Abstract
Objectives: To compare the efficacy and safety of the ultra-pulsed carbon dioxide (CO2) laser and ultra-picosecond laser in managing Xanthelasma palpebrarum (XP). Methods: This retrospective study included 230 XP patients treated from February 2021 to June 2024. Among them, 120 patients received ultra-pulsed CO2 laser treatment, and 110 received ultra-picosecond laser treatment. Treatment effectiveness was assessed based on lesion clearance rate, recurrence, Vancouver Scar Scale (VSS) scores, and safety profiles, with a focus on complications such as scarring and pigmentary changes. Results: Both lasers achieved high clearance rates (> 95%), with no significant difference between the two groups (83.33% in the ultra-pulsed CO2 laser group vs. 80.00% in the ultra-picosecond laser group, P = 0.513). However, the ultra-picosecond group required more treatment sessions (4.74 ± 0.56 vs. 3.26 ± 1.32, P < 0.001) but had a lower recurrence rate (6.36% vs. 15.00%, P = 0.036). The ultra-pulsed CO2 laser group showed a higher incidence of hypertrophic scarring (8.33% vs. 1.82%, P = 0.026) and pigmentary complications (hyperpigmentation: 11.67% vs. 2.73%, P = 0.010; hypopigmentation: 10.83% vs. 3.64%, P = 0.037). A significant difference in erythema incidence was also observed (40.00% vs. 27.27%, P = 0.042). Patient satisfaction levels with the two treatments were comparable (P > 0.05). Conclusions: Both laser therapies were effective in treating XP. However, the ultra-picosecond laser demonstrated superior safety, with fewer complications and lower recurrence rates, despite requiring more treatment sessions.
Keywords: Xanthelasma palpebrarum, ultra-pulsed CO2 laser, ultra-picosecond laser, laser therapy, dermatology, recurrence rate
Introduction
Xanthelasma palpebrarum (XP) is the most common form of cutaneous xanthoma, typically appearing on the eyelids. These lesions consist of lipid-laden macrophages within the skin [1]. While benign, XP often causes cosmetic concern due to its prominent location on the eyelids and progressive growth [2]. Treatment options range from surgical removal to chemical treatments and laser therapy, each with varying effectiveness, limitations, and potential side effects [3].
Laser therapy has become a popular treatment option, offering a minimally invasive approach that may yield better cosmetic results [4]. Among lasers, the carbon dioxide (CO2) laser is widely used. Its effectiveness stems from precise horizontal tissue ablation, with high-energy light delivered in ultra-pulses [5,6]. The ultra-pulsed CO2 laser allows controlled tissue removal while minimizing damage to surrounding areas, which is crucial for sensitive areas like the eyelids [7]. However, concerns remain, including post-treatment erythema, prolonged recovery times, and the risk of scarring [8].
In recent years, picosecond lasers have emerged as a new option for skin treatments [9]. The ultra-picosecond laser, with its extremely short pulse durations, delivers intense, rapid pulses of laser energy that induce a photomechanical effect rather than a photothermal one. This allows precise targeting and disruption of pigmented lesions without causing collateral thermal damage [10,11]. This mechanistic distinction theoretically offers an advantage over traditional laser systems like the ultra-pulsed CO2 laser by potentially reducing recovery times and improving cosmetic outcomes [12]. While the efficacy of the ultra-picosecond laser in treating various pigmented lesions, including melasma and tattoos, has been well-documented, its use in XP remains underexplored [13].
Current literature reveals a gap in comprehensive, head-to-head comparisons between the ultra-picosecond laser and the ultra-pulsed CO2 laser for treating XP [14]. Most studies involve small cohort sizes or lack rigorous comparative designs, limiting the ability to draw robust conclusions about the optimal treatment approach [15]. This study aims to address these gaps by providing a large-scale, real-world clinical comparison of the two laser modalities. Our approach includes detailed evaluations of healing responses, patient satisfaction, and long-term outcomes, which are essential for establishing evidence-based guidelines for XP treatment. By systematically comparing the efficacy and safety profiles of the ultra-picosecond and ultra-pulsed CO2 lasers, this study seeks to identify the most effective and safest treatment options for XP, thereby significantly contributing to clinical practice.
