Next Article in Journal
Endoscopic Forehead Lifting with a Novel Polymer Fixation Peg: A Case Series and Narrative Review
Previous Article in Journal
Present and Future Trends of Aesthetic Medicine
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
J. Aesthetic Med.
Volume 1
Issue 1
10.3390/jaestheticmed1010002
jaestheticmed-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Fractional CO2 Laser for Acne Scar Treatment: A Comparative Analysis of Ablative vs. Combined Ablative and Non-Ablative Modalities

by
Arminda Avdulaj
1,*,
Shaked Menashe
2,
Yoad Govrin-Yehudain
2,
Eran Hadad
2,
Sharon Moscovici
2,
Omer Dor
2 and
Lior Heller
2
1
San Luca Medical Clinic, Rruga e Kavajës 50, 1001 Tiranë, Albania
2
Department of Adult and Pediatric Plastic, Aesthetic and Reconstructive Surgery, Shamir Medical Center, Be’er Ya’akov 70300, Israel
*
Author to whom correspondence should be addressed.
J. Aesthetic Med. 2025, 1(1), 2; https://doi.org/10.3390/jaestheticmed1010002
Submission received: 15 April 2025 / Revised: 23 May 2025 / Accepted: 26 May 2025 / Published: 2 June 2025
Browse Figures
Versions Notes

Abstract

As acne scars remain challenging to treat, this study compared the safety and efficacy of two laser modalities for acne scar treatment. Between 2022 and 2024, 88 patients were treated for acne scars using either the Hybrid platform with the ProScan applicator, which delivers fractional ablative carbon dioxide (CO2) 10,600 nm and non-ablative 1570 nm wavelengths in a dual mode, or the Pixel CO2 laser with the LiteScan applicator, which delivers a fractional ablative CO2 10,600 nm wavelength alone. Clinical efficacy was assessed using the Echelle d’Evaluation Clinique des Cicatrices D’Acne (ECCA) scale. Both groups showed significant improvements in ECCA scores post-treatment (p < 0.001, Wilcoxon signed-rank test). However, the percentage change in scores from baseline to post-treatment did not differ significantly between the groups (p > 0.05, Wilcoxon rank-sum test). Adverse effects were mild and transient, resolving within a few days, with no significant differences between the groups (p > 0.05, chi-squared test). Both laser modalities demonstrated high efficacy and safety in treating acne scars, with significant post-treatment improvement in scar severity.

1. Introduction

Acne vulgaris is one of the most common inflammatory skin conditions. It primarily affects the face but can involve the chest, back, and shoulders [1]. Due to its relapsing and persistent nature, acne may qualify as a chronic disease as defined by the World Health Organization and the U.S. Centers for Disease Control and Prevention [2]. A major consequence of acne is the formation of scars, affecting up to 95% of patients [3,4]. Scarring is a consistent reminder of past episodes and has a profound impact on quality of life, undermining self-confidence and provoking emotional distress [5,6]. In fact, the psychological and functional burden associated with acne scarring is comparable to that of debilitating chronic diseases such as asthma and epilepsy [2]. Acne scars result from disruptions in the wound-healing process. Typically, this process begins with inflammation, followed by proliferation and tissue remodeling [4,7]. These phases involve the migration of various cell types into the wound, angiogenesis, and the reforming of the extracellular matrix (ECM) [8,9,10]. When this process is disrupted, an imbalance between collagen production and degradation occurs. Excessive collagen production produces hypertrophic or keloid scars, while insufficient collagen production produces atrophic scars [11,12,13]. Most acne scars are atrophic, whereas hypertrophic or keloid scars are less common [4,6]. Due to the variety of scar types, their three-dimensional aspect, and their evolution over time, the assessment of acne scars is a challenge that can hinder clinical management. Among the various grading systems used, the Echelle d’Evaluation Clinique des Cicatrices D’Acne (ECCA) scale is a quantitative validated framework, with high interobserver reliability [14]. The ECCA grading scale categorizes six specific scar types, each assigned a semi-quantitative score (0–4) and a weighting factor (15–50) to reflect their severity and clinical impact. The overall scar grade is calculated by multiplying the semi-quantitative score by the weighting factor. Two subgrades are defined: one for four atrophic characteristics (V-shaped, U-shaped, M-shaped, and superficial elastolysis) and another for two hypertrophic/keloid characteristics (hypertrophic inflammatory and keloid scars). The total score, referred to as the global ECCA score, is obtained by summing the subgrades and ranges from 0 to 540 [15].
A wide range of effective methods for reducing acne scars are available depending on the type of scar, its location, and the depth of the lesions [4,7]. The primary focus is on delivering treatments with minimal side effects, enabling patients to quickly resume their daily activities [7]. Energy-based devices are an attractive non-invasive alternative that offers an effective, low-risk therapy for most types of atrophic acne scars [6,16]. Ablative lasers deliver high energy to the skin, superheating water molecules in the epidermis and vaporizing skin cells in a peeling effect. Below the vaporization zone, thermal damage stimulates skin cells to produce new collagen [13]. The CO2 laser has proven effective for various dermatologic conditions, including acne scars [17]. CO2 lasers operate at a wavelength of 10,600 nm, which is strongly absorbed by water in intracellular tissues, allowing precise vaporization of superficial skin layers and controlled heating of dermal collagen. This process eliminates fragmented collagen and promotes the synthesis of new collagen, thereby improving scar appearance [13]. The energy is absorbed within the superficial 20–30 µm of skin, resulting in tissue ablation and the formation of a thermal necrosis zone that coagulates small blood vessels and lymphatics, initiating wound remodeling while reducing the risk of scarring [18]. Non-ablative lasers aim to improve acne scar treatment while minimizing downtime and side effects. They emit visible or infrared wavelengths that stimulate type I and III collagen by creating thermal coagulation in the dermis without damaging the epidermis. However, clinical improvement is often moderate [6]. Nevertheless, evidence suggests that non-ablative laser therapy may provide improvement in facial acne scars [19]. Fractional laser technology allows delivery of energy in a pixelated pattern, creating microscopic zones of thermal injury known as microthermal treatment zones (MTZs). It treats only a fraction of the skin surface by forming narrow columns of controlled thermal damage. This approach can be applied with both ablative lasers, which target the epidermis and dermis, and non-ablative lasers, which target only the dermis [4]. The surrounding unaffected tissue promotes rapid repair through epidermal stem cell regeneration and fibroblast-driven neo-collagenesis, leading to effective skin remodeling [20,21,22]. Despite the wide range of lasers available, acne scars remain challenging, and research into new strategies continues. Combination approaches have been proposed to optimize clinical outcomes [6], with several studies suggesting that the use of multiple laser wavelengths may improve results [7]. Combination therapies are often more effective than monotherapies, as scars may require a comprehensive approach that addresses multiple concerns, including volume restoration, tissue tightening, and collagen remodeling. This can potentially be achieved safely through the synergistic effects of a combination strategy [4]. As extensive literature supports the use of CO2 lasers for treating acne scars [13,17], this study evaluated the clinical outcomes of acne scar treatment using a dual-mode fractional laser modality combining ablative CO2 and non-ablative lasers, compared to a fractional ablative CO2 laser modality alone.

