Journal of Cosmetic and Laser Therapy

ISSN: 1476-4172 (Print) 1476-4180 (Online) Journal homepage: http://www.tandfonline.com/loi/ijcl20

The clinical effectiveness and cost-effectiveness

of fractional CO2 laser in acne scars and skin
rejuvenation: A meta-analysis and economic
evaluation

Fereshteh Ansari, Fatemeh Sadeghi-Ghyassi & Barmak Yaaghoobian

To cite this article: Fereshteh Ansari, Fatemeh Sadeghi-Ghyassi & Barmak Yaaghoobian (2018):
The clinical effectiveness and cost-effectiveness of fractional CO2 laser in acne scars and skin
rejuvenation: A meta-analysis and economic evaluation, Journal of Cosmetic and Laser Therapy,
DOI: 10.1080/14764172.2017.1400173

To link to this article: https://doi.org/10.1080/14764172.2017.1400173

Published online: 31 Jan 2018.

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JOURNAL OF COSMETIC AND LASER THERAPY
https://doi.org/10.1080/14764172.2017.1400173

The clinical effectiveness and cost-effectiveness of fractional CO2 laser in acne scars
and skin rejuvenation: A meta-analysis and economic evaluation
Fereshteh Ansaria, Fatemeh Sadeghi-Ghyassib, and Barmak Yaaghoobianb
a
Iranian Evidence Based Center of Excellence, Tabriz University of Medical Sciences, Iran; bResearch Center for Evidence Based Medicine, Tabriz
University of Medical Sciences, Tabriz, Iran

ABSTRACT ARTICLE HISTORY

Introduction: Fractional CO2 has many indications in medicine including in treatment of acne scars and Received 26 October 2016
rejuvenation. The aim of this study was to evaluate the safety, efficacy, and cost-effectiveness of Fractional Accepted 29 October 2016
CO2 Laser in comparison with other methods of rejuvenation and acne scar treatment. Materials and KEYWORDS
Methods: Several databases including Medline, OVID, EMBASE, CINHAL, SCOPUS, Web of science, CRD, and Fractional CO2 laser;
Cochrane were searched. After conducting the search and evaluation of selected publications, critical rejuvenation; acne scar;
appraisal was done and eligible studies were accepted for inclusion in the systematic review. Results and systematic review
Discussion: From 2667 identified publications two of the trials were eligible. The effectiveness and compli-
cations of Fractional CO2 laser were comparable with Er:YAG but Fractional CO2 laser was 14.7% (p = 0.01)
more effective than Q-Switched ND:YAG laser. Cost affectivity of this method was the same as other
alternative lasers. In conclusion Fractional CO2 laser is an effective and safe method for curing of several
kinds of skin diseases. Nevertheless there was not sufficient evidence to support its advantage. This device
has equal or lower price in comparison to competent technologies except for the non- fractional ablative
CO2 laser that has the same or lower price and comparable effects.

Introduction
The CO2 laser have been developed in 1964 by Patel and collea-
gues (1). This laser can emit energy at wavelength of 10,600 nm
and the target chromophore of this laser is water. Water exists in
all kind of soft tissues and therefore CO2 laser can be applied for
both pigmented and non-pigmented tissues. Furthermore, a single
CO2 laser equipment can be applied for a variety of clinical
purposes from incision to vaporization and coagulation. The
irradiance of a laser beam decreases in an inverse square ratio to
the beam diameter, so the irradiance and intensity of the CO2 laser
equipment can be alternated by focusing and defocusing the
beams (changing the beam diameter) without any modification
of output power. These unique characteristics of CO2 laser made it
from the most popular and appropriate lasers for skin diseases (2).
This laser has been used widely in dermatology including
in the case of skin lesions (2,3), warts and toenail disease (2).
However patients may experience difficulties like oozing and
crusting in first few days and erythema, infection, pigmentary
changes and scarring later after laser therapy (4).
Mansion (2004) developed a new generation of CO2 laser
called fractional CO2 laser. In this new technique, laser beams
are fractionated into micro-beams which ablate the skin in the
shape of separated columns surrounded by normal unda-
maged skin so that reepithelization could be achieved faster
and with less complications (4).
One of the most popular indications of fractional CO2 laser
is in the case of acne scars (2,5,6). The overall prevalence of
acne is between 70% and 87% in the overall population (7).
Acne lesions affect around 90% of adolescent people and 12%
of older ones. The prevalence of acne scar is approximately
1% of the adults (8).
Fractional CO2 laser has also been used to treat facial
rhytids and photodamage since its first development in 2004
(5). Despite the wide and long lasting use of fractional CO2
laser in rejuvenation and acne scars there are not sufficient
documents to support its clinical application and preference
to other alternative medications. The aim of this review was to
evaluate the safety, efficacy, and cost- effectiveness of
Fractional CO2 Laser in comparison with other methods of
rejuvenation and acne scar treatment.
Materials and methods
We selected two most popular applications of fractional CO2
laser and designed the clinical questions based on them: (i) P:
patients with acne scars, I: fractional CO2 laser, C: other
methods of acne scar treatment, O: scar healing, complica-
tions of the treatment method and patient acceptability- (ii) P:
patients with wrinkles, I: fractional CO2 laser, C: other meth-
ods of rejuvenation, O: wrinkle healing, complications of
treatment method and patient acceptability.
Several databases including Medline (via pub med),
OVID, EMBASE, CINHAL, SCOPUS, Web of science,
CRD (HTA and NHS EED), and Cochrane (CENTRAL,

