 ml/min, it is also good to work with antalgic effect of
carboxytherapy – the application is less unpleasant for the patient if we return e.g. after
5 minutes at the site already treated and apply again.
Concerning to wounds healing, with regard to the clientele of the clinic where I am
employed, unfortunately I had no posibility to use carboxytherapy on classic leg ulcers or
on diabetic foot. I used the method only on worse healing small post-excision wounds
(5 patients), however there was always immediate reaction – till the day after the treatment
there was slight exsudation according to the character of the wound, then pacification and
overall improvement (the redness faded, the wound got dry, filled up and epitelised (Fig.5,6)).
Colleagues working in dermatology departments in the country using carboxytherapy
for the treatment of leg ulcers refer surprising improvement and healing of even old defects,
irresponsive to any other treatment. In the treatment of wounds we apply the gas in flow

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40 ml/min in several puctures around the wound, on leg ulcers it is also effective to apply
along vena saphena magna.
From other dermatological indications I use the method in the treatment of defluvium and
alopecias. Here we benefit from the support of blood circulation and improvement
of the metabolism, therefore it is necessary to apply under the skin, not superficially, where
we could on the contrary stimulate collagen production. In alopecia areata we apply directly
into the areas, according to their size in one or more points, in defluvium we apply in 7 points
over the capillitium – on every side of the head 3 points and one in the centre. I do this
treatment usually once in 2 weeks, improvement – hair growth in the area usually comes
during 8-10 sessions (Fig.7,8). Patients often refer diminishing of hair falling already
after one treatment. However, overall improvement and its stability depends on the cause
of the illness. If the patient suffers from thyreopathy (even if with excellent compensation
in laboratory tests) or other endocrinological dysbalances, the effect of carboxytherapy can be
just slight.
Carboxytherapy has a good use even in the treatment of psoriasis. However, I tried
the method on only 2 psoriatic patients (and in one of them for the treatment was facial
rejuvenation, not psoriasis). Patients noticed paling of the patches after the treatment.
Unfortunately, in psoriasis more treatments are necessary – more than 10.
I had only one negative experience with carboxytherapy, when I naively tried to use it
for fresh Dermalive granuloma(this filler is not on Czech market already, contains hyaluronic
acid and copolymer of hydroxy-ethyl-methacrylate and ethyl-methacrylate), with intention
to destroy it by the gas flow, similarly like keloid. However, fast further grow of the
granuloma was a result. On the other hand in the other case, with stable post-Dermalive
granulomas lasting for 2 years (and not so upsetting for the patient, because they were still
filling the folds successfully), skin rejuvenation by carboxytherapy was repetitively done even
nearly upon granulomas and no their worsening occured.

Discussion: Although I use the older device Carbomed, numerous experiences are generally
valid. Indications of the method are wide. However, in the treatment it is necessary to count
with high variability of the effect, from very fast and excellent to slow and not very visible.
Concerning to skin rejuvenation and scars´ treatment - in larger sense effects connected with
collagen rebuilding, individual cell reaction based on biological age of the patient plays a role.
Currently we do not have any simple test of biological age assessment, calendar age is
misleading. We can have excellent result in 60years old patient and small or avarage effect
in 38years old. That is why, with aim to avoid patient´s disillusion, I keep in rejuvenation and
scars treatment the rule to try 2-4 sessions, however if improvement is not apparent,
I recommend to finish the treatment and turn the notice to other possible approaches. In so-
called cellulite, treatment of wounds, alopecias, psoriasis and contouring some improvement
should come during 4-6 sessions, again, if not, it is questionable to continue. The patient can
become even fixed to a new method and positive placebo effect can occur, sometimes
the patient insists that she sees improvement and pushes the doctor to continue, although
the improvement is not objectively visible. Here it is ethical to show on photos how is the real
state and explain the situation, with aim to avoid possible complaints later.
Compared to other techniques carboxytherapy has advantage especially in its natural base –
CO2 gas is normally present in the body, is hemosoluble, there is no risk of embolisation. One
session takes according to the number of treated areas and patient´s sensitivity 10-40 minutes
and the gas is very cheap. I apply the method even in compensated asthmatic patients, it
should not be applied to patients with acute embolism, trombophlebitis or phlebotrombosis,
liver or renal failure, after cerebral apoplexy, in serious ischemic heart disease,
decompensated hypertension, larger gangrenes. However, in individual cases we work always

