Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2024;14(2):e2024087 1 Dermoscopic Evaluation of Combined Treatment with Fractional Co2 and Nanosecond Q-1064 nm Laser for Traumatic Facial Tattoo Claudio Conforti1, Piergiorgio Turco2, Sebastian Laspina3, Domenico Piccolo4, Vito Cazzato5 1 IDI-IRCCS, Dermatological Research Hospital, Rome, Italy 2 Department of Plastic and Reconstructive Surgery, University of Naples Federico II, Naples, Italy 3 Private Practice, Centrolaser Laspina, Udine, Italy 4 Skin Center-Dermo Aesthetic Laser Centers, Avezzano, Italy 5 Department of Plastic and Reconstructive Surgery, Azienda Sanitaria Universitaria Giuliano-Isontina, Trieste University Hospital, Trieste, Italy Key words: laser, dermoscopy, tattoo Citation: Conforti C, Turco P, Laspina S, Piccolo D, Cazzato V. Dermoscopic Evaluation of Combined Treatment With Fractional Co2 and Nanosecond Q-1064 nm Laser for Traumatic Facial Tattoo. Dermatol Pract Concept. 2024;14(2):e2024087. DOI: https://doi.org/10.5826/dpc.1402a87 Accepted: October 1, 2023; Published: April 2024 Copyright: ©2024 Conforti et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Claudio Conforti, MD, IDI-IRCCS, Dermatological Research Hospital, 00167 Rome, Italy. E-mail: claudioconforti@yahoo.com Introduction Traumatic facial tattoos are a disabling sequel altering the person’s appearance. They are caused by the depositing of exogenous pigmented particles during a traumatic event into the dermis. The effectiveness of nanosecond Q-1064 nm has been proven to be an effective procedure to treat this condi- tion, and nowadays it is the first-line option [1], but recently, with the aim to improve the aesthetic outcome of the scars caused by the trauma as well, some authors have success- fully combined the use of the CO2 ablative fractional laser (AFL) with the nanosecond Q-1064 nm laser [2]. However, little is known about the dermatoscopic changes that com- bined laser treatment brings to tissue with traumatic tattoo. Herein, we report one case of upper labial traumatic tattoo (black-blue color) treated with combined use of nanosecond Q-1064 nm and AFL laser; after each laser session, we per- formed a dermatoscopic analysis on the tissue. Each derma- toscopic change has been accurately reported and described. Case Presentation An otherwise healthy 26-year-old female who, after a bicy- cle fall with impact of her face on the asphalt, sustained an injury to the left upper prolabium, resulting in a 12 x 4 mm black pigmented scar located in the upper left labial region ( Figure 1a). First, a dermatoscopic evaluation was performed in order to choose the best laser treatment. Dermoscopically, a white structureless area surrounded by a bluish pigmentation 2 Research Letter | Dermatol Pract Concept. 2024;14(2):e2024087 was observed. The white area corresponded to the scar, while the bluish color corresponded to the presence of small parti- cles of asphalt in the dermis. In order to treat the scar and to bring out the exogenous pigmented particles, a first session of nanosecond Q-1064  nm laser treatment was performed, followed by a fractional CO2 laser treatment. Immediately after the procedure, dermoscopic evaluation was performed, which observed the absence of asphalt particles, the presence of laser-induced channels through which the pigment was re- moved, and mild erythema around the treatment area as a consequence of the two lasers treatment performed. After three months of follow-up, the clinical result was a eutrophic scar with good quality texture and without any pigment; the dermatoscopic exam confirmed the clinical re- sult without presence of residual exogenous pigment. Conclusion Tattoo removal and scarring improvement are the two endpoints for traumatic scarring tattoo treatment [1]. Our experience shows that Q-1064  nm laser can penetrate in skin tissues and fragments the asphalt particles into smaller units. In this condition, fractional CO2 laser creates chan- nels which allow the pigmented particles to escape. The combined protocol optimizes the effectiveness of the treat- ment. According to our experience, combined laser treat- ment with CO2 AFL, and Q-1064 nm laser could facilitate the treatment of asphalt scars, allowing effective removal of the pigment particles and at the same time improving the texture of the scar, as demonstrated by dermatoscopic evaluation. References 1. Cannarozzo G, Negosanti F, Sannino M, et al. Q-switched Nd:YAG laser for cosmetic tattoo removal. Dermatol Ther., 2019;32(5):e13042. doi: 10.1111/dth.13042. 2. Yang Q, Xue P, Fan X, et al. Lasers treatment for traumatic facial tattoo. Lasers Med Sci. 2022 Dec 29;38(1):28. doi: 10.1007 /s10103-022-03658-1. PMID: 36580127; PMCID: PMC9800346. Figure 1. A), B) Clinical and dermoscopic features of traumatic facial tattoo at baseline, showing white structureless area and bluish pigmentation corresponding to the presence of asphalt particles in the dermis; C), D) Clinical and dermoscopic features immediately after combined CO2 fractional and Q-switched laser performed on the scar. Dermoscopy shows mild erythema surrounding laser-induced channels; E), F) 3-month follow-up demonstrat- ing a complete fading of asphalt particles in the dermis.