ORIGINAL ARTICLES

Comparison of a Fractional Bipolar Radiofrequency Device and

a Fractional Erbium-Doped Glass 1,550-nm Device for the
Treatment of Atrophic Acne Scars: A Randomized Split-Face
Clinical Study
NOPNARUEPORN RONGSAARD, MD, AND PAISAL RUMMANEETHORN, MD*

BACKGROUND A fractional erbium-doped glass 1,550-nm and a fractional bipolar radiofrequency (RF)
device are effective in the treatment of atrophic acne scars.
OBJECTIVE To compare the clinical effectiveness and side effects of fractional bipolar RF with those of
fractional erbium-doped glass in atrophic acne scars treatment.
MATERIALS AND METHODS Twenty Thai subjects with atrophic acne scars received three split-face monthly
treatments, one side with fractional bipolar RF and the other with fractional erbium-doped glass. Three
independent physicians and patients evaluated improvement in acne scars 4 weeks after the last treatment.
Side effects were also recorded after each treatment.
RESULTS The study found significant improvement in acne scars after treatment with fractional bipolar RF
and with a fractional erbium-doped glass device without a statistically significant difference between the two
devices. The side effects of both devices were pain, transient facial erythema, and scab formation. The pain
score with fractional erbium-doped glass was higher than that with fractional bipolar RF, but duration of scab
shedding was shorter. One case had postinflammatory hyperpigmentation on only the side treated with
fractional erbium-doped glass.
CONCLUSION Fractional bipolar RF and fractional erbium-doped glass have similar effectiveness for the
treatment of atrophic acne scars.
The authors have indicated no significant interest with commercial supporters.

A cne vulgaris is a common skin disease. The

prevalence of acne vulgaris is >90% in ado-
lescents.1 Some acne lesions result in disfiguring
scars. There are many options for the treatment of
acne scars, such as chemical peeling, dermabrasion,
subcision, punch excision, tissue augmentation, and
laser.2,3 Treatment of acne scars must be individu-
ally chosen for each patient, depending on the type
and severity of the lesions and the patient’s expec-
tations. Laser treatment is useful in treating acne
scars.4 There are many types of laser treatment,
including ablative laser resurfacing and nonablative
laser and fractional photothermolysis (FP). Although
ablative lasers using carbon dioxide and erbium--
doped yttrium aluminum garnet (YAG) lasers pro-
vided significant improvement in acne scars, there
are several side effects associated with this treatment
such as prolonged erythema and dyspigmentation,
especially in patients with darker skin.5 Nonablative
remodeling lasers, such as the 1,064-nm neodym-
ium-doped YAG laser,6 diode (1,450-nm) laser,7 and
585-nm pulsed dye laser,8 can also reduce acne scars

*Both authors are affiliated with Department of Dermatology, School of Anti-Aging and Regenerative Medicine, Mae
Fah Luang University, Bangkok, Thailand

© 2013 by the American Society for Dermatologic Surgery, Inc.  Published by Wiley Periodicals, Inc. 
ISSN: 1076-0512  Dermatol Surg 2014;40:14–21  DOI: 10.1111/dsu.12372

