In vivo model of histologic changes after treatment with the superpulsed CO2 laser, Erbium:YAG laser, and blended lasers: A 4‐ to 6‐month prospective histologic and clinical study

Background and Objective To compare the in vivo histologic effects of the pulsed carbon dioxide (CO2) and erbium:ytrium aluminum garnet (Er:YAG) lasers and to assess the effects of combining CO2 and Er:YAG laser modalities during a single treatment session. We previously reported 10 patients treated with four laser regimens: CO2 alone, CO2/Er:YAG, Er:YAG alone, Er:YAG/CO2 with time points at 1 hour and 7 days between laser treatment and histologic analysis. This study found that the optimal treatment consisted of limited CO2 laser passes followed by Er:YAG. This treatment produced less collagen injury, less thermal necrosis, and more robust epithelial and dermal fibrous tissue regeneration in the acute phase of healing. The present study examines the histologic changes resulting from the host healing response to laser treatment on long-term follow-up of 4–6 months. Study Design/Materials and Methods The Stanford University Committee on Human Subjects in Medical Research approved this study. Nine patients with actinic damage and indications for rhytidectomy volunteered for this interventional study in which each patient served as both experimental and control. The right preauricular area was treated at five sites with the following: (1) CO2, (2) CO2 followed by Er:YAG, (3) Er:YAG, (4) blended CO2/Er:YAG (Derma-K™), (5) phenol. Each was subjected to full-face or sub-unit treatment. Each patient was followed up initially daily then weekly for healing of the full-face laser and for differences in healing of the five treatment areas. Five patients were selected for histologic evaluation. At 4–6 months, these patients underwent rhytidectomy with immediate removal of laser-treated skin, which was evaluated histologically by the study dermatopathologist, who was blinded to the treatment at each site. Results CO2 laser treatment produced the greatest thickness of neocollagen (0.27 mm; P < 0.05), the highest neocollagen density (P < 0.05), the greatest decrease in elastosis (27%), but took the longest time for healing and resolution of erythema and inflammation (up to 6 months). Er:YAG used alone produced the least collagen density, with the thinnest band of neocollagen (0.08 mm), but the most rapid resolution of erythema and inflammation (within 10 days). Combined CO2/Er:YAG treatments, including Derma-K™ and CO2 followed by Er:YAG produced histologic changes that were intermediate, as well as recovery that was intermediate (resolution of erythema within 1 month); the development of neocollagen was greater in CO2-containing modalities than Er:YAG used alone by a statistically significant margin (P = 0.001). These histologic findings were corroborated by clinical correlation by examination of the five treatment spots in nine patients and in full-face treatments in 100 patients. Conclusion Collagenesis is greatest with CO2 and least with Er:YAG. Elastosis decreased to the greatest degree with CO2, least with erbium, and to an intermediate extent with blended CO2/Er:YAG regimens (sequential and Derma-K™). These changes from control are statistically significant with all regimens (P < 0.05). Blended CO2/Er:YAG treatments provide an optimal combination of the benefits of CO2 but with lesser erythema and healing delay. Clinical and histologic findings change over time for different treatments. Thus, long-term histology is critical for predicting results of treatment. Lasers Surg. Med. 27:362–372, 2000. Published 2000 Wiley-Liss, Inc.