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individually, after evaluation of risks and possible benefits, application can be done even very
gently and continue according to the effect. In South America they have good experiences
with carboxytherapy even in erysipel (diminishing of the swelling, faster regress
of the infection), the method can be very useful also in lymphedema (10). However,
pregnancy and nursering are contraindicated for carboxytherapy from legal reasons.
On the contrary to lasers and other light devices there is no contraindication of sunbathing
after the treatment. However, it is injectional technique and hence there is a possibility
of haematoma. Combinations with other methods are possible.
In Czech Republic some patients know the method from balneotherapy as „gas injections“.
Machines for balneotherapy (e.g.. Indap) are designed for application of fixed amount of gas
into one injectional point. In aesthetic medicine, where we need continuous gas flow
of adjustable speed, is hardly possible to use such machines, ease and variability of the use
of the method in all sorts of indications in different locations would totally disappeared.
Currently carboxytherapy spreads in western Europe and in the North America including
the USA, especially naturalness of the access is accentuated, together with absence of side
effects like irritation or pigment change and non-invasiveness of the method.

Conclusion: This communication about my experiences with carboxytherapy should be

benefiting for colleagues, who are beginning with the method or wish to get more information
about it. I believe, that in the field of skin rejuvenation, treatment of hypertrophic, narrow
„normal“ and atrophic scars and some types of acné scars, treatment of striae and so-called
cellulite and especially in the treatment of problematic wounds the method gradually gains its
stable place not only in the world, but also in our country.
For interested colleagues I recommend the web site of French physician Philippe Cadic –
http://www.carboxyworld.com, where it is possible to find many further information and also
short videos of application of carboxytherapy in different indication.

Literature:
1. Body, J.: La Carbocrenoterapie dans les affections arterielles. Paru dans Angeiologie 2000,
52:4, 71-75.
2. Ferreira, J.C.Tavares et al: Increase in Collagen Turnover Induced by Intradermal Injection
of Carbon Dioxide in Rats. J of Drugs in Dermatology 2008, 3: 201-206
3. Hinz, B et al: Mechanical Tension Controls Granulation Tissue Concractile Activity And
Myofibroblasts Differentiation. Am.J.of Pathology 2001,159:1009-1020
4. D´Arcangelo, D. et al.: Acidosis inhibits Endothelial Cell Apoptosis and Function and
Induces Basic Fibroblast Growth Factor and Vascular Endothelial Growth Factor Expression.
Circulation Research 2000, 86:312-318
5. Brandi, C. et al.: Carbon Dioxide Therapy in the Treatment of Localised Adiposities:
Clinical Study and Histopathological Correlations: Aesth. Plast. Surg. 2001, 25:170-174
6. Orentreich, D., Orentreich, N.: Subcutanous Incisionless (Subcision) Surgery for the
Correction of Depressed Scars and Wrinkles. Dermatol Surg 1995, 21:543-549
7. Alam, M. et al: Subcision for Acne Scarring: Technique and Outcomes in 40 Patients.
Dermatol Surg 2005, 31:310-317
8. Berman, B., Villa, A.: Imiquimod 5% Cream for Keloid Management. Dermatol Surg 2003,
29: 1050-1051
9. Stashower, M.: Successful Tratment of Earlobe Keloids with Imiquimod after Tangential
Shave Excision. Dermatol Surg 2006,32: 380-386
10. Varlaro, V. et al: Carboxytherapy: effects on microcirculation and its use in the treatment
of sever lymphedema. Acta Phlebol. 2007, 8:79-92

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Acknowledgement: The author thanks to Planmed company, Drásov-Skalka, Příbram, for
cover of expense for printing of colour photos for this article.

MUDr. Nina Koutná

e-mail: ninakoutna@hotmail.com