2. Materials and Methods

2.1. Study Design

This was a retrospective analysis of consecutive patients (≥16 years) attending for laser-based treatment of acne scars. Treatments were conducted at the San Luca Clinic in Tirana, Albania, between April 2022 and March 2024. The study was conducted in accordance with the Declaration of Helsinki, and all subjects provided written informed consent. Eligible individuals were subjects who had been diagnosed with acne scarring and who were not contraindicated for laser treatment, according to the manufacturer’s instructions for use. Exclusion criteria included acute or chronic local infections, diabetes mellitus, bleeding disorders, a history of systemic autoimmune or oncologic conditions, a history of keloids, or a history of cancer.

2.2. Laser Devices

The Alma Pixel CO2 laser (Alma Lasers Ltd., Caesarea, Israel) is a fractional 10,600 nm CO2 laser system that combines ablative and thermal effects to treat various skin concerns. Its LiteScan Applicator is a microprocessor-controlled scanner that optimizes laser beam parameters for fractional ablation in various patterns and sizes [23]. In this study, the applicator was employed at a pulse duration of 1.6–1.8 milliseconds and a power setting of 20–27 watts.
The Alma Hybrid Platform with ProScan scanning applicator (Alma Hybrid, Alma Lasers Ltd.) enables the emission of 10,600 nm ablative and 1570 nm non-ablative wavelengths in a dual side-by-side fractional manner in a desired ratio. In this study, a ratio of 1:1 was used, indicating that each beam of the CO2 ablative laser was followed by a beam of 1570 nm non-ablative laser, with 50% of the pixels treated with CO2 and 50% with 1570 nm [24]. The study employed the 10,600 nm mode at a pulse duration of 1.6–1.8 msec and a power setting of 22–30 watts, and the 1570 nm mode at a pulse duration of 4 msec and a power setting of 10–12 watts.

2.3. Procedures

Prior to the first treatment session, the physician took 2D photographs of the treated area. Additionally, the physician evaluated the characteristics of the acne scars using the ECCA grading scale (20), based on semiquantitative, weighted assessments of the scars. Patients underwent two to six laser treatments at four-week intervals, based on the severity of the scarring, using the Alma Pixel CO2/LiteScan or Alma Hybrid/ProScan, as determined by the device availability at the patient’s first visit. This device was used for all the patient’s subsequent treatment sessions. All laser procedures were performed by the same surgeon. After disinfecting the target area, local anesthesia (lidocaine 100 mg/50 mL) was applied. Laser parameters were first set to the lowest possible setting and gradually adjusted to suit the size and thickness of the scar. Following treatment, the site was cleaned with antiseptics. All patients were informed about the anticipated post-treatment side effects, which included erythema or swelling at the treatment area, which were expected to resolve within one to three days with no intervention.
Follow-up evaluations were conducted six to twelve months following the last treatment session. During these visits, the physician photographed the treated area using the same settings as at baseline and re-scored the acne scar characteristics using the ECCA grading scale. Clinical efficacy was assessed by comparing the global ECCA score before and after treatment and evaluating the percentage change in the score, calculated using the formula (global ECCA score before treatment − global ECCA score after treatment)/global ECCA score before treatment) × 100. The safety was evaluated through the analysis of documentation on device- and procedure-related adverse events.

2.4. Statistical Analysis

The analysis was performed using R version 4.3.3. Statistical significance was defined as p < 0.05. Descriptive statistics provide a summary of the dataset. Continuous variables are reported as mean ± SD, and categorical variables as frequencies and percentages. Due to the non-parametric nature of the data, the choice of statistical tests was adjusted to ensure reliable analysis. The Wilcoxon signed-rank test was used to compare ECCA global scores before and after treatment within each group. For comparative analysis, the Wilcoxon rank-sum test was used to assess differences in efficacy between groups. The chi-squared test was used to evaluate differences in the incidence of adverse events between groups. Additionally, to assess the distribution of skin types between the Hybrid laser and CO2 laser groups, skin types were grouped into lighter types, including Fitzpatrick Types II and III, and darker types, including Types IV and V. A chi-squared test was performed to evaluate statistical significance. Percentages were also calculated to illustrate the proportion of lighter and darker skin types within each treatment group.

3. Results

All patients included in this analysis underwent laser treatment for acne scars. In total, 45 procedures were performed with the Hybrid laser device (Alma Hybrid/ProScan), and 43 procedures were performed with the Pixel CO2 laser device (Alma Pixel CO2/LiteScan). The distribution of patients’ age, gender, treated body area, number of treatment sessions, and skin type is presented in Table 1.