Research methods
Research design and participants
This retrospective study included 230 XP patients treated at Wuhan No. 1 Hospital between February 2021 and June 2024. Among these, 120 patients received ultra-pulsed CO2 laser treatment, while the remaining 110 were treated with an ultra-picosecond laser. Ethical approval was obtained from the Institutional Review Committee and Ethics Committee of Wuhan No. 1 Hospital.
Eligible patients met the following criteria: clinical diagnosis of XP [16], completion of 6 months of follow-up, age above 18 years, Fitzpatrick skin types III-IV, and stable disease status. Exclusion criteria included pre-existing scarring or infection at the treatment site, allergy to lidocaine, malignant lesions, systemic immunological diseases, a history of sun exposure within the past month, use of topical retinoids or similar preparations, exposure to other laser treatments or chemical peels in the preceding three months, photosensitive diseases, or pregnancy or lactation.
Treatment methods
Patients in the ultra-pulsed CO2 laser group underwent a single treatment session using the HL-1R ultra-pulsed CO2 laser (HEALTH, China), with settings of 10,600 nm wavelength, 100-200 Hz frequency range, and 200-400 μs pulse duration. A continuously adjustable handpiece with a variable spot size (1-2 mm in diameter) and continuous exposure mode was utilized. Patients were instructed to keep their eyes closed during the procedure, with sterile gauze used for additional eye protection. Before laser treatment, anesthesia was administered subcutaneously with a mixture of 100 mL normal saline, 0.1% lidocaine, and 0.4 mL epinephrine using a 1 mL syringe. Charred tissue was carefully removed with gauze soaked in normal saline to expose the treatment areas. The endpoint of therapy was reached when the yellowish fatty tissue was completely removed, revealing the underlying pink tissue. Postoperatively, patients applied fusidic acid ointment as advised until the scabbing phase, typically seen between days five and seven. Patients were also instructed to keep the treated area clean and dry during this period and to follow strict sun protection measures thereafter. Treatments were administered at 4-6-week intervals, allowing complete healing between sessions.
The picosecond laser group followed the same preoperative anesthesia, ocular protection, treatment endpoint criteria, and postoperative care protocols as the ultra-pulsed CO2 laser group. Treatments were delivered using a 1064 nm PicoWay picosecond laser system (OM-PS03, AOMA, China). The treatment utilized a 1064 nm Zoom flat handpiece with the following settings: 3 mm spot diameter, energy density of 0.25-0.40 J/cm2, and a frequency of 8 Hz. These parameters were individually adjusted based on each patient’s skin tone, age, and tissue response. Patients were evaluated six months after the treatment session, and the number of sessions required to achieve the desired outcome was recorded.
Patient characteristics and lesion assessment
Demographic parameters including age, gender, medical history, and XP severity were systematically recorded. Clinical assessment involved categorizing xanthelasma lesions by number, size, location, and extent using a grading system [17]. In this system: Grade I indicated lesions confined to the upper eyelid; Grade II, extension to the medial canthus; Grade III, involvement of the medial upper and lower eyelids; and Grade IV, involvement of the medial-lateral aspects of both eyelids.
Lesion size was measured using a caliper to determine length and width at their longest points, with the skin held taut. Lesion height was measured using a mirror device as described by Nagamatsu et al. [18]: a 45° angled mirror was placed beside the lesion base, and the height scale reflected in the mirror was read. For patients with multiple lesions, the maximum height among all lesions was recorded. The number of laser treatment sessions was documented, with some patients requiring 2 to more than 4 sessions based on individual needs.
Biochemical examination
At baseline, patients underwent testing for abnormal serum lipid levels, including total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglycerides. Mixed hyperlipidemia was defined as combined elevation of triglycerides and total cholesterol, following the Fredrickson classification [19]. Patients with abnormal lipid levels were referred to the outpatient department for dietary counseling and/or pharmacological treatment.
