Journal of Dermatology Research

Open Access Short Communication

The Applications of Fractional Lasers in Taiwan

Hsuan-Hsiang Chen1*
1
Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of
Medicine, Taipei, Taiwan

*Corresponding Author: Hsuan-Hsiang Chen, Department of Dermatology, National Taiwan University

Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; E-mail: [email protected]

Received Date: 07-01-2021; Accepted Date: 02-02-2021; Published Date: 10-02-2021

Copyright© 2021 by Chen HH. All rights reserved. This is an open access article distributed under the terms of
the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are credited.

Abstract
The applications of fractional lasers are enormous. In Taiwan, the most commonly used
fractional lasers can be divided into 3 different categories: ablative, non-ablative, and combined
hybrid laser. The ablative fractional laser was invented as a new instrument to be used for facial
resurfacing initially. On the contrary, the non-ablative fractional laser was introduced primarily
to rejuvenate skin with minimal downtime. It produces dermal thermal damage without
significantly affecting the overlying epidermal layers of the skin. Both the ablative and non-
ablative lasers are applied increasingly to various dermatological conditions. Herein, the author
will review the researches and multiple applications of fractional lasers in Taiwan.

Keywords
Fractional Laser; Taiwan; Percutaneous Enhancer; Hair Regeneration; Cosmetic Tattoo; Acne
Scar

Introduction
In Taiwan, the most common fractional lasers used can be divided into 3 categories:

1. Ablative fractional laser

2. Non-ablative fractional laser
3. Combined hybrid laser
Chen HH | Volume 2; Issue 1 (2021) | JDR-2(1)-016 | Short Communication

Citation: Chen HH. The Applications of Fractional Lasers in Taiwan J Dermatol Res. 2021;2(1):1-9.

DOI: http://dx.doi.org/10.46889/JDR.2021.2101
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The ablative fractional lasers include 10,600 nm CO2 laser, 2,940 nm Er-YAG laser, and 2,790
nm Er-YSGG laser. The non-ablative fractional lasers are 1,550 nm Er-Glass fiber laser, 1,540
nm Er-Glass fiber laser, 1,927 nm Thulium fiber laser, and 1,440 nm Diode laser. The
combined 1,470 nm ablative and 2,940 nm non-ablative lasers were used as a hybrid laser
(Table 1).

The ablative fractional laser is initially used as a new instrument for facial resurfacing. They
are clinically used to treat scarring, photodamaged skin, and deep rhytides primarily. It can
reduce postoperative downtime and stimulate collagen formation through multiple ablated
vertical tissue damages. On the other hand, non-ablative lasers create multiple denatured
Microthermal Zones (MTZs) without epidermal necrosis. These MTZs can result in similar
wound healing responses as ablative lasers. The combination of ablative and non-ablative lasers
may enhance the treatment effects for facial rejuvenation with less downtime and
complications.
The spectrum of the applications of fractional lasers is not limited to skin rejuvenation only.
Herein, the author reviewed the literature and described the various researches on the
applications of fractional lasers in Taiwan.

Type of Laser Wavelength of Laser Examples

Ablative fractional laser 10,600 nm CO2 laser Lutronic eCO2

DEKA SmartXide
Sharplan 150XJ

2,940 nm Er-YAG laser Sciton ProFractional

MCL30 Dermablate

2,790 nm Er-YSGG laser Cutera Pearl fractional

Non-ablative fractional 1,550 nm Er-Glass fiber laser Reliant Fraxel SR 750, SR

laser 1500
Dinona Sellas 3D, evo

1,540 nm Er-Glass fiber laser Starlux Lux 1540

1,927 nm Thulium fiber laser Perméa

1,440 nm Diode laser Perméa

Combined hybrid laser 1,470 nm and 2,940 nm hybrid Sciton Halo

laser

Table 1: Various fractional lasers used in Taiwan.

Chen HH | Volume 2; Issue 1 (2021) | JDR-2(1)-016 | Short Communication

Citation: Chen HH. The Applications of Fractional Lasers in Taiwan J Dermatol Res. 2021;2(1):1-9.