14

without significant downtime. The fractional
erbium-doped glass 1,550-nm laser is a kind of
fractional nonablative laser that has high effective-
ness in acne scar treatment,9–11 based on the
principle of FP, which creates multiple small zones
of thermal injury, called microscopic treatment
zones (MTZs). This technique increases the efficacy
of nonablative lasers and recovery is faster and there
is a lower risk of side effects than with the ablative
resurfacing system. More recently, fractional bipolar
radiofrequency (RF), based on the principle of
“sublative rejuvenation,” which causes low epider-
mal disruption with high dermal remodeling, has
been introduced to improve the efficacy and reduce
the side effects of FP. The fractional bipolar RF
device was also able to improve acne scars signifi-
cantly,12–14 although no controlled study comparing
the efficacy of the fractional bipolar RF device with
that of the fractional erbium-doped glass 1,550-nm
device has been done. This study, therefore, was
conducted to compare the clinical effectiveness and
side effects of the fractional bipolar RF device with
those of the fractional erbium-doped glass 1,550-nm
device for the treatment of atrophic acne scars. It
was a randomized split-faced clinical study.
Materials and Methods
Twenty Thai patients aged 18–55 with Fitzpatrick
skin types III to V and atrophic acne scars on both
cheeks were enrolled in the study. Patients signed an
informed consent form for participation in the study.
Exclusion criteria were pregnancy, lactation,
photosensitivity, electrical implantation, immuno-
compromise, history of deep chemical peeling or
laser resurfacing, botulinum toxin or filler injection
in the previous 6 months, history of hypertrophic
scars and keloids, use of isotretinoin within
6 months, allergy to anesthesia, active inflammatory
skin disease or premalignant and malignant lesions
in the treatment area, and history of herpes simplex
or herpes zoster on the face. The Mae Fah Luang
Ethical Committee, Chiang Rai, Thailand, approved
the study protocol, which conformed to the ethical
guidelines of the 1975 Declaration of Helsinki.
RONGSAARD AND RUMMANEETHORN
The researcher generated randomization sequence
which randomly determined which side of the
patient’s face was to be treated using the fractional
bipolar RF device (eMatrix, Syneron, Haifa, Israel)
and the other with the fractional erbium-doped glass
1,550-nm device (Fraxel re:store DUAL1550/1927,
Solta Medical, Hayward, CA) using random allo-
cation software and concealing the sequence in
opaque envelopes. Before each treatment, the
researcher took a photograph of each patient using
VISIAâ Complexion Analysis System, (Canfield,
Fairfield, NJ). Anesthetic cream (2.5% lidocaine/
prilocaine, EMLA, APP Pharmaceuticals, Schaum-
burg, IL) was applied to the treatment area under
occlusion for 1 hour. The researcher performed the
intervention on each side of the patient’s face
according to the prepared randomized sequence.
Three treatment sessions were done at 4-week
intervals. The device used on each side of the face
was the same at all three treatment sessions. The
parameter of the fractional bipolar RF device with
64-electrode-pin disposable tips was Program C (53–
59 mJ/pin for 2 passes). The energy settings of the
fractional erbium-doped glass 1,550-nm device
ranged from 30 to 50 mJ/MTZ, with treatment
levels 4–5 (corresponding to 10–14% treatment