Additionally, fasting venous blood samples (5 mL) were collected upon admission, treated with ethylenediaminetetraacetic acid as an anticoagulant, and centrifuged at 2,800 rpm for 15 minutes to isolate serum. Fasting blood glucose (FBG) and 2-hour postprandial blood glucose (2hPBG) were measured using an automated biochemical analyzer (BS-280, Mindray, China).
Treatment effectiveness
The primary outcomes for evaluating treatment effectiveness were lesion clearance rate and recurrence rate. These outcomes were assessed objectively by two independent plastic surgeons using standardized photographs taken before and after treatment. Photographs were captured by a trained technician using a digital camera (D7500, Nikon, Thailand) with consistent settings: fixed 1-meter distance from the patient, uniform background, and lighting. Each patient was photographed from three angles: front, right side, and left side.
All patients were independently evaluated by a senior investigator (blinded to the treatment method) using the following grading system [20]: (1) lesion thickness (Grade 1: flat; Grade 2: mildly elevated; Grade 3: moderately elevated; Grade 4: markedly elevated); (2) lesion color (Grade 1: yellowish; Grade 2: yellowish-orange; Grade 3: orange); and (3) lesion area (in mm2, calculated as the product of the two longest dimensions).
Lesion clearance was categorized into four levels by comparing preoperative and post-final-treatment photographs: < 50% cleared, 50%-75% cleared, 76%-95% cleared, and > 95% cleared (proportion of cleared area relative to total lesion surface area).
Recurrence was defined as the reappearance of xanthelasma within the previously treated area; new lesions outside treated areas were not considered recurrence.
Complication monitoring
Complications were monitored for 6 months post-procedure. Postoperative photographs were independently reviewed by two ophthalmologists to identify complications (e.g., hypertrophic scars, pigmentary changes, Koebner-like phenomena). Disagreements between the two ophthalmologists were adjudicated by a senior ophthalmologist.
Immediate treatment related adverse events
All patients were assessed immediately after each laser session for treatment-emergent erythema, edema, burning pain, and pruritus, which were documented within medical records.
Scar evaluation using the Vancouver Scar Scale (VSS)
Scar outcomes were assessed using the VSS, which evaluates color, height, vascularity, and pliability [21]. Each parameter was scored as follows: color (0: normal skin color; 3: very dark); height (0: flat; 3: hypertrophic); vascularity (0: no visible vessels; 3: numerous vessels); and pliability (0: soft; 3: hard). All assessments were performed by an independent dermatologist.
Patient satisfaction assessment
Treatment satisfaction was evaluated in both groups using a hospital-developed questionnaire scored out of 100 points. Satisfaction levels were categorized as: Very Satisfied (90-100 points), Satisfied (60-89 points), and Dissatisfied (< 60 points), with higher scores indicating greater satisfaction.
Statistical analysis
Data were analyzed using SPSS 29.0 (SPSS Inc., Chicago, IL, USA). Normally distributed measurement data were expressed as mean ± standard deviation and compared between groups using the independent-samples t-test. Categorical data were presented as n (%) and analyzed using the chi-square test. A p-value < 0.05 was considered statistically significant.
Results
Comparison of demographic and basic data
There were no significant differences in baseline characteristics between the ultra-pulsed CO2 laser group and ultra-picosecond laser group (all P > 0.05; Table 1). Specifically, the two groups were comparable in terms of age, gender distribution, comorbidities (hypertension, diabetes, hyperlipidemia), duration and size of xanthelasma, lesion location, grading, Fitzpatrick skin type, and other parameters (e.g., lesion height, family history). These results confirm balanced baseline characteristics, providing a reliable basis for subsequent efficacy comparison.
Table 1.