DOI: http://dx.doi.org/10.46889/JDR.2021.2101
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Materials and Methods

On July 29, 2020, the author systematically searched PubMed for published studies examining
the use of fractional lasers in Taiwan. The PubMed database was searched using the terms
“fractional laser”, “Taiwan”, “dermatology”, and “skin”. The searches were filtered to only
include studies involving skin and those written in English, and bibliographies were also
searched for additional studies. Review articles and researches with inflammed skin were not
included in this study.

Results
A total of 19 research articles were found in this review process. Of the 19 articles found, 11
articles met the inclusion criteria. The studies that met inclusion criteria are reviewed. Six
studies examined the effects of percutaneous absorption by fractional lasers. Among them, five
of the studies applied ablative fractional lasers, while only one research evaluated this subject
by non-ablative fractional laser. One study evaluated the effect on hair regeneration by non-
ablative fractional laser. Two studies examined the effects of cosmetic tattoo removal, one by
ablative fractional laser, and the other by non-ablative fractional laser, respectively. Similarly,
two studies examined the effects of depressed acne scar, one by ablative fractional laser, and
the other by non-ablative fractional laser, respectively (Fig. 1).

Figure 1: Search strategy and results.

Chen HH | Volume 2; Issue 1 (2021) | JDR-2(1)-016 | Short Communication

Citation: Chen HH. The Applications of Fractional Lasers in Taiwan J Dermatol Res. 2021;2(1):1-9.

DOI: http://dx.doi.org/10.46889/JDR.2021.2101
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Discussion
Percutaneous Absorption
1. Ablative fractional laser
The upper limit for passive drug permeation is considered to be below the molecular weight of
500 Da. Applying ablative fractional lasers to enhance the absorption of topical chemicals into
the skin has been successfully demonstrated as a minimal invasive procedure recently. The
ablative fractional laser creates multiple tiny pores on the skin surface with microchannel array
formation, facilitating the penetration and absorption of topically applied chemicals. Lee, et al.,
evaluated the results of permeation enhancement of large molecular weight molecules, small
interfering (si)RNA, and plasmid (p)DNA vectors by irradiation with fractional 2,940 nm Er-
YAG laser and 10,600 nm CO2 laser on nude mice skin [1]. After 5 J/cm2 of Er-YAG laser
(MCL30 Dermablate, Asclepion Laser Technologies, Jena, Germany) irradiation, the
percutaneous absorptions of dextran (10 kDa) and siRNA or other similar molecular size were
56 and 11-fold greater than that of untreated skin, respectively. The permeations of dextran and
siRNA were 42 and 12-fold higher than that of intact skin respectively by the CO2 laser
(Lutronic eCO2, San Jose, CA, USA) at the settings of 4 mJ and densities of 400 spots/cm2.
They demonstrated the importance of hair follicles as the deposition areas for fractional laser-
assisted delivery. A higher follicular selectivity of siRNA was found with Er-YAG fractional
lasers than the CO2 modality. In another similar study, the laser enhanced a 2 to 5-fold increased
absorption of small-molecule drugs after single irradiation of a fractional CO2 laser (Lutronic
eCO2, San Jose, CA, USA) under the fluence of 2 or 4 mJ and densities of 100-400 spots/cm2
[2]. The fractional laser could selectively enhance drugs targeting follicles such as imiquimod
and dextran but not hydroquinone. These results indicated that selecting adequate drugs is
important in laser-assisted percutaneous delivery. It is also noted that within 12 hours after
irradiation, the skin barrier function (defined by trans-epidermal water loss, TEWL) can be
recovered completely.

Another fractional 10,600nm CO2 laser (150XJ, Sharplan Laser Inc., Yokneam, Israel) for
transdermal absorption of ascorbic acid 2-glucoside (AA2G) was researched by Hsiao, et al.,
with the setting of 5-9 W, MTZ 150μm, and 2% coverage for a total of four passes [3]. The
percutaneous absorption of L-ascorbic acid 2-phosphate sesquimagnesium salt (MAP-1) was
8 to 13-fold increased, while that of magnesium L-ascorbic acid-2-phosphate (MAP-2) was 20
to 22-fold higher after 5W irradiation by the fractional CO2 laser. Similarly, the absorption of
MAP-1 was 14 to 19-fold increased, while that of MAP-2 was 30 to 42-fold higher after 9W
irradiation. This study showed CO2 fractional laser is capable of enhancing the penetration of
vitamin C derivatives into the skin. The skin permeation of tranexamic acid was also studied
by the same research group using the same CO2 fractional laser in another similar study design
[4]. One to four passes of irradiation with the setting of 5 to 11 W, MTZ 150μm, and 2%
coverage was performed on the skin. The ablative fractional laser could result in at least 85%

Chen HH | Volume 2; Issue 1 (2021) | JDR-2(1)-016 | Short Communication

Citation: Chen HH. The Applications of Fractional Lasers in Taiwan J Dermatol Res. 2021;2(1):1-9.

