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Carbon dioxide laser treatment is an effective means of alleviating photo-aging and mild scarring and of removing solitary cutaneous lesions. This activity reviews the indications and techniques for carbon dioxide laser skin resurfacing and highlights the role of the interprofessional healthcare team in evaluating and treating patients who undergo carbon dioxide laser resurfacing. Objectives: Identify the indications and contraindications for carbon dioxide laser resurfacing. Describe the equipment, personnel, preparation, and technique required to perform carbon dioxide laser resurfacing. Review the potential complications of carbon dioxide laser resurfacing. Outline interprofessional team strategies for improving care coordination and communication to improve outcomes of carbon dioxide laser resurfacing. Access free multiple choice questions on this topic.

Carbon dioxide (CO2) lasers have been in use since the 1960s; they were initially used primarily for cutting and destruction of tissue, employing a continuous wave mode that ablates tissue to a depth of 400-500 μM. This modality was used across a broad range of clinical applications, such as the treatment of cervical intraepithelial neoplasia and upper eyelid blepharoplasty.[1][2] In the 1990s, CO2 laser technology evolved, resulting in high-energy pulsed CO2 lasers that ablate tissue at a more superficial depth, between 20 and 100 μM, while minimizing thermal injury to deeper tissue. These high-energy pulsed CO2 lasers are particularly useful for less aggressive applications, including cutaneous resurfacing. Further advancing the state of the art, fractional CO2 laser delivery systems were subsequently introduced in 2004. Fractional treatment involves splitting the laser beam into a large number of microbeams, which creates columns of ablation through the skin surrounded by normal, undamaged tissue. This treatment modality may provide an improved side effect profile compared with non-fractional treatment, particularly with respect to avoiding dyspigmentation after treating patients with darker skin.[3][4]

The typical post-procedure course involves the development of erythema, peeling, and skin fragility, which can last for up to 3 months after the treatment. Short-term complications of treatment include the formation of milia and acneiform eruptions in the treated area. Herpes simplex virus reactivation may also occur, for which prophylactic valacyclovir should be given in patients with a known history of herpes simplex virus infection.[12] Any procedure carries the risk of infection. Bacterial and fungal infections are less commonly seen after CO2 laser resurfacing due to "thermal sterilization" but are often seen in the setting of prolonged use of occlusive dressings, which should generally be removed 48 hours after the procedure. Changes in pigmentation, both hyperpigmentation and hypopigmentation, are also common. The risk of these changes is increased in Fitzpatrick skin types III-VI compared with types I-II. Hyperpigmentation is more likely to be self-limited than hypopigmentation; hyperpigmentation is also, fortunately, the more common sequela. Bleaching preparations and chemical peels may be used to reduce the appearance of hyperpigmentation, either prophylactically or therapeutically. Hypopigmentation is more common with the use of CO2 lasers than with other laser types due to the degree of thermal injury and subsequent inflammation that occurs; this complication can be very difficult to treat. Common methods of addressing hypopigmentation include fractionated CO2 laser treatment, blue lasers or intense pulsed light, and ultraviolet light exposure.[18]

The provision of care by an interprofessional team can increase the likelihood of achieving optimal outcomes for patients. Patient education regarding pre- and post-procedure care, as well as expectations for outcomes, can improve overall satisfaction with treatment as well as aesthetic outcomes.[19][Level 4] When CO2 laser resurfacing is employed in conjunction with other surgical modalities, such as face-lifts and blepharoplasty, laser operators and cosmetic surgeons should follow a team-based approach to improve communication, reduce patient confusion, and maximize long-term outcomes.