CONTACT Barmak Yaaghoobian yaghoobi.barmak@gmail.com Research Center for Evidence Based Medicine, School of Medicine, Tabriz University of Medical
Sciences, Tabriz, 5166614766 Iran.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/ijcl.
© 2018 Taylor & Francis Group, LLC
2 F. ANSARI ET AL.
DARE, and four other databases) were searched according
these two clinical questions. We also used Google and
Google Scholar search engines for finding other related
sites and matters. Hand searching was also conducted.
We did not limit our search by language and time and
searching the literature ended in October 2015.
All the selected materials at first step were evaluated
according inclusion and exclusion criteria. Inclusion cri-
teria were as followed: Randomized Clinical Trials (RCT),
systematic reviews, meta-analysis and economic evalua-
tions comparing fractional CO2 laser with other methods
in treatment of acne scars and skin wrinkles regarding
effectiveness and complications.
Publications which did not include the fractional CO2 laser
separately as a treatment arm and had combined other thera-
pies such as other optical techniques with fractional CO2 laser
were excluded.
Economic information and researches about fractional
CO2 laser were also considered in literature review.
Following keywords were selected according clinical
queries (Mesh terms, free language, synonyms and relate
terms were considered):
CO2 laser* OR Carbone Dioxide Laser*
Fraction*
“Lasers, Gas” (Mesh)
For restriction of search results to specific study types we
used subsequent keywords:
systematic review* OR technology assessment OR random*
OR randomized controlled trial OR technical report OR
(meta-analysis OR meta analysis) OR controlled clinical trial
OR compar* OR proceeding*
One specialist in medical librarian conducted the research
and two independent reviewers evaluated the selected publi-
cations. After all a critical appraisal was done regarding
Validity, Reliability and importance by two specialists in
health evaluation and evidenced based medicine.
Results and discussion
Safety and efficacy
The main complication observed in this method are tran-
sient erythema, Post Inflammatory Hyperpigmentation
(PIH) and moderate pain (7). One to 2 days after the
treatment procedure, patients can resume their normal
activities (8) and satisfactory effects of this method can
maintain for years (9).
For assessing the efficacy of this method a total of 2667
publications were identified and after exclusion of duplicate
and repeat records and screening titles, abstracts and full
texts, 3 clinical trials were selected (Figure 1).
These trials were evaluated through CASP (Critical
Appraisal Checklist for Systematic Review) international
worksheet and Cochrane Collaboration’s tool for assessing
risk of bias (Table 1). Regarding these evaluations 2 of
trials identified eligible for inclusion in the systematic
review. Summarized results of these articles are demon-
strated in Table 2.
The article of Cho (2010) was excluded due to high risk of
bias and small sample size.
In Manuskiatti et al. study, fractional CO2 laser was com-
pared with Er:YAG laser in treatment of atrophic acne scars in
20 female patients. The treatment effect which was assessed by
both physicians and patients, had not shown any difference
between two groups after one, three and six months of follow
up (p = 0.870).
There was no difference between two groups in Post-
inflammatory hyperpigmentation (p = 0.520) and other
main complications in follow up. Finally all kinds of compli-
cations were treated successfully.
In Asilian et al. study on 64 patients the comparison
performed between Q-Switched ND:YAG and fractional CO2
laser in treatment of acne scars in both groups, complications
were mild and transient. Both patients’ and physicians’ assess-
ment showed that the healing effect of CO2 laser is better than
Q-Switched ND:YAG laser (p-value<0.010).
Economical evaluation
From two alternatives of laser therapy introduced in
included trials Q-Switched Nd: YAG was left out from
cost effectiveness analysis because this method is not used
frequently for acne scar treatment and rejuvenation.
Considering the results of the remained study Er: YAG is
not significantly different from fractional CO2 laser regard-
ing effectiveness and complications therefore we just com-
pared the costs of laser devices and have not taken into
account benefits and effectiveness of these two treatment
methods. Price and conditions of these two laser devices
and other competent technologies are shown in Table 2.
The former version of CO2 lasers (none fractional ablative
CO2 laser) can also be compared with the fractional one. This
equipment has the same price (1285.71 €) and same warranty
conditions; furthermore, by using this device patients need
less treatment sessions to achieve satisfactory clinical conse-
quences. Nevertheless, it has more adverse effects and is not
routinely used for cosmetic purposes.
The results of this review indicate that fractional CO2 laser
therapy is a safe and effective method for treatment of acne
scars.
The safety of fractional CO2 laser was assessed in three
articles. In one of these articles evaluating facial rhytids,
hyperpigmentation, enlarged pores, skin laxity, and acne
scarring, 15 patients were treated and then biopsy specimens
were used to define efficacy of treatment method. At the end
of the study fourteen subjects achieved good to excellent
improvement in overall appearance and after 1 to 2 days
they were able to resume normal activities (12). In another
article on long-term efficacy of fractional CO2 laser in acne
scars and rejuvenation, 10 patients were followed for 1 to
2 years. Seventy four percent of these patients maintained
their overall improvement at their long-term visits compared
to 3-month follow-up visits (13). According the results of a
review performed on 26 articles published between 2003 and
2011, fractional CO2 laser can be introduced as a relatively
safe and effective technique. According the results of this
 JOURNAL OF COSMETIC AND LASER THERAPY 3

