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Year : 2009  |  Volume : 2  |  Issue : 2  |  Page : 72-80
Carbon dioxide laser guidelines

Department of Dermatology, Manipal Hospital, Bangalore, Karnataka, India

Click here for correspondence address and email

Date of Web Publication24-Dec-2009


The carbon dioxide (CO 2 ) 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 CO 2 laser and offers guidelines for use in many of the above indications.

Keywords: CO 2 laser, CO 2 pixel, dermatological surgery

How to cite this article:
Krupa Shankar D S, Chakravarthi M, Shilpakar R. Carbon dioxide laser guidelines. J Cutan Aesthet Surg 2009;2:72-80

How to cite this URL:
Krupa Shankar D S, Chakravarthi M, Shilpakar R. Carbon dioxide laser guidelines. J Cutan Aesthet Surg [serial online] 2009 [cited 2022 May 20];2:72-80. Available from:

   Introduction Top

The carbon dioxide (CO 2 ) laser is the gold standard in ablative lasers. Detailed knowledge of the machines is essential. Over the past decade, advances in laser technology have allowed dermatologists to improve the appearance of scars and wrinkles and to remove benign skin growths using both ablative and nonablative lasers. CO 2 laser treatment ensures minimal discomfort and rapid recovery, enabling a quick return to daily routine. The CO 2 laser emits an invisible infrared beam at 10,600 nm, targeting both intracellular and extracellular water. When light energy is absorbed by water-containing tissue, skin vaporization occurs.

   Indications Top


Actinic and seborrheic keratosis, [1],[2],[3],[4],[5] warts, [6],[7],[8],[9] moles, skin tags, epidermal and dermal nevi, [10],[11],[12],[13],[14],[15] xanthelasma. [16],[17],[18],[19]

Other conditions that have been shown to respond favorably to CO 2 laser resurfacing include dermatofibroma, [20] rhinophyma, [21],[22],[23],[24],[25] severe cutaneous photodamage (observed in Favre-Racouchot syndrome), sebaceous hyperplasia, syringomas, [1],[26],[27],[28],[29] actinic cheilitis, [30],[31],[32],[33] angiofibroma, [34],[35],[36] scar treatment, [37],[38],[39] keloid, [40],[41],[42],[43] skin cancer, [44],[45],[46],[47] neurofibroma, [48],[49],[50] diffuse actinic keratoses, granuloma pyogenicum, [51] and pearly penile papules. [52]


Periorbital and perioral wrinkles, [53],[54],[55] facial resurfacing [56],[57],[58],[59],[60] and acne scars, [61],[62],[63],[64],[65] dyschromias including solar lentigines. [66],[67]

   Contraindications Top

Isotretinoin use within the previous six months, active cutaneous bacterial or viral infection in the area to be treated, history of keloid formation or hypertrophic scarring, ongoing ultraviolet exposure, prior radiation therapy to treatment area, collagen vascular disease, chemical peel and dermabrasion.

   Preoperative Preparation Top

Informed consent

Informed consent should be obtained before the procedure according to guidelines. [68] The consent form should specifically state the possible postoperative appearance of the treated area, possible pigmentation changes and need for post-treatment care.


Position the patient according to the area of lesion such that the area to be treated is close to the laser [Table 1].

Aseptic measures

Gloves, mask and cap should be used by surgeons and assistants. Clean the area with povidone iodine 5% solution (spirit should not be used because it is inflammable).


Depending upon the site and type of lesions, one of the following types of anesthesia can be given:

Topical anesthesia

Eutectic Mixture of Local Anesthesia (EMLA) cream is used. Apply 2mg/cm 2 topically under occlusion for 60 min. The occlusion should be removed just before the procedure.

Local infiltration

Lignocaine 2% with or without adrenaline 1:100000 is used. Dosage of lignocaine plain is 3 mg/kg and lignocaine with adrenaline is 7 mg/kg. Lignocaine with adrenaline should be avoided at areas with end arteries like fingers, toes, earlobes, nose, and penis. Local anesthesia (LA) is injected as follows:

  • Using 30G needle with bevel pointing upward LA is injected immediately below the planned area of laser. Pinching the lesion before injection will reduce the pain.
  • In case of palms and soles, insert the needle with 45Ί angulation to the skin surface.
  • Inject the anesthesia while withdrawing and slowly to minimize the pain.
  • Insert the needle at a distance from the lesion such that the tip of the needle is below the lesion after it is pushed in to its full length, failing which anesthesia will be deposited distal to the lesion
  • Anesthesia must be infiltrated slowly and not pushed in briskly to avoid pain.

Ring block

Ring block is employed to anesthetize fingers, toes and penis. The needle is inserted at the base of the fingers and toes on either side or a ring of anesthesia is deposited around the digit. The LA is injected while withdrawing. A distal digital nerve block on either sides of lateral nail folds can supplement a ring block for nail surgeries. In case of penile region, LA is given at the base of the shaft.

Field block

LA is infiltrated circumferentially around the site blocking the nerve impulse from leaving the area. The actual surgical site is not injected. They are particularly useful when a large area needs to be anesthetized.