Comparison of demographic and basic data between the two groups
| Parameters | Ultra-pulsed CO2 laser group (n = 120) | Ultra-picosecond laser group (n = 110) | t/χ2 | P |
|---|---|---|---|---|
| Age (years) | 43.48 ± 8.41 | 43.23 ± 8.22 | 0.227 | 0.821 |
| Gender (Female, %) | 91 (75.83%) | 79 (71.82%) | 0.480 | 0.488 |
| Hypertension [n (%)] | 24 (20.00%) | 24 (21.82%) | 0.115 | 0.735 |
| Diabetes [n (%)] | 50 (41.67%) | 50 (45.45%) | 0.335 | 0.563 |
| Hyperlipidemia [n (%)] | 76 (63.33%) | 75 (68.18%) | 0.598 | 0.439 |
| Duration of xanthelasma (months) | 3.16 ± 1.24 | 2.95 ± 1.54 | 1.177 | 0.240 |
| Location of xanthelasma [n (%)] | 1.966 | 0.374 | ||
| Upper eyelid | 57 (47.50%) | 60 (54.55%) | ||
| Lower eyelid | 10 (8.33%) | 5 (4.55%) | ||
| Upper and lower eyelids | 53 (44.17%) | 45 (40.91%) | ||
| Mean size of lesions (mm2) | 10.08 ± 1.05 | 10.16 ± 1.23 | 0.537 | 0.592 |
| Grade [n (%)] | 1.504 | 0.681 | ||
| I | 100 (83.33%) | 88 (80.00%) | ||
| II | 6 (5.00%) | 10 (9.09%) | ||
| III | 9 (7.50%) | 8 (7.27%) | ||
| IV | 5 (4.17%) | 4 (3.64%) | ||
| Fitzpatrick skin type [n (%)] | 0.262 | 0.609 | ||
| III | 52 (43.33%) | 44 (40.00%) | ||
| IV | 68 (56.67%) | 66 (60.00%) | ||
| Involved eye [n (%)] | 0.062 | 0.803 | ||
| Unilateral | 20 (16.67%) | 17 (15.45%) | ||
| Bilateral | 100 (83.33%) | 93 (84.55%) | ||
| Lesion height [n (%)] | 0.489 | 0.484 | ||
| ≤ 2 mm | 113 (94.17%) | 101 (91.82%) | ||
| > 2 mm | 7 (5.83%) | 9 (8.18%) | ||
| Family history of similar lesions [n (%)] | 17 (14.17%) | 17 (15.45%) | 0.076 | 0.783 |
| Medication [n (%)] | 1.032 | 0.597 | ||
| Diet control | 42 (35.00%) | 32 (29.09%) | ||
| Anti-lipid medication (statins) | 26 (21.67%) | 28 (25.45%) | ||
| Unknown | 52 (43.33%) | 50 (45.45%) | ||
| Time of onset [n (%)] | 0.192 | 0.661 | ||
| Initial onset | 113 (94.17%) | 105 (95.45%) | ||
| Recurrence | 7 (5.83%) | 5 (4.55%) |
Comparison of biochemical profiles
No statistically significant differences were observed in biochemical profiles between the two groups (all P > 0.05; Table 2). This included total cholesterol, HDL-C, LDL-C, triglycerides, FBG, and 2hPBG, indicating similar metabolic status at baseline.
Table 2.
Comparison of Biochemical profiles between the two groups
| Parameters | Ultra-pulsed CO2 laser group (n = 120) | Ultra-picosecond laser group (n = 110) | t | P |
|---|---|---|---|---|
| Total cholesterol (mg/dL) | 244.57 ± 84.63 | 238.43 ± 79.14 | 0.567 | 0.572 |
| HDL-C (mg/dL) | 42.75 ± 7.85 | 43.51 ± 6.32 | 0.812 | 0.418 |
| LDL-C (mg/dL) | 109.36 ± 22.09 | 114.67 ± 29.17 | 1.544 | 0.124 |
| Triglycerides (mg/dL) | 129.84 ± 42.65 | 126.68 ± 41.56 | 0.568 | 0.570 |
| FBG (mg/dL) | 109.32 ± 43.35 | 102.54 ± 35.26 | 1.305 | 0.193 |
| 2hPBG (mg/dL) | 145.67 ± 78.21 | 134.63 ± 40.15 | 1.362 | 0.175 |
HDL-C: High density lipoprotein cholesterol; LDL-C: Low-Density Lipoprotein Cholesterol; FBG: Fasting Blood Glucose; 2hPBG: 2h Postprandial Blood Glucose.