3.1. Clinical Efficacy

All 88 patients completed the treatments and returned for follow-up visits, and overall improvement was achieved with both ablative and combined ablative and non-ablative laser modalities after an average of four sessions. Figure 1 and Figure 2 show the aesthetic improvement observed following the Hybrid/ProScan and CO2/LiteScan treatments, respectively.
In the ProScan-treated group, the mean percentage change in global score was 69.4% ± 18.3 (mean ± SD), whereas in the LiteScan-treated group, the mean percentage change in global score was 64.7% ± 11.1 (mean ± SD). The statistical analysis demonstrated significant differences in global scores before and after treatment for both groups, with p-values < 0.001 (Wilcoxon signed-rank test). In the ProScan group, the mean global score decreased from 194 ± 80.3 (mean ± SD) at baseline to 60.6 ± 44.6 (mean ± SD) after the treatment, and in the LiteScan group, the mean global score decreased from 162 ± 50.6 (mean ± SD) at baseline to 59 ± 31 (mean ± SD) after treatment. The results are presented in Figure 3 and Figure 4.
Comparative outcomes between groups: Visible improvements in acne scar severity were observed after 7–8 weeks in the Hybrid/ProScan group, while results in the CO2/LiteScan group appeared after approximately 3 months. The statistical analysis revealed no significant difference in the percentage change in ECCA global scores from baseline to post-treatment between the groups, with p-value > 0.05 (Wilcoxon rank-sum test). The median percentage change was 66.7% (IQR: 55.3–88.7%) in the Hybrid/ProScan group and 61.1% (IQR: 58.1–71.8%) in the CO2/LiteScan group. Figure 5 presents the results.
When comparing the distribution of skin types between the treatment groups, the Hybrid group had 93.3% lighter skin types (Types II–III) and 6.7% darker skin types (Types IV–V), compared to 79.1% lighter and 20.9% darker skin types in the CO2 group. While these differences suggest a trend, the overall distribution of lighter and darker skin types between the two treatment groups was not statistically significant (chi-squared test, χ2 = 2.684, df = 1, p = 0.101).

3.2. Safety Assessment

No unanticipated adverse events (AEs) were reported in either treatment group. Anticipated treatment reactions observed in some patients were mild and transient erythema or post-inflammatory hyperpigmentation (PIH), which resolved within a few days. The frequency of these anticipated treatment reactions was calculated for both treatment groups. In the Hybrid/ProScan-treated group, the frequency was 15.56%, with 7 out of 45 participants experiencing side effects, while in the CO2/LiteScan-treated group, the frequency was 16.28%, with 7 out of 43 participants experiencing side effects. A chi-squared test indicated no statistically significant difference between the treatment groups in terms of side effects occurrence (p-value > 0.05). Recovery time was shorter in the Hybrid/ProScan-treated group, with the treatment generally being more tolerable and less painful compared to the CO2/LiteScan-treated group.