Eye protection

Patient's eye should be protected with the eye shield or with wet gauze. Dermatologist and assistants should use wavelength-rated spectacles.

   General Instructions for the Operation of Laser Top

Hold the hand piece perpendicular to the lesion and press the foot pedal to fire the laser. Vaporize the lesion in coiled, whorled, centrifugal, vertical or horizontal fashion. Vaporize the flat lesions from the top.

Pedunculated lesions can be excised by lasing from the base of the lesion. Hold the lesion with toothed forceps on the top, pull it to the side on the top of the wet gauze (to prevent charring of the normal skin). Always use wet gauze as dry gauze can catch fire.

Wipe the vaporized lesions with wet gauze. Always make sure to dry the area or wipe the water with dry gauze. Look for the raw areas. Coagulate the bleeding spots if any by defocusing the laser beam.

   Laser Specifications for Various Dermatological Conditions and Special Concerns Top

In additions to the above general measures that have to be adopted for lasing various cutaneous lesions, there are special considerations for some. The same and the laser settings are summarized in [Table 2]. [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10],[Figure 11],[Figure 12],[Figure 13],[Figure 14] show the results after CO 2 laser in different conditions. It is important to know the relation between the power, irradiance and fluence before performing the procedure [Table 3].

   Postoperative Care Top

  • Always apply hydrocolloid dressings on facial procedures, never undertake a facial procedure, if hydrocolloid dressings are unavailable. [See Appendix for instructions on use of hydrocolloid dressings].
  • Apply topical antibiotics for the superficial lesions for one week.
  • Allow the scabs to fall on own. Avoid picking.
  • Emphasize on sunscreen application three times a day from day one for the lesions on the face and neck.
  • Treat for post-inflammatory hyperpigmentation if any with Kligman's formula.
  • Allow occlusive pressure dressing to remain in place for three to seven days.
  • Look for healthy granulation tissue after removal of the occlusive dressing.
  • Avoid contact with dust. Use handyplast if needed for a couple of days for protection.

   Complications Top

Minor complications although frequent, are usually of minimal consequence and include post-inflammatory hyperpigmentation, milia formation, perioral dermatitis, acne and/or rosacea exacerbation and contact dermatitis. Hyperpigmentation or erythema over the treated area is common in colored skin and causes anxiety to patients. However, this is temporary, lasting for only about six weeks and gradually improves.

More serious complications include localized viral, bacterial, and candidial infection, delayed hypopigmentation, persistent erythema, and prolonged healing. The most severe complications are hypertrophic scarring, disseminated infection, and ectropion. Early detection of complications and rapid institution of appropriate therapy are extremely important. Delay in treatment can have severe deleterious consequences including permanent scarring and dyspigmentation.

   Practical Tips on use of Co 2 Laser Top

  • Always use hand piece pointer on skin to cut.
  • Remember, lens focuses beam and renders it collimated.
  • Moving hand piece away [defocusing] leads to logarithmic fall in irradiance; use this to coagulate.
  • Super-pulse CO 2 laser reduces dwell time, maximizes power.
  • Use continuous wave in highly vascular lesions and areas, debulking and where esthetics is not an issue e.g., foot.
  • Under-treat, eschew therapeutic greed.
  • Laser settings in texts are often for collimated hand pieces, read carefully before applying. One-third to one-fourth the irradiance suggested in the texts seems to deliver the results.
  • The newer CO 2 lasers with advanced output control software when used in the super-pulsed mode for carrying out free hand procedures are versatile devices with numerous therapeutic options.

   Guidelines for Co 2Pixel Laser Top

  • Apply topical anesthesia liberally. Occlude the anesthetic cream with provided plastic sheets and 3M transpore and leave it for 30-45 min.
  • After 30-45 min, remove the occlusion and wipe the anesthesia completely with dry gauze.
  • Set the pixel laser at 21 watts.
  • Give single pass using 7*7 tip, that is, 49 pixel dots. Avoid overlapping but give two passes if scars are deep.
  • Apply hydrocolloid dressing for 12 h.
  • Procedure has to be repeated every month for four months.