DOI: http://dx.doi.org/10.46889/JDR.2021.2101
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of the absorption of tranexamic acid at the same fluence when comparing with conventional
laser treatment. The number of passes needed to achieve a certain level of absorption will
decrease when the fluence increased,

Other characteristics of skin absorption with antibiotics, sunscreens, and macromolecules were
studied by Chen, et al., via a fractional CO2 laser (Lutronic eCO2, Fremont, CA, USA) [5]. The
skin received single irradiation by using the settings of 4 to 10 mJ fluencies and 100-400
spots/cm2. When drugs (such as tetracycline hydrochloride or macromolecules) were applied
immediately after laser treatment, the optimized drug dose was 1/70-1/60 of the regular dose
for skin treated with the fractional laser. However, the skin absorption of oxybenzone or other
chemical sunscreens was not affected by fractional laser treatment.

2. Non-ablative fractional laser

Non-ablative fractional lasers cause dermal tissue damage without obviously destructing the
superficial epidermal layers. The epidermal barrier function was preserved because the stratum
corneum remains intact. Cutaneous penetration of small-molecule drugs, macromolecules, and
nano-particles can be facilitated. A non-ablative 1,550 nm Er-Glass fractional laser (Dinona,
Sellas evo, Daejeon, Korea) was used by Lee, et al., as an instrument to enhance percutaneous
drug absorption [6]. They used the fluence of 30 mJ with MTZ 100 μm, and spot densities 256
to 529 spots/cm2 on the pigs and nude mice skin. The delivery and penetration into the skin
with dextrans (40 kDa) were achieved by quantum dots of a diameter of 20 nm. Depending on
the densities of the laser spots, the barrier function of the epidermis could be recovered 8 to 60
hours after laser beam irradiation. They found the level of increased penetration was decreased
according to the increase of lipophilicity of the drugs. For example, 2 folds increased
absorption for tretinoin and 1200 folds for 5-aminolevulinic acid were found.

In conclusion, most of the studies showed that fractional CO2 laser can increase the
percutaneous absorption of topically applied chemicals from 2 to 42 folds (Table 2). The
fractional Er-YAG laser can result in better skin permeation than that of the fractional CO2
laser. Hair follicles were demonstrated to be important deposition areas for ablative fractional
laser-assisted delivery. The permeation by non-ablative fractional lasers could vary
enormously by permeant lipophilicity.

Chen HH | Volume 2; Issue 1 (2021) | JDR-2(1)-016 | Short Communication

Citation: Chen HH. The Applications of Fractional Lasers in Taiwan J Dermatol Res. 2021;2(1):1-9.

DOI: http://dx.doi.org/10.46889/JDR.2021.2101
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Type of Laser Parameters Absorption

10,600 nm Lutronic eCO2 4 mJ, 400 spots/cm2 12-42 fold increase

CO2 laser Lutronic eCO2 2 or 4 mJ, 100-400 spots/cm2 2-5 fold increase

Lutronic eCO2 4-10 mJ, 100–400 spots/cm2 1/70–1/60 of the

regular dose

Sharplan 5-9 W, MTZ: 150μm, 2% coverage 8-42 fold increase

150XJ

Sharplan 5-11 W, MTZ: 150μm, 2% coverage at least 85% of the

150XJ cumulative
permeation

2,940 nm MCL30 5 J/cm2 11-56 fold increase

Dermablate
Er-YAG laser

1,550 nm Dinona Sellas 30 mJ, MTZ: 100 μm, 256-529 spots/cm2. 2-1200 fold increase
evo
Er-Glass laser

Table 2: The parameters used for enhanced percutaneous absorption by fractional lasers.

