CME

Carbon Dioxide Laser Guidelines

The carbon dioxide (CO2) laser is a versatile tool that has applications in ablative lasing and caters to the needs of
routine dermatological practice as well as the aesthetic, cosmetic and rejuvenation segments. This article details the
basics of the laser physics as applicable to the CO2 laser and offers guidelines for use in many of the above indications.

KEYWORDS: CO2 laser, CO2 pixel, dermatological surgery

Introduction Contraindications

The carbon dioxide (CO2) laser is the gold standard in Isotretinoin use within the previous six months, active
ablative lasers. Detailed knowledge of the machines cutaneous bacterial or viral infection in the area to be
is essential. Over the past decade, advances in laser treated, history of keloid formation or hypertrophic
technology have allowed dermatologists to improve the scarring, ongoing ultraviolet exposure, prior radiation
appearance of scars and wrinkles and to remove benign therapy to treatment area, collagen vascular disease,
skin growths using both ablative and nonablative chemical peel and dermabrasion.
lasers. CO2 laser treatment ensures minimal discomfort
and rapid recovery, enabling a quick return to daily Preoperative preparation
routine. The CO 2 laser emits an invisible infrared
beam at 10,600 nm, targeting both intracellular and Informed consent
extracellular water. When light energy is absorbed by Informed consent should be obtained before the
water-containing tissue, skin vaporization occurs. procedure according to guidelines.[68] The consent form
should specifically state the possible postoperative
Indications appearance of the treated area, possible pigmentation
changes and need for post-treatment care.
Therapeutic
Actinic and seborrheic keratosis,[1-5] warts,[6-9] moles, skin Position
tags, epidermal and dermal nevi,[10-15] xanthelasma.[16-19] Position the patient according to the area of lesion such
that the area to be treated is close to the laser [Table 1].
Other conditions that have been shown to respond favorably
to CO2 laser resurfacing include dermatofibroma,[20] Aseptic measures
rhinophyma, [21-25] severe cutaneous photodamage Gloves, mask and cap should be used by surgeons and
(observed in Favre-Racouchot syndrome), sebaceous assistants. Clean the area with povidone iodine 5% solution
hyperplasia, syringomas, [1,26-29] actinic cheilitis, [30-33] (spirit should not be used because it is inflammable).
angiofibroma,[34-36] scar treatment,[37-39] keloid,[40-43] skin
cancer,[44-47] neurofibroma,[48-50] diffuse actinic keratoses, Table 1: Appropriate positioning of the area to be treated
granuloma pyogenicum,[51] and pearly penile papules.[52] Area to be treated Position
Face, chest and abdomen Supine position
Aesthetic Sides of face, neck and body Lateral position
P e r i or b i t a l a n d p e r i or a l w r i n k l e s, [ 5 3 - 5 5 ] f a ci a l Nape of neck and back Prone position
resurfacing [56-60] and acne scars, [61-65] dyschromias Palms Supine position with palms above his head
Soles Prone position with extended ankle
including solar lentigines.[66,67]

Krupa Shankar DS, Chakravarthi M1, Rachana Shilpakar1

Professor and Head, 1Resident, Department of Dermatology, Manipal Hospital, Bangalore, Karnataka, India
DOI: 10.4103/0974-2077.58519
Address for correspondence:
Dr. Chakravarthi M, Department of Dermatology, Manipal Hospital, 98 Rustom Bagh, HAL Airport Road, Bangalore - 560 017, Karnataka, India.
E-mail: chakravarthi.mailer@gmail.com

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 Krupa Shankar, et al.: Carbon dioxide laser guidelines

Anesthesia press the foot pedal to fire the laser. Vaporize the lesion
Depending upon the site and type of lesions, one of the in coiled, whorled, centrifugal, vertical or horizontal
following types of anesthesia can be given: fashion. Vaporize the flat lesions from the top.

Topical anesthesia Pedunculated lesions can be excised by lasing from the

Eutectic Mixture of Local Anesthesia (EMLA) cream is base of the lesion. Hold the lesion with toothed forceps
used. Apply 2mg/cm2 topically under occlusion for 60 on the top, pull it to the side on the top of the wet gauze
min. The occlusion should be removed just before the (to prevent charring of the normal skin). Always use wet
procedure. gauze as dry gauze can catch fire.

