Carboxytherapy medical and aesthetic indications

We can split indications into two groups: medical vascular diseases and aesthetic procedures. The first group is the best documented, with a large number of publications since 1930.

Vascular

• Raynaud’ phenomenon
• Lower limbs arterial diseases and ischemia
• Erectile dysfunction with microvascularization disorders

Aesthetic

• Localized fat
• Acne scars
• Surgical scars
• Traumatic scars
• Stretch marks
• Eye wrinkles, fat deposits and under-eye dark circles
• Rejuvenation of the hands, decolletage, neck
• Psoriasis
• Nasogenian folds and peri-oral wrinkles

It should be noted that some South American physicians, although not published, use CDT prior to surgery
to lower scarring complications. Some operators also use CDT to treat skin grafts, hair loss and burnt skin.

Raynaud’s Phenomenon
Raynaud’s phenomenon is a vasospastic disorder of the extremities causing discoloration of fingers and toes, and pain. It is an inappropriate vasomotor response to cold and/or emotional stress, with sympathetic system hyper-activation, which leads to strong vasoconstriction of the peripheral blood vessels, causing tissue hypoxia. Chronic Raynaud’s phenomenon may lead to skin atrophy.

CDT has blood flow increase properties, especially targeting microcirculation of the superficial tissues. In addition, the Bohr effect has strong anti-ischemic properties. CDT may therefore be a complementary treatment for this  condition.

Lower Limb Vascular Diseases with Ischemic Symptoms
CDT has been widely used in France’s Royat Spa since the beginning of the 20th century to treat arterial diseases of the legs. There are now better treatments available such as bypasses and vessel grafts. CDT should only be seen as a complementary procedure for lower limb ischemic arteriopathy.

Localized Fat
Since its publication at the University of Siena, the use of CDT for localized fat has been among the best known indications for the technique. Direct pressure causes trauma to the adiposities and, although this is unproven, seems to weaken them. Blood flow increase and the Bohr effect bring more oxygen to the adiposities leading to an optimized physiological lipolysis.

CDT can be used alone for localized fat or combined with liposuction for even better results. It can also be used to improve the ‘wave effect’, which may be seen after a liposuction, especially in areas which were either not treated or not treated effectively. Physicians should be aware that liposuction may create septations, preventing the gas from diffusing normally and requiring multiple CO2 punctures.

Acne Scars
CDT works in various ways for acne scars. It has been demonstrated that CO2 injections stimulate the synthesis of collagen. This property is used to improve atrophic scars by increasing the quantity of collagen below the atrophy. Nd–YAG (1064 nm) or erbium–glass (1320–1550 nm) lasers produce the same effect. The use of CDT is adapted to imperfections and mild acne scarring.

Some CDT procedures may also be of use in a way which can be compared to subcision. Some physicians use high flows of CO2 to simulate the effect of a needle. This technique aims to break fibrous septae which pull the scar below the skin surface. As yet, no stabilized protocol has been published but before/after photographs show interesting results.

Surgical Scars
CDT is also used to improve post-surgery scars. CO2 may restore skin laxity and color, and speeds up the wound-healing process. It is an interesting procedure for white thyroidectomy, caesarean, appendectomy scars and other scars in general.

Some physicians also use CDT in a presurgical procedure to prepare the skin for the healing phase before the surgical incision.

Traumatic Scars
Recent trauma may benefit from the healing properties of CO2. The improvement of oxygen concentration and the neo-vascularization induced by subcutaneous injections shortens skin restoration times. CO2 may prevent hypocromic scars, especially with dark phototypes.

Stretch Marks
Stretch marks are very common among women and are a good indication for CDT. While recent marks may benefit from pulsed dye laser or potassiumtitanyl-phosphate (KTP) laser sessions, old white marks still remain a problem for the physicians.

Some authors have stimulated pigmentation using excimer lasers or UV-B narrow-band lamps. Others are using collagen remodeling lasers such as with Nd–YAG, erbium–glass and fractional lasers. All these approaches have a non-negligible level of patient dissatisfaction. CDT is a relatively new indication for old white stretch marks. It works in three different ways:

• neo-angiogenesis below the mark, which adds a pink color
• elanin stimulation caused by increased oxygen in the tissues
• collagen synthesis, which reduces the creased appearance.

Eye Wrinkles, Lower Lid Fat Deposits and Under-eye Circles
Because it stimulates collagen synthesis and has a local lipolytic action, CO2 injection may be an indication for eye rejuvenation and fat deposits. The procedure is easy, fast and produces virtually no pain.
There are several possible causes of dark undereye circles:

• Deposition of pigments and melanin after the lower lid has been exposed to allergy and chronic  irritation/inflammation can be compared to postinflammatory hyperpigmentation. This is not a good CDT indication. Physicians would probably use peelings and/or lasers (KTP, Q-switched).
• Vascular pooling with congestion of the lower eye u0955 lid capillary network results in a bluish appearance that can be seen through the skin. CDT is a good indication for this condition: better oxygenation and higher flow will convert the blue color to red, decreasing the dark circle appearance.
• The depression beneath the lower eyelids known as ‘tear trough deformity’ is not a good indication for CDT. Patients need fillers to restore volume.
• Fat accumulation in the lower part of the lower lid, known as ‘fatty prolapse’ is a good indication for CDT sessions as the procedure has lipolytic properties. Extreme care should be taken in this area because the skin is fragile and thin. Low flow values should be used.

Rejuvenation of the Hands, Decolletage and Neck
Carbon dioxide injections are also good for skin laxity and therefore skin rejuvenation, in all the exposed areas.
The dorsal side of the hands may be treated using intradermal injections. The expected effect is skin tightening after four or more sessions. CDT will have no effects on lentigos, which will require other treatment modalities such as nitrogen, KTP laser, Alexandrite laser or Q-switched laser. Neck and decolletage rejevenation are very good indications for CDT.

Psoriasis
Some physicians use CDT for psoriasis treatment. There do not appear to be any protocols or published studies about this indication, which should be considered experimental.

Nasogenian Folds and Peri-oral Wrinkles
CDT is an alternative to fillers in some cases.
Patients with contraindications to fillers or who do not want filler injections may be treated with CO2 injections. Physicians and patients should be informed that several sessions are necessary with CO2, with progressive improvement, whereas fillers have immediate results.