Hair Regeneration
The non-ablative fractional laser has been proposed as a treatment for patterned hair loss
recently. It is hypothesized that the laser energy may trigger the inflammatory response and
release of regenerative cytokines to stimulate hair growth. Various energies (5-35 mJ) and
densities (500-3,500 MTZ/cm2) of a 1,550nm Er-Glass fractional laser (Fraxel RE: STORE SR
1,500, Solta Medical, USA) were used to irradiate mice skin by Wu, et al., [7]. The energy
settings that could activate the hair follicle stem cells are dependent on the laser beam fluence
and density. As beam energy increased gradually from 10 mJ to 35 mJ, a corresponding trend
of decreased density (10-12 mJ/1500 MTZ, 15 mJ/1000 MTZ, and 25 mJ/500 MTZ) was noted.
Their research showed that the induction of anagen irradiated by lasers was an all-or-none
response within 7-9 days. A threshold change within the irradiated skin could be induced by a
laser before hair regenerate. Above the threshold, all the hair follicles within irradiated skin
enter anagen. The anagen phase may be induced directly or indirectly by appropriate laser beam
irradiation and adequate inflammation to the skin around an open wound. The various
combinations of beam energy and density will result in anagen induction or ulcer formation.
Ulcer formation followed by scarring may be caused by intense and persistent inflammation.

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Citation: Chen HH. The Applications of Fractional Lasers in Taiwan J Dermatol Res. 2021;2(1):1-9.

DOI: http://dx.doi.org/10.46889/JDR.2021.2101
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Clinical dermatologists may enhance anagen induction without ulcer formation by choosing an
appropriate therapeutic window of energy and density.

Cosmetic Tattoo Removal

The cosmetic tattoos were traditionally managed with q-switched ruby or Nd-YAG lasers. The
picosecond laser is now the preferred laser for cosmetic tattoo removal. However, to remove
non-black colored cosmetic tattoos is still very difficult. Using CO2 ablative fractional
resurfacing by five sessions at 1-month intervals with the settings of 17.5 mJ, 120 μm spot size,
and 10% density (AcuPulse, Lumenis, Yokneam, Israel), Wang, et al., tried to treat white and
flesh-colored cosmetic tattoos on rats [8]. Their results showed immediate ablation of tattoo
pigments and the formation of Microscopic Exudative Necrotic Debris (MENDs) as tattoo
pigments in the MTZ migrated to the epidermis on day 2 and exfoliated after 5 days. The effect
of a 1,550 nm Er-Glass non-ablative fractional laser (Sellas, Dinona, Korea) on rat skin was
also studied with 2 passes for five sessions at 1-month intervals under the energy settings of 17
mJ, and MTZ 169/cm2 [9]. Their results demonstrated the non-ablative fractional laser could
also disrupt the dermal-epidermal junction and remove skin-colored or white cosmetic tattoos
successfully by trans-epidermal elimination of tattoo pigments. Although CO2 ablative
fractional laser is traditionally thought to be more effective than non-ablative fractional laser
for cosmetic non-black colored tattoo removal, their reports revealed that non-ablative
fractional laser was as effective as CO2 ablative fractional laser.

Depressed Acne Scar

The most common application of fractional laser used in Taiwan is for the treatment of
depressed acne scars. The safety and effectiveness of 2,940 nm ablative fractional Er-YAG
laser for the treatment of atrophic facial acne scars in Taiwanese patients was evaluated by Hu,
et al., [10]. They performed two passes of Er-YAG laser on the cheeks and nose first, followed
by one more pass on the forehead with the setting of 100 to 150 μm, 5 to 20 mm2 scanning
mold, 430 μm spot size, and 11% coverage density (Profractional-XC, Sciton, Palo Alto, CA).
In order to create more thermal effects, extra passes under a level 2 to 3 coagulation mode were
performed on the cheeks, as well as level 1 on the forehead and mandible. Nearly three-quarters
of the patients were noted to achieve good or excellent improvement. The safety and
effectiveness of a 1,550 nm non-ablative Er-Glass fiber laser for the treatment of atrophic facial
acne scars were also investigated [11]. Sixty percent of the patients had good or excellent
results through one treatment session under the setting of 15-20 mJ/MTZ and a density of
1,000-2,000 MTZ/cm2 (spot width: 146-160 μm, depth: 682-754 μm) (Fraxel SR 750, Reliant,
USA). Similar results were found with the setting of 30-40 mJ/MTZ and a density of 392-520
MTZ/cm2 (spot width: 180-190 μm, depth: 980-1,120 μm) (Fraxel SR 1,500, Reliant, USA).