4. Discussion

This study demonstrates the high efficacy and safety of both laser devices in the treatment of acne scars, with significant improvement in post-treatment scar grading compared to baseline. Treatment with the Alma Hybrid/ProScan showed better improvement than the Pixel CO2/LiteScan, but the difference was not statistically significant. Nevertheless, the improvement in the Hybrid group was evident after a much shorter period of time. There were no AEs, and only mild and transient anticipated side effects were observed, with a low frequency in both groups and an even lower frequency in the Hybrid group, although not statistically significant. However, the recovery time was shorter, and the treatment was more tolerable in the Hybrid group than in the CO2 group for the same CO2 laser mode parameters. This suggests a potential trend toward improved safety and efficacy with the Hybrid device. With that said, it is important to note that lighter skin types (Types II and III) were more common in the Hybrid group, and darker skin types (Types IV and V) in the CO2 group. Although this difference was not statistically significant, this imbalance may challenge the suggested trend toward improved safety with the Hybrid device, as higher Fitzpatrick skin types are generally more susceptible to complications such as hyperpigmentation and scarring [26]. Further research is needed to substantiate these observations. These findings align with previous clinical trials demonstrating both the safety and efficacy of non-ablative and ablative fractional lasers for the treatment of acne scars, although different assessment scales have been used. For instance, Lu and Cai (2022) conducted a prospective split-face trial in 27 patients, comparing a 1927 nm non-ablative thulium laser with a 2940 nm ablative Er:YAG laser; both modalities achieved similar reductions in Goodman–Baron scar scores (≈ 35%) with only transient, mild side effects and no significant differences in efficacy or safety [27]. Moreover, combined therapy may further enhance outcomes and reduce downtime as Asri et al. (2019) reported that the combination of fractional CO2 and 1540 nm Erbium GaAs lasers led to statistically significant improvements in Goodman–Baron acne scar scores, with mild to moderate side effects in 50% of a 20-patient cohort [28].
Improvement rates for acne scars treated with ablative laser resurfacing, as measured by the ECCA scale, can vary, typically ranging from 40% to as high as 75%. While higher rates of improvement are possible, they may be associated with a greater likelihood of adverse events. For example, Dai et al. (2023) investigated the comparative efficacy and safety of Nd:YAG picosecond lasers (P-MLA) and ablative fractional 2940 nm Er:YAG lasers (AF-Er) in a controlled, split-face study with ECCA percent reductions recorded at 39.11% for picosecond lasers and 43.73% for ablative fractional lasers [29]. Similarly, Ding et al. (2024) achieved a 60% improvement in 68 patients with facial acne scars treated with fractional CO2 laser [30]. Additionally, Zhang et al. (2013), in a randomized split-face design, evaluated thirty-three Asian patients treated for acne scars and reported ECCA score reductions of 56.4% for microplasma radio-frequency technology and 59.2% for the fractional CO2 laser system [31]. Yuan et al. compared the effects of different fluences and densities in fractional CO2 laser treatment of acne scars in 20 patients. Using the ECCA grading scale, results showed up to 75% improvement with higher densities or fluences. However, side effects were more pronounced and lasted longer in patients treated with higher densities or fluences [32]. In the current study, the improvements in ECCA scores (means of 69.4% and 64.7% for LiteScan and ProScan, respectively) were relatively high compared to those reported in the literature. Given the high safety profile demonstrated by both devices with no associated adverse events, these improvement rates are remarkable.
An exaggerated wound-healing response is closely associated with acne scarring [33]. Wound repair includes re-epithelialization, angiogenesis, and remodeling of the ECM—a dynamic network of macromolecules and proteolytic enzymes that, along with cells such as fibroblasts, endothelial cells, and keratinocytes, form the skin [14]. Dysregulated ECM remodeling is considered to be a fundamental cause of scarring [5,9]. The ECM participates in wound healing and goes through direct and indirect interactions with growth factors such as fibroblast growth factor, vascular endothelial growth factor, epidermal growth factor, bone morphogenetic proteins, and transforming growth factor-β (TGF-β) [9,34], with the latter playing a central role in ECM remodeling [9,33,34,35,36]. TGF-β regulates the production of several ECM components, including collagens, the most abundant proteins of the ECM. Collagens form a relaxed network of cross-linked, long-chain fibers that provide the strength and elasticity of normal tissue [9]. It has been suggested that TGF-β promotes a compensatory recovery of collagen I over collagen III, thereby increasing the ratio of type I to type III collagen [37]. A low ratio of collagen I to collagen III in scarless fetal skin suggests that an adequate level of collagen III is critical to prevent scarring. Consistent with these findings, Moon et al. observed an elevated ratio of collagen I to collagen III, along with substantially higher levels of TGF-β1, in patients prone to acne scarring compared to those not prone to scarring. They proposed that these factors, leading to an unbalanced configuration of the ECM, may be at the root of atrophic acne scarring [5]. Restoring the dermal matrix to resemble unwounded tissue could improve scar quality, enhancing tensile strength and elasticity [9,34]. Ablative fractional resurfacing facilitates deep skin remodeling by penetrating to the low reticular dermis. It may reduce aberrant wound healing through the regulation of cytokine and growth factor secretion, promoting proper ECM organization [38,39]. The fractional pattern, characterized by the creation of microthermal treatment zones (MTZs), supports re-epithelialization and collagen remodeling by stimulating the adjacent unaffected skin [16,20,35]. Histological evidence from multiple studies has shown modulation of cytokines and other extracellular matrix components, including collagen remodeling, following fractional ablative CO2 laser treatment [40,41,42]. Specifically, in the case of acne scars, the fractional CO2 laser is well-established as an effective treatment, with numerous studies validating its efficacy [13,30,43,44,45,46,47]. In recent years, research efforts have mainly focused on optimizing treatment parameters [20,32] and exploring combination strategies with the CO2 laser to further enhance efficacy and safety [35,48,49].
The Hybrid/ProScan handpiece used in this study combines an ablative fractional laser (AFL) and a non-ablative fractional laser (NAFL) in a single modality. The combination of ablative and non-ablative lasers is recognized as an effective approach for improving cosmetic outcomes. This dual-energy technique utilizes the precision and efficacy of an ablative laser to target deep tissue and stimulate robust collagen remodeling alongside the gentler effects of a non-ablative laser, which support skin healing. Such synergistic effects have been widely documented across various dermatological conditions [50,51,52]. Specifically for the treatment of acne scars, Kim et al., in a split-face comparative study, used a non-ablative 1064 nm Nd:YAG laser treatment following an AFL CO2 laser treatment on one facial half and AFL CO2 laser treatment on the contralateral facial half in twenty subjects with mild to severe acne scars. Results showed that the combination of AFL treatment with NAFL treatment produced superior scar improvement with fewer complications than AFL treatment alone [53]. Recent advances in laser technology have further refined this concept by enabling the seamless integration of AFL and NAFL within a single device. This innovation not only preserves the proven benefits of combining these wavelengths in one treatment but also enhances treatment efficiency, safety, and convenience. For example, Belletti et al., in a pilot study, demonstrated that a dual-wavelength laser combining CO2 and 1540 nm effectively improved facial atrophic acne scars. Patients reported excellent to slight improvements, minimal side effects, short downtime (5.8 ± 0.5 days), and a low risk of scarring or hypopigmentation [54]. Similarly, Naranjo and Lopez demonstrated, in 16 patients, that a multimodal CO2 and 1570 nm laser system effectively improved facial acne scars. Reductions were observed in scar volume (47.0 ± 7.9% mm3) and affected area (43.2 ± 8.6% mm2). Additionally, high satisfaction and no serious adverse reactions were reported [55].
In this study, both the Hybrid and CO2 Pixel devices provided safe treatment options. Although the Hybrid laser device exhibited a slightly lower frequency of post-treatment reactions compared to the CO2 Pixel, the difference was not statistically significant. However, the Hybrid group experienced shorter recovery times, and the treatment was generally more tolerable and less painful compared to the Pixel group. While definitive conclusions about a superior safety profile for either device cannot be drawn, this study adds to the existing evidence supporting the efficacy of combining AFL and NAFL energies for treating acne scars. Based on previous research indicating a high safety profile for these treatments, we hypothesize that larger study groups will be necessary to more effectively investigate potential safety differences, particularly due to the low incidence of treatment side effects.
Limitations of this study included its retrospective design and the absence of a control group. Despite these limitations, statistically significant improvements in scarring were observed in both treatment groups, indicating that both devices were effective. An imbalance in skin type distribution between treatment groups may have influenced the results and should be considered when interpreting the findings. Further well-controlled, long-term studies are necessary to assess the safety, tolerability, and efficacy of laser-based therapies for the treatment of acne scarring. Future research should also incorporate objective measures to evaluate treatment outcomes more accurately and compare the performance of each device.