Comparison of degree of improvement in area, color, and thickness of XP lesions
Pre-treatment lesion area, color grade, and thickness grade showed no significant differences between the groups (all P > 0.05; Figure 1). However, post-treatment differences were observed: the ultra-pulsed CO2 laser group achieved a significantly greater reduction in lesion area (P = 0.031) and lesion thickness (P = 0.001), while the ultra-picosecond laser group demonstrated significantly superior color improvement (P = 0.013).
Figure 1.
Comparison of Degree of Improvement in Area, Color, and Thickness of XP Lesions between the two groups. A: Area (mm2) before treatment; B: Area (mm2) after treatment; C: Color (grade) before treatment; D: Color (grade) after treatment; E: Thickness (grade) before treatment; F: Thickness (grade) after treatment. ns: no significant difference; *: P < 0.05; **: P < 0.01.
Comparison of clearance rate
High clearance rates (> 95%) were achieved in both groups, with 83.33% in the ultra-pulsed CO2 laser group and 80.00% in the ultra-picosecond laser group. No significant difference was observed in clearance rates between the two groups (P = 0.513; Table 3).
Table 3.
Comparison of clearance rate between the two groups
| Parameters | Ultra-pulsed CO2 laser group (n = 120) | Ultra-picosecond laser group (n = 110) | χ2 | P |
|---|---|---|---|---|
| < 50% | 0 (0.00%) | 0 (0.00%) | 0.427 | 0.513 |
| 50-75% | 0 (0.00%) | 0 (0.00%) | ||
| 76-95% | 20 (16.67%) | 22 (20.00%) | ||
| > 95% | 100 (83.33%) | 88 (80.00%) |
Comparison of treatment sessions and recurrence rate
Clinical photographs of a patient with bilateral XP lesions are shown in Figure 2, demonstrating progressive clearance following ultra-picosecond laser treatment.
Figure 2.
A patient with bilateral XP lesions. A: Before treatment; B: After 1st session; C: After 2nd session; D: 1 month after 3 sessions treatment of picosecond laser with complete removal of lesions. XP: Xanthelasma palpebrarum.
The ultra-picosecond laser group required significantly more treatment sessions than the ultra-pulsed CO2 laser group (t = 11.224, P < 0.001; Table 4). However, the recurrence rate was significantly lower in the ultra-picosecond laser group (χ2 = 4.418, P = 0.036).
Table 4.
Comparison of treatment sessions and recurrence rate between the two groups
| Parameters | Ultra-pulsed CO2 laser group (n = 120) | Ultra-picosecond laser group (n = 110) | t/χ2 | P |
|---|---|---|---|---|
| Treatment sessions | 3.26 ± 1.32 | 4.74 ± 0.56 | 11.224 | < 0.001 |
| Recurrence rate [n (%)] | 18 (15.00%) | 7 (6.36%) | 4.418 | 0.036 |
Comparison of complications
The ultra-pulsed CO2 laser group had a significantly higher incidence of hypertrophic scars (P = 0.026), hyperpigmentation (P = 0.010), and hypopigmentation (P = 0.037) compared to the ultra-picosecond laser group (Table 5). Koebner-like phenomena were rare and did not differ significantly between groups (1 case in the ultra-pulsed CO2 group vs. none in the ultra-picosecond group). These findings suggest the ultra-picosecond laser was associated with a lower risk of pigmentary changes and scarring.
Table 5.