Local infiltration Wipe the vaporized lesions with wet gauze. Always
Lignocaine 2% with or without adrenaline 1:100000
make sure to dry the area or wipe the water with dry
is used. Dosage of lignocaine plain is 3 mg/kg and
gauze. Look for the raw areas. Coagulate the bleeding
lignocaine with adrenaline is 7 mg/kg. Lignocaine
spots if any by defocusing the laser beam.
with adrenaline should be avoided at areas with end
arteries like fingers, toes, earlobes, nose, and penis. Local
Laser Specifications For Various
anesthesia (LA) is injected as follows:
Dermatological Conditions And Special
• Using 30G needle with bevel pointing upward LA
Concerns
is injected immediately below the planned area
of laser. Pinching the lesion before injection will
In additions to the above general measures that have to
reduce the pain.
be adopted for lasing various cutaneous lesions, there
• In case of palms and soles, insert the needle with
are special considerations for some. The same and the
45º angulation to the skin surface.
laser settings are summarized in Table 2. Figures 1-14
• Inject the anesthesia while withdrawing and slowly
show the results after CO2 laser in different conditions.
to minimize the pain.
It is important to know the relation between the power,
• Insert the needle at a distance from the lesion such
that the tip of the needle is below the lesion after it is irradiance and fluence before performing the procedure
pushed in to its full length, failing which anesthesia [Table 3].
will be deposited distal to the lesion
• Anesthesia must be infiltrated slowly and not Postoperative Care
pushed in briskly to avoid pain.
• Always apply hydrocolloid dressings on facial
Ring block procedures, never undertake a facial procedure,
Ring block is employed to anesthetize fingers, toes and penis. if hydrocolloid dressings are unavailable. [See
The needle is inserted at the base of the fingers and toes Appendix for instructions on use of hydrocolloid
on either side or a ring of anesthesia is deposited around dressings].
the digit. The LA is injected while withdrawing. A distal • Apply topical antibiotics for the superficial lesions
digital nerve block on either sides of lateral nail folds can for one week.
supplement a ring block for nail surgeries. In case of penile • Allow the scabs to fall on own. Avoid picking.
region, LA is given at the base of the shaft. • Emphasize on sunscreen application three times a
day from day one for the lesions on the face and neck.
Field block • Treat for post-inflammatory hyperpigmentation if
LA is infiltrated circumferentially around the site
any with Kligman’s formula.
blocking the nerve impulse from leaving the area. The
• Allow occlusive pressure dressing to remain in
actual surgical site is not injected. They are particularly
place for three to seven days.
useful when a large area needs to be anesthetized.
• Look for healthy granulation tissue after removal
Eye protection of the occlusive dressing.
Patient’s eye should be protected with the eye shield or • Avoid contact with dust. Use handyplast if needed
with wet gauze. Dermatologist and assistants should use for a couple of days for protection.
wavelength-rated spectacles.
Complications
General Instructions For The
Operation Of Laser Minor complications although frequent, are usually of
minimal consequence and include post-inflammatory
Hold the hand piece perpendicular to the lesion and hyperpigmentation, milia formation, perioral
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Krupa Shankar, et al.: Carbon dioxide laser guidelines