5. Conclusions

This study demonstrates that fractional CO2 laser devices provide safe and effective treatment options for the treatment of acne scars. Statistically significant improvements were observed in both groups following treatment with two different CO2 laser systems. The incorporation of a non-ablative fractional laser as part of the treatment may enhance both safety and efficacy, warranting further investigation in future research.

Author Contributions

Conceptualization, A.A.; methodology, A.A.; investigation, A.A., S.M. (Shaked Menashe), Y.G.-Y., E.H., S.M. (Sharon Moscovici), O.D., and L.H.; resources, A.A., S.M. (Shaked Menashe), Y.G.-Y., E.H., S.M. (Sharon Moscovici), O.D., and L.H.; writing—original draft preparation, A.A.; writing—review and editing, S.M. (Shaked Menashe), Y.G.-Y., E.H., S.M. (Sharon Moscovici), O.D., and L.H. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Shamir Medical Center, Approval # 0083-23-ASF, date: 20 June 2023.

Informed Consent Statement

Informed consent was obtained from all individual participants included in the study. The authors affirm that human research participants provided informed consent for the publication of the images in Figure 1 and Figure 2.

Data Availability Statement

The original data presented in the study are openly available and were provided as part of the submitted data materials.

Acknowledgments

The authors acknowledge the statistical analysis and text editing services of Merav Cohen. The authors have reviewed and edited the output and take full responsibility for the content of this publication.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
ECCAEchelle d’Evaluation Clinique des Cicatrices D’Acne
NAFLNon-ablative fractional laser
AFLFractional laser
ECMExtracellular matrix
MTZMicrothermal treatment zone
PIHPost-inflammatory hyperpigmentation
TGF-βTransforming growth factor-β
AEAdverse event
CO2Carbon dioxide
SDStandard deviation