Comparison of complications between the two groups
| Parameters | Ultra-pulsed CO2 laser group (n = 120) | Ultra-picosecond laser group (n = 110) | χ2 | P |
|---|---|---|---|---|
| Hypertrophic scar [n (%)] | 10 (8.33%) | 2 (1.82%) | 4.926 | 0.026 |
| Hyperpigmentation [n (%)] | 14 (11.67%) | 3 (2.73%) | 6.700 | 0.010 |
| Hypopigmentation [n (%)] | 13 (10.83%) | 4 (3.64%) | 4.343 | 0.037 |
| Koebner-like phenomena [n (%)] | 1 (0.83%) | 0 (0.00%) | None | 1.000 |
Comparison of immediate side effects during treatment
Significantly more patients in the ultra-pulsed CO2 laser group developed erythema compared to the ultra-picosecond laser group (P = 0.042; Table 6). No significant differences were observed in the incidence of edema (P = 0.597), burning pain (P = 0.726), or itching (P = 0.055, approaching but not reaching statistical significance).
Table 6.
Immediate side effects between the two groups
| Parameters | Ultra-pulsed CO2 laser group (n = 120) | Ultra-picosecond laser group (n = 110) | χ2 | P |
|---|---|---|---|---|
| Erythema | 48 (40.00%) | 30 (27.27%) | 4.148 | 0.042 |
| Edema | 17 (14.17%) | 13 (11.82%) | 0.279 | 0.597 |
| Burning Pain | 24 (20.00%) | 20 (18.18%) | 0.123 | 0.726 |
| Itching | 41 (34.17%) | 25 (22.73%) | 3.670 | 0.055 |
Comparison of VSS scores
VSS scores differed significantly between groups in terms of color (P = 0.047), height (P = 0.029), and vascularity (P = 0.029), with higher scores in the ultra-pulsed CO2 laser group (Table 7). No significant difference was found in plasticity (P = 0.732).
Table 7.
Comparison of VSS scores between the two groups
| Parameters | Ultra-pulsed CO2 laser group (n = 120) | Ultra-picosecond laser group (n = 110) | t | P |
|---|---|---|---|---|
| Color | 1.47 ± 0.46 | 1.35 ± 0.42 | 1.993 | 0.047 |
| Height | 0.93 ± 0.30 | 0.85 ± 0.28 | 2.193 | 0.029 |
| Plasticity | 1.86 ± 0.55 | 1.83 ± 0.53 | 0.342 | 0.732 |
| Vascularity | 1.07 ± 0.33 | 0.98 ± 0.31 | 2.194 | 0.029 |
Comparison of patient satisfaction
Overall patient satisfaction rates were comparable between the ultra-pulsed CO2 laser group (85.83%) and the ultra-picosecond laser group (88.18%; P = 0.597; Table 8), with high levels of satisfaction in both groups.
Table 8.
Comparison of patient satisfaction between the two groups
| Parameters | Ultra-pulsed CO2 laser group (n = 120) | Ultra-picosecond laser group (n = 110) | χ2 | P |
|---|---|---|---|---|
| Very satisfied | 32 (26.67%) | 30 (27.27%) | ||
| Satisfied | 71 (59.16%) | 67 (60.91%) | ||
| Dissatisfied | 17 (14.17%) | 13 (11.82%) | ||
| Satisfaction rate [n (%)] | 103 (85.83%) | 97 (88.18%) | 0.279 | 0.597 |
Discussion
In the present study, we compared the efficacy and safety of ultra-picosecond lasers versus ultra-pulsed CO2 lasers in treating XP. First, the underlying mechanisms contributing to the observed outcomes warrant discussion. The ultra-pulsed CO2 laser operates at a wavelength of 10,600 nm, which is absorbed by tissue water, enabling effective ablation through vaporization [22,23]. This explains its superior performance in reducing lesion thickness and area, as evidenced by significantly smaller post-treatment dimensions - consistent with its established role in remodeling severe scars [24]. However, the CO2 laser’s thermal properties, while enabling aggressive ablation, elevate the risk of hypertrophic scarring and pigmentary changes, aligning with findings from previous studies [25]. The higher rates of hyperpigmentation and hypopigmentation in the CO2 laser group likely result from post-inflammatory pigmentary alterations, a common consequence of deeper dermal injury affecting underlying skin structures [26]. VSS assessments further confirmed inferior outcomes in the CO2 laser group compared to the ultra-picosecond group, with higher scores in color, height, and vascularity indicating poorer scar quality.