Chen HH | Volume 2; Issue 1 (2021) | JDR-2(1)-016 | Short Communication

Citation: Chen HH. The Applications of Fractional Lasers in Taiwan J Dermatol Res. 2021;2(1):1-9.

DOI: http://dx.doi.org/10.46889/JDR.2021.2101
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In conclusion, the treatment of depressed acne scars can be achieved by ablative or non-ablative
fractional lasers with similar comparable effective results. The ablative fractional Er-YAG
laser seemed to have better results than the CO2 laser did. With the higher fluence used, the
lower density should be used to avoid thermal damage. It remains to be studied whether the
effect of combined ablative and non-ablative laser treatment for depressed acne scars will be
more beneficial to the patients.

Limitations
Interpretation of our search results is limited by the few numbers of studies found, small sample
sizes, and various methodologies of the study designs.

Conclusion
The ablative fractional laser creates multiple tiny pores on the skin surface with MTZs
formation. Non-ablative fractional lasers cause dermal tissue damage without obviously
destructing the superficial epidermal layers, reserving the epidermal barrier function by intact
stratum corneum. Both of their clinical applications are enormous, from percutaneous
absorption, hair regeneration, cosmetic tattoo removal, to depressed acne scar treatments. We
believe that through these researches described above, we can successfully apply the ablative
or non-ablative fractional laser clinically to enhance the treatment results of different aspects
of dermatological conditions on our patients.

References
1. Lee WR, Shen SC, Chen WY, Aljuffali IA, Suen SY, Fang JY. Noninvasive delivery of siRNA and plasmid
DNA into skin by fractional ablation: Erbium:YAG laser versus CO 2 laser. Euro J Pharmaceutics and
Biopharmaceutics. 2014;86(2014):315-23.
2. Lee WR, Shen SC, Al-Suwayeh SA, Yang HH, Li YC, Fang JY. Skin permeation of small-molecule drugs,
macromolecules, and nanoparticles mediated by a fractional carbon dioxide laser: the role of hair follicles.
Pharm Res. 2013;30:792-802.
3. Hsiao CY, Sung HC, Hu S, Huang YL, Huang CH. Fractional CO 2 laser pretreatment facilitates transdermal
delivery of two vitamin c derivatives. Molecules. 2016;21(11):1547.
4. Hsiao CY, Sung HC, Hu S, Huang CH. Fractional CO 2 laser treatment to enhance skin permeation of
tranexamic acid with minimal skin disruption. Dermatol. 2015;230(3):269-75.
5. Chen WY, Fang CL, Al-Suwayeh SA, Yang HH, Li YC, Fang JY. Risk assessment of excess drug and
sunscreen absorption via skin with ablative fractional laser resurfacing optimization of the applied dose for
postoperative care. Lasers Med Sci. 2013;28:1363-74.
6. Lee WR, Shen SC, Aljuffali IA, Lin YK, Huang CW, Fang JY. Non-ablative fractional laser assists cutaneous
delivery of small- and macro-molecules with minimal bacterial infection risk. Euro J Pharmaceutical Sci.
2016;92:1-10.

Chen HH | Volume 2; Issue 1 (2021) | JDR-2(1)-016 | Short Communication

Citation: Chen HH. The Applications of Fractional Lasers in Taiwan J Dermatol Res. 2021;2(1):1-9.

DOI: http://dx.doi.org/10.46889/JDR.2021.2101
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7. Wu YF, Wang SH, Wu PS, Fan SMY, Chiu HY, Tsai TH, et al. Enhancing hair follicle regeneration by
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9. Wang CC, Huang CL, Lee SC, Sue YM, Leu FJ. Treatment of cosmetic tattoos with nonablative fractional
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Chen HH | Volume 2; Issue 1 (2021) | JDR-2(1)-016 | Short Communication

Citation: Chen HH. The Applications of Fractional Lasers in Taiwan J Dermatol Res. 2021;2(1):1-9.

DOI: http://dx.doi.org/10.46889/JDR.2021.2101