References

  1. Wilcock, J.; Kuznetsov, L.; Ravenscroft, J.; Rafiq, M.I.; Healy, E. New NICE Guidance on Acne Vulgaris: Implications for First-Line Management in Primary Care. Br. J. Gen. Pract. 2021, 71, 568–570. [Google Scholar] [CrossRef] [PubMed]
  2. Layton, A.M.; Gupta, G.; Seukeran, D.; Maruthappu, T.; Gaillard, S.; Whitehouse, H.; Ali, F.R.; Razzaque, A.; Al-Niaimi, F.; Copperwheat, S. What’s New After NICE Acne Guidelines. Dermatol. Ther. 2024, 14, 2727–2738. [Google Scholar] [CrossRef] [PubMed]
  3. Xu, W.; Sinaki, D.G.; Tang, Y.; Chen, Y.; Zhang, Y.; Zhang, Z. Acne-Induced Pathological Scars: Pathophysiology and Current Treatments. Burn. Trauma 2024, 12, tkad060. [Google Scholar] [CrossRef]
  4. Bhargava, S.; Cunha, P.R.; Lee, J.; Kroumpouzos, G. Acne Scarring Management: Systematic Review and Evaluation of the Evidence. Am. J. Clin. Dermatol. 2018, 19, 459–477. [Google Scholar] [CrossRef]
  5. Moon, J.; Yoon, J.Y.; Yang, J.H.; Kwon, H.H.; Min, S.; Suh, D.H. Atrophic Acne Scar: A Process from Altered Metabolism of Elastic Fibres and Collagen Fibres Based on Transforming Growth Factor-β1 Signalling. Br. J. Dermatol. 2019, 181, 1226–1237. [Google Scholar] [CrossRef]
  6. Sadick, N.S.; Cardona, A. Laser Treatment for Facial Acne Scars: A Review. J. Cosmet. Laser Ther. 2018, 20, 424–435. [Google Scholar] [CrossRef]
  7. Chilicka, K.; Rusztowicz, M.; Szyguła, R.; Nowicka, D. Methods for the Improvement of Acne Scars Used in Dermatology and Cosmetology: A Review. J. Clin. Med. 2022, 11, 2744. [Google Scholar] [CrossRef] [PubMed]
  8. Karppinen, S.-M.; Heljasvaara, R.; Gullberg, D.; Tasanen, K.; Pihlajaniemi, T. Toward Understanding Scarless Skin Wound Healing and Pathological Scarring. F1000Research 2019, 8, 787. [Google Scholar] [CrossRef]
  9. Xue, M.; Jackson, C.J. Extracellular Matrix Reorganization During Wound Healing and Its Impact on Abnormal Scarring. Adv. Wound Care 2015, 4, 119–136. [Google Scholar] [CrossRef]
  10. Fernández-Guarino, M.; Hernández-Bule, M.L.; Bacci, S. Cellular and Molecular Processes in Wound Healing. Biomedicines 2023, 11, 2526. [Google Scholar] [CrossRef]
  11. Kurokawa, I.; Layton, A.M.; Ogawa, R. Updated Treatment for Acne: Targeted Therapy Based on Pathogenesis. Dermatol. Ther. 2021, 11, 1129–1139. [Google Scholar] [CrossRef] [PubMed]
  12. Liu, L.; Xue, Y.; Chen, Y.; Chen, T.; Zhong, J.; Shao, X.; Chen, J. Prevalence and Risk Factors of Acne Scars in Patients with Acne Vulgaris. Ski. Res. Technol. 2023, 29, e13386. [Google Scholar] [CrossRef]
  13. Xu, Y.; Deng, Y. Ablative Fractional CO2 Laser for Facial Atrophic Acne Scars. Facial Plast. Surg. 2018, 34, 205–219. [Google Scholar] [CrossRef]
  14. Clark, A.K.; Saric, S.; Sivamani, R.K. Acne Scars: How Do We Grade Them? Am. J. Clin. Dermatol. 2018, 19, 139–144. [Google Scholar] [CrossRef]
  15. Dreno, B.; Khammari, A.; Orain, N.; Noray, C.; Mérial-Kieny, C.; Méry, S.; Nocera, T. ECCA Grading Scale: An Original Validated Acne Scar Grading Scale for Clinical Practice in Dermatology. Dermatology 2007, 214, 46–51. [Google Scholar] [CrossRef] [PubMed]
  16. Salameh, F.; Shumaker, P.R.; Goodman, G.J.; Spring, L.K.; Seago, M.; Alam, M.; Al-Niaimi, F.; Cassuto, D.; Chan, H.H.; Dierickx, C.; et al. Energy-Based Devices for the Treatment of Acne Scars: 2022 International Consensus Recommendations. Lasers Surg. Med. 2022, 54, 10–26. [Google Scholar] [CrossRef] [PubMed]
  17. Chapas, A.M.; Brightman, L.; Sukal, S.; Hale, E.; Daniel, D.; Bernstein, L.J.; Geronemus, R.G. Successful Treatment of Acneiform Scarring with CO 2 Ablative Fractional Resurfacing. Lasers Surg. Med. 2008, 40, 381–386. [Google Scholar] [CrossRef]
  18. Meghe, S.R.; Khan, A.; Jangid, S.D.; Sarda, B.; Vangala, N.; Saoji, V. Shedding Light on Acne Scars: A Comprehensive Review of CO2 vs. Erbium-Doped Yttrium Aluminium Garnet (Er:YAG) Laser Therapy. Cureus 2024, 16, e57572. [Google Scholar] [CrossRef]
  19. Kubik, P.; Bighetti, S.; Bettolini, L.; Gruszczyński, W.; Łukasik, B.; Guida, S.; Stabile, G.; Murillo Herrera, E.M.; Carugno, A.; D’Este, E.; et al. Effectiveness and Safety of the Use of 1470 Nm Laser Therapy in Patients Suffering From Acne Scarring of the Facial Skin. Clin. Cosmet. Investig. Dermatol. 2025, 18, 543–551. [Google Scholar] [CrossRef]
  20. Laubach, H.-J.; Tannous, Z.; Anderson, R.R.; Manstein, D. Skin Responses to Fractional Photothermolysis. Lasers Surg. Med. 2006, 38, 142–149. [Google Scholar] [CrossRef]
  21. Hantash, B.M.; Mahmood, M.B. Fractional Photothermolysis: A Novel Aesthetic Laser Surgery Modality. Dermatol. Surg. 2007, 33, 525–534. [Google Scholar] [CrossRef]
  22. Arsiwala, S.Z.; Desai, S.R. Fractional Carbon Dioxide Laser: Optimizing Treatment Outcomes for Pigmented Atrophic Acne Scars in Skin of Color. J. Cutan. Aesthet. Surg. 2019, 12, 85–94. [Google Scholar] [CrossRef] [PubMed]
  23. Trelles, M.A.; Shohat, M.; Urdiales, F. Safe and Effective One-Session Fractional Skin Resurfacing Using a Carbon Dioxide Laser Device in Super-Pulse Mode: A Clinical and Histologic Study. Aesthetic Plast. Surg. 2011, 35, 31–42. [Google Scholar] [CrossRef] [PubMed]
  24. Shenhav, L.T.; Shehadeh, W.; Alcotzer, I.; Artzi, O. Hybrid Fractional Laser Facial Resurfacing: A Comparison between a Single Treatment at High Settings versus Multiple Treatments at Low to Moderate Settings. Lasers Surg. Med. 2024, 56, 68–74. [Google Scholar] [CrossRef]
  25. Fitzpatrick, T.B. The Validity and Practicality of Sun-Reactive Skin Types I through VI. Arch. Dermatol. 1988, 124, 869–871. [Google Scholar] [CrossRef] [PubMed]
  26. Sharma, A.N.; Patel, B.C. Laser Fitzpatrick Skin Type Recommendations. In StatPearls; StatPearls Publishing: Treasure Island, FL, USA, 2025. [Google Scholar]
  27. Lu, K.; Cai, S. Efficacy and Safety Comparison between 1927 Nm Thulium Laser and 2940 Nm Er:YAG Laser in the Treatment of Facial Atrophic Acne Scarring: A Prospective, Simultaneous Spilt-Face Clinical Trial. Lasers Med. Sci. 2022, 37, 2025–2031. [Google Scholar] [CrossRef]
  28. Asri, E.A.; Widayati, R.I.; Malik, D.A. Effectiveness of Combined 10,600 Nm Fractional CO2 and 1540 Nm Erbium GaAs Laser Therapy on Acne Scar Score Alteration in Patients with Atrophic Acne Scars. Turk. J. Dermatol. 2019, 13, 126. [Google Scholar] [CrossRef]
  29. Dai, R.; Cao, Y.; Su, Y.; Cai, S. Comparison of 1064-Nm Nd:YAG Picosecond Laser Using Fractional Micro-Lens Array vs. Ablative Fractional 2940-Nm Er:YAG Laser for the Treatment of Atrophic Acne Scar in Asians: A 20-Week Prospective, Randomized, Split-Face, Controlled Pilot Study. Front. Med. 2023, 10, 1248831. [Google Scholar] [CrossRef]
  30. Ding, Z.; Pan, Z.; Tang, Y.; Wang, S.; Hua, H.; Hou, Z.; Zhou, B. Effectiveness and Safety of the Modified Multiple Mode Procedures versus Traditional Multiple Mode Procedures on Treating Facial Atrophic Acne Scars: A Propensity Score Matching Retrospective Cohort Study. Lasers Med. Sci. 2024, 39, 260. [Google Scholar] [CrossRef]
  31. Zhang, Z.; Fei, Y.; Chen, X.; Lu, W.; 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. 2013, 39, 559. [Google Scholar] [CrossRef]
  32. Yuan, X.-H.; Zhong, S.-X.; Li, S.-S. 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. 2014, 40, 545–552. [Google Scholar] [CrossRef] [PubMed]
  33. Jennings, T.; Duffy, R.; McLarney, M.; Renzi, M.; Heymann, W.R.; Decker, A.; Lawrence, N. Acne Scarring-Pathophysiology, Diagnosis, Prevention and Education: Part I. J. Am. Acad. Dermatol. 2024, 90, 1123–1134. [Google Scholar] [CrossRef]
  34. Schultz, G.S.; Wysocki, A. Interactions between Extracellular Matrix and Growth Factors in Wound Healing. Wound Repair Regen. 2009, 17, 153–162. [Google Scholar] [CrossRef]