coverage) for eight passes. A cooling system (Cryo 6
Skin Cooling System, Zimmer MedizinSystems,
Irvine, CA) was used at the setting of 5. Patient skin
response was used to set the appropriate energy for
the treatment. After treatment, patients applied
noncomedogenic moisturizer (Cetaphil moisturizing
cream, Galderma, Biot, France) and sunscreen
(Cetaphil UVA/UVB Defense SPF 50, Galderma) and
washed their face with mild soap (Cetaphil Gentle
Skin Cleanser, Galderma).
Clinical evaluation was done 1 month after com-
pleting the three treatment sessions. First, three
masked dermatologists and patients evaluated clin-
ical improvement of acne scars. They independently
evaluated improvement in acne scars by comparing
the photographs taken before and after three treat-
ment sessions (grading scale: 0 = no improvement,
1 = <25% (mild) improvement, 2 = 25–50%
40:1:JANUARY 2014 15
 FRACTIONAL RF AND ERBIUM LASER FOR ACNE SCARS
(moderate) improvement, 3 = 51–75% (good)
improvement, 4 = >75% (excellent) improvement).
Second, improvement in facial texture was evaluated
by comparing the texture scores obtained from the
Complexion Analysis System before and after treat-
ment. Texture scores indicate irregularity on the
facial surface. Third, patients were asked to evaluate
their satisfaction with the treatment using a grading
scale (0 = dissatisfied, 1 = less satisfied, 2 = moder-
ately satisfied, 3 = very satisfied, 4 = most satisfied).
Side effects, including pain score (0, no pain to 10,
the most pain), duration of facial erythema, facial
dryness, duration of scab shedding, infection, ulcer-
ation, scar formation, dyspigmentation, and acne-
iform eruption, were record. The data were reported
as means  standard deviations. Statistical analysis
was conducted using the paired samples t-test for
comparison of the effectiveness and side effects of
the two treatment devices. p < .05 was considered
statistically significant.
Results
Nineteen (14 with Fitzpatrick skin type III, 2 with
type IV, 3 with type V) of 20 patients (12 male, 8
(A)
(C)
Figure 1. (A) and (B) Before treatment; (C) 1 month after three treatment sessions with the fractional erbium-doped glass
device; (D) 1 month after three treatment sessions with the fractional bipolar radiofrequency (RF) device.
16 DERMATOLOGIC SURGERY
female) completed three treatment sessions. One
man with Fitzpatrick skin type III withdrew from the
study because he developed side effects in the form
of prolonged dyspigmentation, which became
evident after the second treatment session and
negatively affected his professional life.
Mean improvement grade in acne scars of derma-
tologists after treatment was 2.70  0.37 for the
fractional bipolar RF device and 2.86  0.42 for the
fractional erbium-doped glass device. Mean
improvement grade of patients was 2.74  0.73 for
the fractional bipolar RF device and 2.89  0.57 for
the fractional erbium-doped glass device. There was
no statistically significant difference in mean acne
scars improvement grade between the two devices.
Clinical improvement results are shown in Figures 1
and 2.
Figure 3 presents mean texture scores before and
after each treatment session. Reduction in texture
score indicates improvement in facial texture.
There were statistically significant (p < .001)
reductions in texture scores after treatment with
the fractional RF device (2.71  1.92) and the
(B)
(D)

