Fractional / Pixel CO2 Laser Treatment of Vulvar Atrophy and Lichen Sclerosus

Many studies have been published recently describing the use of a fractional/pixel CO2 laser for the treatment of various disorders of the vulva and the vagina, such as atrophy due to estrogen deficiency, urinary stress incontinence, skin diseases (lichen sclerosus) and more.

The results of the studies that investigated this technology in relation to vaginal atrophy and urinary stress incontinence have shown improvement in symptoms after a series of only 3 treatments.

The proposed effect of the fractional CO2 laser is based on studies performed on non-genital tissues [Daffon, Capon], which demonstrated changes in the connective tissue and proliferation of fibroblasts, as well as formation of collagen and elastic fibers. The suggested explanation is based on the theory that heat shock proteins are involved in the process and arise due to thermal tissue damage, and this in turn activate tissue cytokines, growth factors and fibroblasts. These theories have not been proven for vulvar and vaginal tissues, and except for the demonstration of histologic and morphologic changes in the irradiated tissues [Salvatore, Menopause 2015], the cellular mechanism of action and the nature of the process mediating the changes in uro-genital tissues has not yet been examined.

The technology known as fractional CO2 has been used for many years in dermatology and plastic surgery. In this method, the laser beam splits while passing through a lens to 81 dots (9 x 9 pixels) onto approximately 1 cm2. The laser beam penetrates the tissue and causes minimal evaporation around each spot of the fractionated beams and release of heat only at the desired tissue depth. The method of energy transfer to tissues in tiny dots leads to the creation of various thermal effects in the focus of the beam, around the focus, and in the areas between these heat foci. Following the tissue irradiation, different processes occur: epithelial cell proliferation and thickening of the epithelial layer, migration and proliferation of endothelial cells, creation of neo-vasculature in the lamina propria, creation of collagen and elastic fibers, and accumulation of glycogen in the cells [Salvatore, Menopause 2015]. The result of these processes is improved tissue elasticity and plasticity as well as regeneration of the epidermis layer. Previous studies demonstrated that the effect of this treatment on the atrophic vagina is identical to long-term local estrogen treatment, with improved cytological index, improved lubrication, alteration of the vaginal flora, and reduced acidity to the level of "estrogenic" levels (approx. pH 4 -4.5) [Salvatore, Menopause, 2015;Perino; Gasper; Salvatore, Climacteric, 2015].

Considering the multitude of recently published articles presenting impressive clinical results, the investigators decided to examine the effects of the treatment with a fractional CO2 laser on the vaginal and vulvar tissue at a cellular level for two conditions: vaginal atrophy due to estrogen deficiency and lichen sclerosus. These two conditions were chosen due to the magnitude of recent publications dealing with clinical and histological improvement in these two pathological conditions following laser treatment. Understanding the cytological processes will enable the foundation of knowledge about the basic mechanism of action, and propose methods to improve the current therapeutic protocols. It will also enable the observation of the duration of the treatment effect, and the assessment of whether these changes are associated with undesired events, such as increased risk of malignant tissue transformation.