Table 2: Laser specifications and special considerations for various cutaneous lesions
Dermatological conditions Laser settings Comments
Actinic and seborrhoeic keratoses 4 to 7 watts super pulse mode Topical local anesthesia applied under occlusion at lesions
for 45 to 60 min prior to procedure.
Dermatosis papulosa nigra 3.5 to 4.5 watts super-pulsed Procedure carried out after applying topical LA at each
repeat mode with 0.1 second on lesion under occlusion.
and 0.1 second off
Warts 9 to 15 watts continuous mode, Precede the vaporization of all types of warts with
continuous wave for common superficial vaporization of a 1-mm margin of normal skin
warts, use 4 to 6 watts superpulse at half the fluence, before treating the actual lesion, to
for flat warts reduce lesional recurrence.
Filiform warts can be excised by
vaporizing the base
Palmoplantar warts 8 to 15 watts continuous mode, Precede the vaporization of all types of warts with
continuous wave superficial vaporization of a 1-mm margin of normal skin
at half the fluence, before treating the actual lesion, to
reduce lesional recurrence
Skin tags 4.5 to 7.5 watts continuous mode Cut the base of the lesion in focused cutting mode,
and avulse the skin tag, in case of giant skin tags,
exsanguinate the lesion by applying hemostats to peduncle
of anesthetized lesion for 5 min prior to laser avulsion
Epidermal and dermal nevi 4.5 to 7.5 watts super pulse mode The procedure is repeated till the pigmented areas are
visible. Do not go too deep to prevent scar formation
Intradermal and melanocytic nevi on face 4.5 to 7.5 watts super pulse mode Always send the excised specimen for histopathology and
keep a close watch for recurrence for lesions with reported
junctional activity. Review the patient on Days 30, 120,
360. If any pigment is noted at treated area, vaporize and
repeat follow-up as above
Syringomas, angiofibroma, sebaceous 4.5 to 6.5 watts super pulse mode In case of syringomas, mark all the lesions with skin
hyperplasia, senile comedones marking pen, as they will be rendered invisible after
infiltration of anesthetic. The marks must be made with a
thin-tipped surgical pen and must circumambulate each
lesion
Scars 2.5 to 4.5 watts super pulse mode
Granuloma pyogenicum 9 to 15 watts continuous mode, Coagulate the lesion including the cuff with slight
continuous wave defocusing to avoid puncturing the lesions which will lead
to torrential bleeding
To attain hemostasis during the procedure, pinch the
lesion between the thumb and index finger of the left,
hand or apply tourniquet at proximal end
Earlobe keloids 9 to 15 watts continuous mode, Follow up the patient at Day 3, 7, 14 and 30, and inject
continuous wave for large earlobe intralesional triamcinalone at site of healed keloids
lesions and 4 to 7 watts super showing early signs of recurrence
pulse for smaller lesions
Mucocele 3.5 to 4.5 watts super pulse mode Mark the outer border of the lesion with dotted lines
Pearly penile papules 3.5 to 4.5 watts super pulse
mode using single fixed pulses of
0.1 to 0.5 sec
Nail bed reconstruction 8 to 12 watts continuous mode Mark the part of the nail to be avulsed with marker pen.
Vaporize the nail in vertical fashion running from the
proximal to distal end over the marked line. Separate the
nail fold from the nail bed with nail elevator, separate
proximal and lateral nail folds from nail plate with
curved nail elevator. Avulse the part of the nail from
the laser marked line to the lateral nail fold. Vaporize
the overhanging mass of lateral nail fold tissue that
contributes to onychocryptosis
Nail bed biopsy 6.5 to 8.5 watts super pulse mode Mark a round of 4 to 5 mm on the nail plate just above
the site of biopsy
Perform the punch biopsy from the nail bed, the size being
1 mm lesser than the avulsed nail plate
Put back the circular piece of nail bed on the top of the
biopsy area to seal the wound

dermatitis, acne and/or rosacea exacerbation and for only about six weeks and gradually improves.
contact dermatitis. Hyperpigmentation or erythema over
the treated area is common in colored skin and causes More serious complications include localized viral, bacterial,
anxiety to patients. However, this is temporary, lasting and candidial infection, delayed hypopigmentation,

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 Krupa Shankar, et al.: Carbon dioxide laser guidelines

Figure 1: Earlobe keloid before laser Figure 2: Earlobe keloid after laser

Figure 3: Melanocytic nevi before laser Figure 4: Melanocytic nevi has healed without scarring after
laser

Figure 5: Pre-treatment photograph of rhinophyma Figure 6: Laser ablation of rhinophyma has healed well with
mild residual surface irregularity

persistent erythema, and prolonged healing. The disseminated infection, and ectropion. Early detection of
most severe complications are hypertrophic scarring, complications and rapid institution of appropriate therapy

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Krupa Shankar, et al.: Carbon dioxide laser guidelines

Figure 7: Beckers melanosis on face before treatment Figure 8: Significant reduction in pigmentation due to Beckers
melanosis after laser

Figure 9: Verrucous epidermal nevus involving left cheek

Figure 10: Verrucous epidermal nevus on cheek cleared with
and neck
mild post-inflammatory hypopigmentation and scarring

Figure 11: Granuloma telangiectaticum, pre-treatment Figure 12: Effective ablation of granuloma telangiectaticum
by laser

are extremely important. Delay in treatment can have Practical Tips On Use Of Co2 Laser
severe deleterious consequences including permanent
scarring and dyspigmentation. • Always use hand piece pointer on skin to cut.