(A)
(C)
Figure 2. (A) and (B) before treatment; (C) 1 month after three treatment sessions with the fractional erbium-doped glass
device; (D) 1 month after three treatment sessions with the fractional bipolar radiofrequency (RF) device.
Figure 3. Mean texture scores before and after treatment at
each session. Reduction in texture score indicates improve-
ment in facial texture.
fractional erbium-doped glass device (2.94  1.84),
although there was no statistically significant
difference in mean reduction in texture scores
between the two treatment devices (p = .62).
After being treated with the fractional bipolar RF
device, six patients (31.6%) rated their satisfaction
RONGSAARD AND RUMMANEETHORN
(B)
(D)
as moderately satisfied, 10 (52.6%) rated as very
satisfied, and three (15.8%) rated as most satisfied.
After being treated with the fractional erbium-doped
glass device, five patients (26.3%) rated their satis-
faction as moderately satisfied, 13 (68.4%) rated as
very satisfied, and one (5.3%) rated as most satis-
fied.
Side effects of both treatment devices were pain,
transient facial erythema, facial dryness, and scab
formation. Mean pain scores were 5.90  1.21 on
the side treated using the fractional bipolar RF
device, and 7.75  1.37 on the side treated using the
fractional erbium-doped glass device. The pain score
after treatment with the fractional erbium-doped
glass device was higher than with the fractional
bipolar RF device (mean difference = 1.85  1.30;
p < .001). Duration of facial erythema was
3.10  1.17 days after treatment with the fractional
bipolar RF device and 2.90  1.65 days after
treatment with the fractional erbium-doped glass
device. There was no statistically significant differ-
ence between the two devices. The duration of scab
shedding was 5.00  2.60 days after treatment with
40:1:JANUARY 2014 17
 FRACTIONAL RF AND ERBIUM LASER FOR ACNE SCARS
the fractional bipolar RF device and
3.45  2.95 days with the fractional erbium-doped
glass device. Duration of scab shedding treatment
was longer with the fractional bipolar RF device
than with the fractional erbium-doped glass device
(mean difference = 1.55  2.65 days; p = .01).
Duration of facial dryness was 3.85  3.15 days
after treatment with the fractional bipolar RF device
and 3.25  2.71 days with the fractional erbium-
doped glass device. There was no statistically
significant difference between the two devices
(Table 1).
One case (1/20 = 5%) with skin type III had pro-
longed facial erythema, especially when being
exposed to the sunlight, lasting more than 2 weeks
and had post-inflammatory hyperpigmentation after
the second treatment session with fractional erbium-
doped glass device, at parameter; fluence 40 mJ/cm2,
treatment level 5 (14% coverage), 8 passes. The
hyperpigmentation resolved at 6 weeks after being
treated with bleaching agent (combination of 4%
hydroquinone, 0.01% fluocinolone acetonide, and
0.05% tretinoin; Trilumaâ). The other side of the face
treated with the fractional bipolar RF did not have
these side effects (Figure 4). However, no other side
effects such as infection, ulceration, scar formation or
acneiform eruption were present in any subjects.
Discussion
The fractional erbium-doped glass 1,550-nm laser is
a type of FP laser. In 2006, the second generation of
TABLE 1. Side Effects after Treatment with Each Device
Side Effect Treatment Method
Pain score Fractional RF
Fractional erbium-doped glass
Erythema, days Fractional RF
Fractional erbium-doped glass
Scab, days Fractional RF
Fractional erbium-doped glass
Dryness, days Fractional RF
Fractional erbium-doped glass
SD, standard deviation; RF, radiofrequency.
18 DERMATOLOGIC SURGERY
the fractional erbium-doped glass 1,550-nm was
launched. The energy can be adjusted from 4 to
100 mJ/MTZ. With the highest pulse energy of
100 mJ/MTZ, mean depth of MTZ was
1,408  53 lm. With the pulse energy of 30, 40,
and 50 mJ, which were used in this study, mean
depth of MTZ was 890  65 lm, 1,007  75 lm,
and 1,079  97 lm, respectively.15 After the
healing process, the MTZ was replaced with
new collagen.16
Radiofrequency is nonionizing electromagnetic radi-
ation with a frequency range between 3 kHz and
300 GHz. With the fractional bipolar RF device, the
RF current flows through the skin between the
electrode-pin rows. It generates fractional deep der-
mal heating in the region of the electrode matrix to
induce skin injury and then elicits a wound healing
response, stimulating the remodeling of dermal col-
lagen. It generates RF current flows between the
multi-electrode pins, which causes volumetric dermal
heating, followed by stimulation of the remodeling of
dermal collagen in healing process.17 In this study,
64-pin tips, which can deliver RF at 5% epidermal
coverage, were used. The depth of RF effect was
approximately half of the distance between the
electrode pins. Therefore, the 64 electrode pins on a
12- by 12-mm tip, with a distance between pins of
1.5 mm, could generate the thermal effect of
approximately 750-lm depths.
Previous studies showed that fractional erbium-
doped glass 1,550-nm and fractional bipolar RF
Mean  SD Difference, Mean  SD p-Value
5.90  1.21 –1.85  1.30 <.001
7.75  1.37
3.10  1.17 0.20  1.70 .60
2.90  1.65
5.00  2.60 1.55  2.65 .01
3.45  2.95
3.85  3.15 0.60  1.57 .10
3.25  2.71
 RONGSAARD AND RUMMANEETHORN