  35. Mu, Y.-Z.; Jiang, L.; Yang, H. The Efficacy of Fractional Ablative Carbon Dioxide Laser Combined with Other Therapies in Acne Scars. Dermatol. Ther. 2019, 32, e13084. [Google Scholar] [CrossRef]
  36. Varga, J.; Rosenbloom, J.; Jimenez, S.A. Transforming Growth Factor β (TGFβ) Causes a Persistent Increase in Steady-State Amounts of Type I and Type III Collagen and Fibronectin mRNAs in Normal Human Dermal Fibroblasts. Biochem. J. 1987, 247, 597–604. [Google Scholar] [CrossRef] [PubMed]
  37. Creely, J.J.; DiMari, S.J.; Howe, A.M.; Haralson, M.A. Effects of Transforming Growth Factor-Beta on Collagen Synthesis by Normal Rat Kidney Epithelial Cells. Am. J. Pathol. 1992, 140, 45–55. [Google Scholar]
  38. Carniol, P.J.; Hamilton, M.M.; Carniol, E.T. Current Status of Fractional Laser Resurfacing. JAMA Facial Plast. Surg. 2015, 17, 360–366. [Google Scholar] [CrossRef] [PubMed]
  39. Nowak, K.C.; McCormack, M.; Koch, R.J. The Effect of Superpulsed Carbon Dioxide Laser Energy on Keloid and Normal Dermal Fibroblast Secretion of Growth Factors: A Serum-Free Study. Plast. Reconstr. Surg. 2000, 105, 2039–2048. [Google Scholar] [CrossRef]
  40. Tretti Clementoni, M.; Galimberti, M.; Tourlaki, A.; Catenacci, M.; Lavagno, R.; Bencini, P.L. Random Fractional Ultrapulsed CO2 Resurfacing of Photodamaged Facial Skin: Long-Term Evaluation. Lasers Med. Sci. 2013, 28, 643–650. [Google Scholar] [CrossRef]
  41. Clementoni, M.T.; Lavagno, R.; Munavalli, G. A New Multi-Modal Fractional Ablative CO2 Laser for Wrinkle Reduction and Skin Resurfacing. J. Cosmet. Laser Ther. 2012, 14, 244–252. [Google Scholar] [CrossRef]
  42. Prignano, F.; Campolmi, P.; Bonan, P.; Ricceri, F.; Cannarozzo, G.; Troiano, M.; Lotti, T. Fractional CO2 Laser: A Novel Therapeutic Device upon Photobiomodulation of Tissue Remodeling and Cytokine Pathway of Tissue Repair. Dermatol. Ther. 2009, 22 (Suppl. S1), S8–S15. [Google Scholar] [CrossRef] [PubMed]
  43. Li, B.; Ren, K.; Yin, X.; She, H.; Liu, H.; Zhou, B. Efficacy and Adverse Reactions of Fractional CO2 Laser for Atrophic Acne Scars and Related Clinical Factors: A Retrospective Study on 121 Patients. J. Cosmet. Dermatol. 2022, 21, 1989–1997. [Google Scholar] [CrossRef] [PubMed]
  44. Chan, N.P.Y.; Ho, S.G.Y.; Yeung, C.K.; Shek, S.Y.N.; Chan, H.H. Fractional Ablative Carbon Dioxide Laser Resurfacing for Skin Rejuvenation and Acne Scars in Asians. Lasers Surg. Med. 2010, 42, 615–623. [Google Scholar] [CrossRef]
  45. Majid, I.; Imran, S. Fractional CO2 Laser Resurfacing as Monotherapy in the Treatment of Atrophic Facial Acne Scars. J. Cutan. Aesthetic Surg. 2014, 7, 87–92. [Google Scholar] [CrossRef]
  46. Qian, H.; Lu, Z.; Ding, H.; Yan, S.; Xiang, L.; Gold, M.H. Treatment of Acne Scarring with Fractional CO 2 Laser. J. Cosmet. Laser Ther. 2012, 87, 162–165. [Google Scholar] [CrossRef]
  47. Reinholz, M.; Schwaiger, H.; Heppt, M.; Poetschke, J.; Tietze, J.; Epple, A.; Ruzicka, T.; Kaudewitz, P.; Gauglitz, G. Comparison of Two Kinds of Lasers in the Treatment of Acne Scars. Facial Plast Surg. 2015, 31, 523–531. [Google Scholar] [CrossRef] [PubMed]
  48. Zhang, J.; Xu, F.; Lin, H.; Ma, Y.; Hu, Y.; Meng, Q.; Lin, P.; Zhang, Y. Efficacy of Fractional CO2 Laser Therapy Combined with Hyaluronic Acid Dressing for Treating Facial Atrophic Acne Scars: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Lasers Med. Sci. 2023, 38, 214. [Google Scholar] [CrossRef]
  49. Galal, O.; Tawfik, A.A.; Abdalla, N.; Soliman, M. Fractional CO2 Laser versus Combined Platelet-rich Plasma and Fractional CO2 Laser in Treatment of Acne Scars: Image Analysis System Evaluation. J. Cosmet. Dermatol. 2019, 18, 1665–1671. [Google Scholar] [CrossRef]
  50. Belletti, S.; Pennati, B.M.; Madeddu, F. A Sequential CO2 and 1540 Nm Laser for the Treatment of Neck Skin Laxity. Ski. Res. Technol. 2023, 29, e13469. [Google Scholar] [CrossRef]
  51. Mezzana, P.; Valeriani, M.; Valeriani, R. Combined Fractional Resurfacing (10600 Nm/1540 Nm): Tridimensional Imaging Evaluation of a New Device for Skin Rejuvenation. J. Cosmet. Laser Ther. 2016, 18, 397–402. [Google Scholar] [CrossRef]
  52. Fiorentini, F.; Fusco, I. Synergistic Sequential Emission of Fractional 1540 Nm and 10 600 Lasers for Abdominal Postsurgical Scar Management: A Clinical Case Report. Am. J. Case Rep. 2022, 24, e938607-1. [Google Scholar] [CrossRef] [PubMed]
  53. Kim, S.; Cho, K.-H. Clinical Trial of Dual Treatment with an Ablative Fractional Laser and a Nonablative Laser for the Treatment of Acne Scars in Asian Patients. Dermatol. Surg. 2009, 35, 1089. [Google Scholar] [CrossRef] [PubMed]
  54. Belletti, S.; Madeddu, F.; Amoruso, G.F.; Provenzano, E.; Nisticò, S.P.; Fusco, I.; Bennardo, L. An Innovative Dual-Wavelength Laser Technique for Atrophic Acne Scar Management: A Pilot Study. Medicina 2023, 59, 2012. [Google Scholar] [CrossRef] [PubMed]
  55. García, P.N.; Andrino, R.L. Resurfacing of Atrophic Facial Acne Scars with a Multimodality CO2 and 1570 Nm Laser System. J. Cosmet. Dermatol. 2024, 23, 13–18. [Google Scholar] [CrossRef]
Jaestheticmed 01 00002 g001
Figure 1. Improvement of acne scars following Hybrid/ProScan treatments. Shown are representative acne scars at baseline (a) and at least 6 months after treatment (b).
Figure 1. Improvement of acne scars following Hybrid/ProScan treatments. Shown are representative acne scars at baseline (a) and at least 6 months after treatment (b).
Jaestheticmed 01 00002 g001
Jaestheticmed 01 00002 g002
Figure 2. Improvement of acne scars following Pixel CO2/LiteScan treatments. Shown are representative acne scars at baseline (a) and at least 6 months after treatment (b).
Figure 2. Improvement of acne scars following Pixel CO2/LiteScan treatments. Shown are representative acne scars at baseline (a) and at least 6 months after treatment (b).
Jaestheticmed 01 00002 g002
Jaestheticmed 01 00002 g003
Figure 3. Comparison of mean global ECCA score at baseline and after treatment in the Hybrid/ProScan group. *** p-value < 0.001.
Figure 3. Comparison of mean global ECCA score at baseline and after treatment in the Hybrid/ProScan group. *** p-value < 0.001.
Jaestheticmed 01 00002 g003
Jaestheticmed 01 00002 g004
Figure 4. Comparison of mean global ECCA score at baseline and after treatment in the CO2/LiteScan group. *** p-value < 0.001.
Figure 4. Comparison of mean global ECCA score at baseline and after treatment in the CO2/LiteScan group. *** p-value < 0.001.
Jaestheticmed 01 00002 g004
Jaestheticmed 01 00002 g005
Figure 5. Comparison of the proportion of change in ECCA global scores between groups from baseline to post-treatment.
Figure 5. Comparison of the proportion of change in ECCA global scores between groups from baseline to post-treatment.
Jaestheticmed 01 00002 g005
Table 1. Patient demographics and treatment characteristics.
Table 1. Patient demographics and treatment characteristics.
CharacteristicAlma Hybrid/ProScanAlma Pixel CO2/LiteScan
Patients4543
Age (years) 131.11 (7.95)30.19 (7.45)
Treatment sessions 14.16 (1.36)4.23 (1.39)
Gender 2
F33 (73.3)19 (44.2)
M12 (26.7)24 (55.8)
Body area 2
Back1 (2.2)3 (7.0)
Chest1 (2.2)2 (4.7)
Face43 (95.6)38 (88.4)
Skin types 2,3
Type II26 (57.8)4 (9.3)
Type III16 (35.6)30 (69.8)
Type IV3 (6.7)7 (16.3)
Type V02 (4.7)
1 Mean (SD); 2 frequency (%); 3 skin tone classification based on tanning and burning responses to ultraviolet (UV) radiation [25].
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Avdulaj, A.; Menashe, S.; Govrin-Yehudain, Y.; Hadad, E.; Moscovici, S.; Dor, O.; Heller, L. Fractional CO2 Laser for Acne Scar Treatment: A Comparative Analysis of Ablative vs. Combined Ablative and Non-Ablative Modalities. J. Aesthetic Med. 2025, 1, 2. https://doi.org/10.3390/jaestheticmed1010002