Figure 1. Flow diagram of systematic review.

the efficacy and complications of fractional CO2 laser are

Table 1. Bias risk evaluation of selected publications.
comparable with Er:YAG(11) but fractional CO2 laser was
Domain Cho (9) Asilian (10) Manuskiatti (11)
14.7% (p = 0.01) more effective than Q-Switched ND:YAG
Random sequence Low risk Unclear risk Low risk
generation (Selection bias) laser (11). Obviously we need more, well designed RCTs to
Allocation concealment Unclear risk Low risk Unclear risk show the efficiency of using this method of laser therapy for
(Selection bias) acne scars. One of the positive points of fractional CO2 laser is
Blinding of participants and High risk Low risk Unclear risk
personnel (Performance its ability to be applied for other therapeutic indications for
bias) example in vulvovaginal atrophy (15) and laparoscopic sur-
Blinding of outcome Low risk Low risk Low risk geries (2).
assessment (Detection
bias) The price of the fractional CO2 laser equipment is
Incomplete outcome data Low risk Unclear risk Low risk almost the same as or cheaper than similar devices includ-
(attrition bias)
Selective reporting Low risk Low risk Low risk
ing Er: YAG. As we explained earlier fractional CO 2 laser
(Reporting bias) and Er: YAG are clinically equivalent and there are not
Other sources of bias High risk Unclear risk Low risk sufficient documents to support fractional CO2 laser clin-
ical preference. In conclusion fractional CO2 laser can’t be
introduced as a cost effective technique especially with
review the most common complications of this method are respect to cosmetic indications.
as follows: Erythema (experienced in 1–3 days after treat- We were not able to gather suitable RCTs about the frac-
ment and resolves within 1 week, Post Inflammatory tional CO2 laser and rejuvenation therefore we should wait for
Hyperpigmentation (PIH) (experienced by up to 13% of more acceptable RCTs in this field.
patients which resolves within a week) and moderate In conclusion however fractional CO2 laser is an effective
pain (14). and safe technique for treatment of several kinds of skin
We found just two eligible RCTs regarding efficacy of diseases there are not sufficient clinical studies and documents
fractional CO2 laser. The findings of these studies show that to support its advantage over other techniques. Regarding the
4 F. ANSARI ET AL.

Table 2. Price and characteristics of fractional CO2 laser and its competent technologies.
Laser device Equivalent Price (€) Other costs Warranty Requiring Piece replacement Other applications
Fractional CO2 laser 12,857.1 to 85,714.3 – Exchanging: 1 month After 10–20 years Yes
Repairmen: 10 years (For example in atrophic
Vaginitis[13])
Non Fractional CO2 laser 12,857.1 – Exchanging: 1 year After 10 years 1week medical leave after treatment
Repairmen: 10 years
Er:YAG laser 32,857.1 – Exchanging: 1 year After 10 years routine application in Acne scars
Repairmen: 10 years and skin
Rejuvenation
Nd:YAG laser 42,857.1 – Exchanging: 1 year After 10 years No routine application in Acne scars
Repairmen: 10 years and skin
Rejuvenation. Only for research
intense pulsed light 8000 to 9142.8 – Exchanging: 1 year After 50,000 to 60,000 usage Only in very mild cases of Acne scars
Repairmen: 10 years and skin
Rejuvenation. The ordinary
application is hair removal

price of fractional CO2 laser device the main cost effectiveness
of the technique may be due to less treatment sessions needed
to achieve satisfactory clinical consequences.
Declaration of interest
The authors declare that they have no conflict of interest.
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