The ultra-picosecond laser, utilizing 1064 nm wavelength energy, acts via photoacoustic effects [27], precisely targeting pigmentation while limiting heat diffusion to adjacent tissues. This aligns with prior research showing that picosecond lasers reduce risks of pigmentary changes and scarring compared to traditional ablative methods [28]. Although requiring more treatment sessions, the ultra-picosecond laser achieved a lower recurrence rate - an advantage attributed to its precision in targeting both melanin and lipid-laden cells in xanthelasma, thereby minimizing residual lesion tissue that could regrow [29,30].
Both modalities demonstrated significant efficacy, with clearance rates exceeding 95%, consistent with previous research highlighting the ultra-pulsed CO2 laser’s high efficiency via tissue vaporization [31]. The ultra-pulsed CO2 laser achieved these results in fewer sessions, owing to its aggressive tissue-removal capacity, which enables substantial reductions in lesion size and thickness per session [32]. However, this efficiency comes with a higher risk of adverse effects (e.g., scarring), a critical concern given the eyelid’s sensitivity [33].
Differences in treatment session requirements also offer insights for patient management. Ultra-picosecond laser therapy, while requiring more sessions, may involve greater initial time investment and perceived inconvenience [34]. However, it yields superior long-term aesthetic outcomes, with reduced scarring, pigmentary alterations, persistent erythema, and lower recurrence rates - key considerations for XP patients, whose motivations are predominantly cosmetic [35]. This longer treatment timeline reflects a strategic focus on gradual yet safer lesion clearance, avoiding immediate postoperative complications, a priority emphasized in previous studies evaluating laser treatments [36].
Notably, patient satisfaction was comparable between the two groups despite their differing profiles. This suggests that while the ultra-pulsed CO2 laser offers quicker results, patients also value the ultra-picosecond laser’s favorable safety profile. Satisfaction with laser treatments depends not only on clearance speed but also on factors like side effects, healing time, and post-treatment skin texture [37,38]. The ultra-picosecond laser’s lower rates of pigmentary changes, hypertrophic scarring, and recurrence likely balanced the need for more sessions, indicating that patients holistically weigh immediate results against long-term safety and aesthetics when assessing treatment success.
These findings have implications for clinical practice: clinicians should tailor laser selection to individual patient profiles, weighing the priority of rapid results against long-term cosmetic outcomes [39]. For patients prone to scarring or with darker skin types (where pigmentary changes are more conspicuous), the ultra-picosecond laser is preferable [40]. In contrast, the ultra-pulsed CO2 laser remains a viable option for patients seeking fewer interventions, provided they are fully informed of the higher risk of adverse skin reactions [41].
When drawing these conclusions, it is crucial to acknowledge the limitations of this study and point out directions for future research. The single-center design, which is affected by the demographic characteristics of local patients and operator-dependent techniques, may restrict the generalizability of the results. Retrospective data collection brings the risk of selection bias, although strict inclusion criteria have alleviated confounding factors to a certain extent. The six-month follow-up period is insufficient to evaluate long-term recurrence and persistent pigment changes, especially the late scarring related to ultra-pulsed CO2 laser treatment. Although our sample size is sufficient and the follow-up period is consistent, extending the follow-up period beyond six months can provide insights into the long-term efficacy and recurrence patterns of each laser modality. In addition, further comparative studies that include patient-reported outcome measures in addition to clinical evaluations will deepen our understanding of the factors influencing subjective satisfaction.
In conclusion, this study provides evidence that both the ultra-picosecond laser and the ultra-pulsed CO2 laser are effective in the treatment of XP, and each has unique advantages that should guide clinical decision-making. The ultra-pulsed CO2 laser may achieve faster lesion clearance, while the ultra-picosecond laser has a better safety profile, with fewer complications and a lower recurrence rate - these attributes may improve long-term patient satisfaction. As laser technology continues to develop, ongoing research and evidence-based practice improvements will further optimize the treatment paradigms for this common and challenging dermatological condition.
Disclosure of conflict of interest
None.
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