(A) (B) (C) (D)

(E) (F) (G) (H)

Figure 4. Thai man with Fitzpatrick skin type III: (A) and (E) before second treatment session; (B) prolonged facial erythema
2 weeks after treatment with the fractional erbium-doped glass device, fluence 40 mJ/MTZ, treatment level 5, 8 passes (14%
coverage); (C) 4 weeks after treatment, there was hyperpigmentation on the treated area; (D) 6 weeks after treatment, the
hyperpigmentation resolved; (F)-(H) no such side effects occurred on the side treated with the fractional bipolar
radiofrequency device, 59 mJ/pin, 2 passes.

devices were effective for skin rejuvenation and
treatment of acne scars.
Ong and Bashir reviewed the literature about the use
of the FP laser for acne scar treatments. Twenty-six
studies (13 ablative and 13 nonablative FP), were
included in this review. For ablative FP, improve-
ment ranged between 26% and 83%, whereas for
nonablative FP, improvement ranged between 26%
and 50%. The side effects included facial erythema
lasting 3–14 days with ablative FP laser and
1–3 days with nonablative FP laser, postinflamma-
tory hyperpigmentation (PIH), which occurred in a
higher proportion of patients (up to 92.3%) who
underwent ablative FP than those who underwent
nonablative FP (up to 13%). The maximum dura-
tion of PIH in ablative FP was up to 6 months,
whereas in nonablative FP, it lasted for up to
1 week. The pain score (scale 1–10) ranged from 5.9
to 8.10 with ablative FP and from 3.90 to 5.66 with
nonablative FP.18
In 2010, Ramesh and colleagues evaluated the
efficacy of a matrix-tunable RF device in 30 patients
with acne scars. Two independent observers evalu-
ated improvement in acne scars on an visual analog
scale (VAS) 2 and 6 months after completing four
treatments. VAS improvement in acne scars ranged
from 10% to 50% at the end of 2 months and 20%
to 70% at the end of 6 months. Side effects were
transient facial erythema and edema for 2–3 days.
No postinflammatory pigmentary changes were
reported in any of the patients.14
As in previous studies, this study also found signif-
icant improvement in acne scars and skin texture
after treatment with the fractional bipolar RF device
and the fractional erbium-doped glass device. The
present study found that there was no statistically
significant difference between the devices in mean
acne scar improvement grade evaluated by inde-
pendent dermatologists (p = .26) and patients
(p = .33), mean satisfaction (p = .75), or facial

40:1:JANUARY 2014 19
 FRACTIONAL RF AND ERBIUM LASER FOR ACNE SCARS
texture improvement evaluated using VISIAâ
Complexion Analysis System (p = .62), although the
quantitative measurement validity of skin texture
using VISIAâ Complexion Analysis System has not
been established in any previous studies.
Because this study was a split-face study, the side
effects of the two devices could be compared
without any influence of various characteristics of
the patients, including skin type and post-treat-
ment care. There were statistically significant
differences in pain scores and duration of scab
shedding after treatment with the fractional bi-
polar RF device and the fractional erbium-doped
glass device. The pain score with the fractional
erbium-doped glass device was higher than of the
fractional bipolar RF device, but the duration of
scab shedding after using the fractional erbium-
doped glass device was shorter than with the
fractional bipolar RF device.
In the present study, one case (5%) with skin type III
had prolonged erythema and PIH after the second
treatment session with the fractional erbium-doped
glass device, at a fluence of 40 mJ/cm2, treatment
level 5 (14% coverage), and eight passes, although
the side of the face treated with fractional bipolar RF
device did not have such side effect. Further study is
needed to confirm whether the fractional bipolar RF
has less risk of PIH than FP.
The consensus recommendations on the use of a
fractional erbium-doped glass laser suggest that
treatment settings for acne scars should be between
30–70 mJ.11 The present study used the parameter
of 30–50 mJ; further study at a higher energy setting
is required.
The present study has a limitation in that the
comparison of effectiveness with atrophic acne scar
subtypes (ice-pick, boxcar, rolling) was not done
because most participants had mixed types of acne
scars. For rolling scars, subcision is a recommended
treatment method.19 Further research is therefore
needed to evaluate the effectiveness of combination
20 DERMATOLOGIC SURGERY
treatment of subcision and subablative fractional
bipolar RF.
Moreover, further 3- and 6-month follow-up studies
are needed to investigate the sustainability of the
acne scar treatment using the two devices. Addi-
tional treatment sessions are required to explore an
increase in improvement of such treatment.
In conclusion, a fractional erbium-doped glass
1,550-nm device and the fractional bipolar RF
device are safe and effective treatment modalities for
the treatment of atrophic acne scars in patients with
Fitzpatrick skin types III to V. Most patients were
very satisfied with the result of the treatment. The
effectiveness of both devices in the treatment of
atrophic acne scars was similar. Side effects from the
treatment were mild and transient.
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Address correspondence and reprint requests to:
Nopnarueporn Rongsaard, MD, Mae Fah Luang
University Hospital, Bangkok, 38/11–13 Asoke Place
Building, Asoke Road, Sukhumvit 21, Klong Toey Nua,
Wattana, Bangkok 10110, Thailand, or e-mail:
nopnarueporn@gmail.com
40:1:JANUARY 2014 21