AMA Style

Avdulaj A, Menashe S, Govrin-Yehudain Y, Hadad E, Moscovici S, Dor O, Heller L. Fractional CO2 Laser for Acne Scar Treatment: A Comparative Analysis of Ablative vs. Combined Ablative and Non-Ablative Modalities. Journal of Aesthetic Medicine. 2025; 1(1):2. https://doi.org/10.3390/jaestheticmed1010002

Chicago/Turabian Style

Avdulaj, Arminda, Shaked Menashe, Yoad Govrin-Yehudain, Eran Hadad, Sharon Moscovici, Omer Dor, and Lior Heller. 2025. "Fractional CO2 Laser for Acne Scar Treatment: A Comparative Analysis of Ablative vs. Combined Ablative and Non-Ablative Modalities" Journal of Aesthetic Medicine 1, no. 1: 2. https://doi.org/10.3390/jaestheticmed1010002

APA Style

Avdulaj, A., Menashe, S., Govrin-Yehudain, Y., Hadad, E., Moscovici, S., Dor, O., & Heller, L. (2025). Fractional CO2 Laser for Acne Scar Treatment: A Comparative Analysis of Ablative vs. Combined Ablative and Non-Ablative Modalities. Journal of Aesthetic Medicine, 1(1), 2. https://doi.org/10.3390/jaestheticmed1010002

Article Metrics

Back to TopTop