Achieving the maximum efficacy by combining non‐ablative fractional laser with vitamin C, vitamin E and ferulic acid serum for skin quality improvement in Asian population

Skin quality is a crucial consideration in early stage facial skin rejuvenation, particularly when faced with issues like enlarged facial pores and uneven skin tone, which can be especially bothersome for the Asian population. In the field of aesthetic dermatology, lasers have emerged as valuable tools for skin resurfacing and remodeling. Considering the tolerance and effectiveness, non-ablative fractional lasers (NAFL) stand out among the available treatments. NAFL have demonstrated its effectiveness in treating acne scar with minimal complications.1, 2 While challenges persist for a subset of patients, including erythema and postinflammatory hyperpigmentation (PIH) and skin barrier damage following laser treatments. Research has shown that a combination of antioxidants including l-ascorbic acid (an active isoform of vitamin C), vitamin E, and ferulic acid (CE Ferulic) is effective in improving the signs of photoaging.3 When combined with ablative fractional laser, it showed adjunctive effect of enhancing scar detachment, and reducing post-treatment erythema and edema.4 Therefore, CE Ferulic has the potential to accelerate the wound healing process after NAFL and enhance its effectiveness in improving skin quality. To contribute to this expanding body of research, we present a case series involving patients who underwent NAFL therapy across multiple centers, with subsequent topical application of CE Ferulic serum. We have undertaken a series of clinical and instrumental evaluation in four subjects aged 20–40 assessing changes related to combined therapy for skin quality improvement. In this series of cases, topical application of CE Ferulic serum (SkinCeuticals Inc., New York, NY, USA) was employed immediately after NAFL treatment and once or twice a day for periods ranging from 1 to 4 weeks for one side of face. Normal saline (NS) or placebo cream was employed for the other side as control. VISIA® (Canfield Scientific, USA) was employed to obtain the standardized clinical photograph and assess facial skin erythema, along with key skin quality parameters. NAFL (1440 nm; Clear + Brilliant® Permea™, Solta Medical, Hayward, CA, USA) was undertaken for a 38-year-old female patient presented with a long-term skin quality concern involving enlarged pores and skin tone unevenness. The results revealed an overall improvement in skin parameters on the CE Ferulic-treated side, especially in terms of winkles, skin texture and pore size. Conversely, the skin parameters on the control side did not exhibit a noticeable improvement and even showed slightly increase in ultraviolet spots, brown spots and porphyrin levels 7 days after procedure (Figure 1). Patient reported less discomfort and improved skin radiance with CE Ferulic-treated side compared to the control side. A 27-year-old female patient, previously diagnosed with papulopustular rosacea with no intermittent flushing and newly occurred pustule and papule in the past year, had long-term skin quality concern of enlarged pores. She had undergone multiple sessions of intense pulsed light treatment for skin rejuvenation for the past years with no discernible improvement. 1550 nm Erbium-Doped NAFL System (Fraxel SR 1500, Reliant Technologies Inc., Mountain View, CA, USA) was performed with eight passes, at 40–45 mJ and 11% of coverage. Tewameter TM300 and Mexameter MX18 (Courage + Khazaka Electronic GmbH, Koln, Germany) was utilized to measure the transepidermal water loss (TEWL) and erythema index (EI) additionally. The results exhibited a noteworthy improvement in facial erythema on the CE Ferulic-treated side immediately after the procedure and continued to show substantial enhancement 7 days post-treatment in comparison to the control side. TEWL and EI were lower on the CE Ferulic-treated side compared with the control side during the observation time (Figure 2). Consistent with improvement in EI, patients reported less burning sensation and pain on the treated side. Furthermore, there was an outburst of pustular rashes after procedure, while CE Ferulic-treated side showed less papules left than the control side at Day 7, suggesting its potential anti-inflammatory effect. Two male patients presented with acne scars and enlarged pores predominantly on their facial skin. Topical application of CE Ferulic serum and a novel formulation containing high levels of physiological barrier lipids (Triple Lipid Restore 2:4:2, SkinCeuticals Inc., New York, NY, USA) was undertaken immediately and twice a day after NAFL treatment, placebo cream to the other side of face as control. Time required for complete scab detachment was monitored and pigmentation was assessed by melanin index (MI) measured by Mexameter MX18. For the first patients, non-ablative 1565 nm laser (ResurFX; Lumenis, Yokneam, Israel) was performed at 50 mJ, with a spot density of 200 μb/cm2. CE Ferulic-treated side showed a significant improvement in erythema in comparison to the control side immediately after procedure, 3, 10, and 25 days following the treatment (Figure 3). The 1550-nm erbium-doped NAFL System (Fraxel SR 1500, Reliant Technologies