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 Krupa Shankar, et al.: Carbon dioxide laser guidelines

Figure 13: Multiple, brown-black papules of Dermatosis Figure 14: Dermatosis papulosa nigra effectively cleared
papulosa nigra on face with laser

Table 3: The relation between irradiance and fluence Appendix

Power Irradiance [w/cm2] Fluence How to use hydrocolloid dressings?
0.5 6369.43 5.14 Remove the dressing before bath
1.0 12738.85 11.46
Wipe the pus-like material with wet cotton
2.0 25477.7 22.93
3.0 38216.56 34.39 Wash the area with soap and water when you take bath
4.2 53503.18 48.15 Press the area dry after bath
6 76433.12 68.79
6.3 80254.78 72.23 Paint the area and skin around it with povidone iodine 5% solution
9 114547.54 103.09 Wait for 3 min for the solution to dry
Apply the dressing, so that the sticky side of the dressing which adheres
to the paper sticks to the wound
• Remember, lens focuses beam and renders it Please remember that when you change the dressing you will find a
collimated. yellowish brown material which may look and smell like pus,
• Moving hand piece away [defocusing] leads to but this is not pus, it is the material in the dressing which melts
logarithmic fall in irradiance; use this to coagulate. when it comes into contact with the wound
• Super-pulse CO 2 laser reduces dwell time, Calibration of CO2 laser fluence[69]
maximizes power. Power 5 joules/sec watts
• Use continuous wave in highly vascular lesions Spot size 5 pR2
and areas, debulking and where esthetics is not an
R 5 Radius 5 Diameter/2 cm
issue e.g., foot.
Irradiance 5 Power/spot size
• Under-treat, eschew therapeutic greed.
Fluence 5 Irradiance 3 Time in sec
• Laser settings in texts are often for collimated hand
pieces, read carefully before applying. One-third If
to one-fourth the irradiance suggested in the texts Diameter 5 0.1 mm 5 0.01 cm
seems to deliver the results. Time 5 0.9 m sec 5 0.0009 sec
• The newer CO 2 lasers with advanced output Radius 5 0.005 cm
control software when used in the super-pulsed Radius2 5 0.000025 cm
mode for carrying out free hand procedures are Spot size 5 pR2 5 0.00007857
versatile devices with numerous therapeutic Calibration of CO2 pixel laser
options.
W 5 J/sec
Guidelines For Co2 Pixel Laser 21 W 5 21J/1 sec ⇒ 21W × 1 sec 5 21J
⇒ 21 W × 0.5 sec 5 10.5J
• Apply topical anesthesia liberally. Occlude the We are using the 7*7 tip, hence 49 pixel dots.
anesthetic cream with provided plastic sheets and
For each pixel dot: 10.5 W/49 pixels 5 0.21 W/pixel dot
3M transpore and leave it for 30-45 min.
The diameter of each pixel dot is 100 micron:
• After 30-45 min, remove the occlusion and wipe the
J 5 W/A ⇒ 0.21/(0.1)2*II/4 5 26.75 J/P/cm2
anesthesia completely with dry gauze.

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Krupa Shankar, et al.: Carbon dioxide laser guidelines

• Set the pixel laser at 21 watts. rhinophyma: Combined erbium-YAG/CO2 laser. Aesthetic Plast Surg
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58. Huilgol SC, Poon E, Calonje E, Seed PT, Huilgol RR, Markey AC, et al.
Source of Support: Nil, Conflict of Interest: None declared.
Scanned continuous wave CO2 Laser resurfacing: A closer look at the

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Shankar, et al.: Carbon dioxide laser guidelines

Multiple-Choice Questions

1. Which of the following is true about CO2 laser?

(a) It is an ablative laser
(b) It is a non-ablative laser
(c) It is a semi-ablative laser
(d) It is a minimally ablative laser
2. The wavelength of the CO2 laser is
(a) 10,600 nm
(b) 1,064 nm
(c) 2,640 mm
(d) 10,640 nm
3. The chromophore for CO2 laser is
(a) Air
(b) Water
(c) Melanin
(d) Hemoglobin
4. The following is not an absolute contraindication for CO2 laser therapy:
(a) Patient on isotretinoin
(b) Keloidal tendency
(c) Active viral infection
(d) Skin phototype 4 and 5
5. The following must not be used to sterilize the treatment area in CO2 laser therapy:
(a) Povidone iodine
(b) Chlorhexidine
(c) Cetrimide
(d) Ethanol
6. This equipment is mandatory while carrying out a CO2 laser procedure
(a) Cold air blower
(b) Airconditioning
(c) Smoke evacuator
(d) Operating theatre lights
7. Dermatosis papulosa nigra is treated with the following type of anesthesia:
(a) Ring block
(b) Field block
(c) Topical anesthesia
(d) General anesthesia
8. To cut with the CO2 laser, which mode is most suited?
(a) Focused
(b) Defocused
(c) Fractionated
(d) Collimated
1. a, 2. a, 3. b, 4. d, 5. d, 6. c, 7. c, 8. a.
Answers

80 Journal of Cutaneous and Aesthetic Surgery - Jul-Dec 2009, Volume 2, Issue 2