   References Top

1.Trimas SJ, Ellis DA, Metz RD. The carbon dioxide laser: An alternative for the treatment of actinically damaged skin. Dermatol Surg 1997;23:885-9.  Back to cited text no. 1      
2.Phahonthep R, Sindhuphak W, Sriprajittichai P. Lidocaine iontophoresis versus EMLA cream for CO 2 laser treatment in seborrheic keratosis. J Med Assoc Thai 2004;87:S15-8.   Back to cited text no. 2      
3.Fulton JE, Rahimi AD, Helton P, Dahlberg K, Kelly AG. Disappointing results following resurfacing of facial skin with CO 2 lasers for prophylaxis of keratosis and cancers. Dermatol Surg 1999;25:729-32.   Back to cited text no. 3      
4.Fitzpatrick RE, Goldman MP, Ruiz-Esparza J. Clinical advantage of the CO 2 laser superpulsed mode. Treatment of verruca vulgaris, seborrheic keratosis, lentigines and actinic cheilitis. J Dermatol Surg Oncol 1994;20:449-56.  Back to cited text no. 4      
5.Quaedvlieg PJ, Ostertag JU, Krekels GA, Neumann HA. Delayed wound healing after three different treatments for widespread actinic keratosis on the atrophic bald scalp. Dermatol Surg 2003;29:1052-6.  Back to cited text no. 5      
6.Lauchli S, Kempf W, Dragieva G, Burg G, Hafner J. CO 2 laser treatment of warts in immunosuppressed patients. Dermatology 2003;206:148-52.   Back to cited text no. 6      
7.Geronemus RG, Kauvar AN, McDaniel DH. Treatment of recalcitrant verrucae with both the ultrapulse CO 2 and PLDL pulsed dye lasers. Plast Reconstr Surg 1998;101:2010.  Back to cited text no. 7      
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12.Verma KK, Ovung EM. Epidermal and sebaceous nevi treatment with CO 2 laser. Indian J Dermatol Venereol Leprol 2002;68:23-4.   Back to cited text no. 12  [PUBMED]  Medknow Journal  
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25.Greenbauns SS, Krull EA, Watrick K. Comparison of CO 2 laser and electrosurgery in the treatment of rhinophyma. J Am Acad Dermatol 1988;18:363-8.   Back to cited text no. 25      
26.Wang JI, Roenigk HH Jr. Treatment of multiple facial syringomas with the carbon dioxide laser. Dermatol Surg 1999;25:136-9.   Back to cited text no. 26      
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34.Belmar P, Boixeda P, Baniandres O, Fernandez-Lorente M, Arrazola JM. Long-term follow up of angiofibromas treated with CO 2 laser in 23 patients with tuberous sclerosis. Actas Dermosifiliogr 2005;96:498-503.  Back to cited text no. 34      
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49.Becker DW. Use of the carbon dioxide laser in treating multiple cutaneous neurofibromas. Ann Plast Surg 1991;26:582-6.   Back to cited text no. 49      
50.Roenigk RK, Ratz JL. CO 2 laser treatment of cutaneous neurofibromas. J Dermatol Surg Oncol 1987;13:187-90.  Back to cited text no. 50      
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54.Pitanguy I, Soares GL, Machado BH, de Amorim NF. CO 2 laser peeling associated with the 'round lifting' technique. J Cosmet Laser Ther 1999;1:145-52.  Back to cited text no. 54      
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56.Alster T, Hirsch R. Single-pass CO 2 laser skin resurfacing of light and dark skin: Extended experience with 52 patients. J Cosmet Laser Ther 2003;5:39-42.   Back to cited text no. 56      
57.Tanzi EL, Alster TS. Single-pass carbon dioxide versus multiple-pass Er:YAG laser skin resurfacing: A comparison of postoperative wound healing and side-effect rates. Dermatol Surg 2003;29:80-4.   Back to cited text no. 57      
58.Huilgol SC, Poon E, Calonje E, Seed PT, Huilgol RR, Markey AC, et al. Scanned continuous wave CO 2 Laser resurfacing: A closer look at the different scanning modes. Dermatol Surg 2001;27:467-70.   Back to cited text no. 58      
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63.Goh CL, Khoo L. Laser skin resurfacing treatment outcome of facial scars and wrinkles in Asians with skin type III-IV with the Unipulse CO 2 laser system. Singapore Med J 2002;43:28-32.   Back to cited text no. 63      
64.Tanzi EL, Alster TS. Single-pass carbon dioxide versus multiple-pass Er:YAG Laser skin resurfacing: A comparison of postoperative wound healing and side-effect rates. Dermatol Surg 2003;29:80-4.   Back to cited text no. 64      
65.Goodman GJ. Carbon dioxide laser resurfacing: Preliminary observations on short-term follow up: A subjective study of 100 patients' attitudes and outcomes. Dermatol Surg 1998;24:665-72.   Back to cited text no. 65      
66.Stern RS, Dover JS, Levin JA, Arndt KA. Laser therpy versus cryo therapy of lentigines: A comparative trial. J Am Acad Dermatol 1994;30:985-7.   Back to cited text no. 66      
67.Dover JS, Smoller BR, Stern RS, Rosen S, Arndt KA. Low-fluence carbon dioxide laser irradiation of lentigines. Arch Dermatol 1986;124:8.  Back to cited text no. 67      
68.Krupashankar DS. Standard guidelines of care: CO 2 laser for removal of benign skin lesions and resurfacing. Indian J Dermatol Venereol Leprol 2008;74:61-7.  Back to cited text no. 68  [PUBMED]  Medknow Journal  
69.Rosio TJ. Basic laser physics. In: Roenigk RK, Ratz JL, Roenigk HH. Roenigk's dermatologic surgery. 3 rd ed. New York: Informa Healthcare; 2007. p. 607-24.  Back to cited text no. 69      

Correspondence Address:
M Chakravarthi
Department of Dermatology, Manipal Hospital, 98 Rustom Bagh, HAL Airport Road, Bangalore - 560 017, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-2077.58519

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]

  [Table 1], [Table 2], [Table 3]

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