Inc., Mountain View, CA, USA) was performed with eight passes, at 35 mJ and 11% of coverage, for the second male patient. The results consistently indicated the improvement of erythema immediately after treatment and at 3, 7, and 30 days post-treatment, compared to the control side (Figure 4). Additionally, the CE Ferulic-treated side showed a 6.67% decrease in MI from baseline at day 80, while the control side experienced a 30% increase in MI (Δ = −36.67%). Complete scabbing detachment at the CE Ferulic-treated side was 5 days compared to 7 days for the NS side. Furthermore, the CE Ferulic-treated side showed more noticeable improvements in acne scars and enlarged pores, which became increasingly apparent over time. This real-world case series aimed to evaluate the effectiveness of a combination of antioxidants serum comprising vitamin C, vitamin E and ferulic acid, as an adjuvant to NAFL treatment in patients experiencing skin quality concerns, including photoaging, rosacea, and acne scars. Our cases demonstrated that this serum is noted as an adjunct of NAFL for improving skin quality. Patients in this case series reported reduced erythema and shorter downtime due to the accelerated scabbing detachment after CE Ferulic serum usage, indicating a positive impact on the healing process and overall skin condition post-laser treatment. The serum also showed significant capacity to ameliorate symptoms of rosacea-related erythema and immediate pain, suggesting its broader application in promoting skin barrier repairment. Topical application of CE Ferulic serum was well tolerated immediately post non-ablative fractional laser with no drug-related adverse event occurred in this case series. Laser treatments aimed at enhancing skin tone and quality have gained increasing popularity. Fractional lasers fall into two categories: ablative and non-ablative, both of which stimulate neocollagenesis for improving the skin quality.5 Ablative skin resurfacing is associated with extended recovery periods, potential scarring and dyspigmentation, pain and discomfort.6 While NAFL is effective in improving skin quality with fewer side effects and shorter downtime.7 However, challenges like PIH and skin barrier damage persist, which can be potentially addressed by CE Ferulic serum. The decrease of MI level indicated the benefits of CE Ferulic in preventing PIH after procedure. In this context, the combination of NAFL with C E Ferulic serum has introduced new perspectives in terms of minimal complications and enhanced effectiveness. The topical application of triple lipid restore cream has been demonstrated to recover damaged skin barrier function,8 and might contribute to the decrease of erythema and accelerated recovery with additional moisturization function. Vitamin C derivatives are commonly used as adjunctive treatments for dyspigmentation. Studies have demonstrated that ascorbic acid suppresses melanin production by reducing dopaquinone, which has been shown in in vitro studies to inhibit tyrosinase-dependent melanogenesis.9, 10 Vitamin C also serves as an essential cofactor in collagen biosynthesis, playing a pivotal role in facilitating the activities of prolyl hydroxylase and lysyl hydroxylase enzymes, thus contributing significantly to the wound healing process.11 Furthermore, the use of CE Ferulic serum may enhance wound healing by preventing the downregulation of beta fibroblast growth factor (β-FGF) induced by laser treatment. This insight provides a plausible explanation for the observed clinical trend of reduced postoperative downtime, enabling patients to return to work and resume their social activities more rapidly.4 Fractional lasers have been shown to enhance the penetration of topical medications into cutaneous tissue, addressing a key limitation in the bioavailability of topical application. Typically, the cutaneous absorption of these medications is limited, ranging from only 1% to 5%,12 with some failing to penetrate to the necessary depth. The fractional laser technique generates a pattern of microscopic lesions on the skin's surface, each surrounded by substantial areas of intact tissue. These micro-lesions act as channels, potentially increasing the uptake of topical agents like CE Ferulic serum used in these cases. This mechanism may contribute to the immediate effectiveness of CE Ferulic serum following the procedure. Split-face studies in large-scale population with blinded reviewers are needed for further validation of the findings. Furthermore, studies with long-term follow-up are important to assess the sustainability of the skin quality improvement achieved with this combination treatment. This split-face case series indicates that the topical application of an optimal combination of antioxidant may further improve skin condition after NAFL treatment. Furthermore, the application of CE Ferulic immediately reduced erythema and enhanced the healing process following laser treatments. Additional studies are required to assess the long-term clinical impact and the underlying mechanisms involved in reducing skin hyperpigmentation. No conflict of interest was claimed for this manuscript. Informed consent was obtained from all individual participants included in the study. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.