Today's laser meta-analysis found no significant difference in post-inflammatory hyperpigmentation between fractional carbon dioxide and erbium - across 130 patients, with a confidence interval running from 0.67 to 4.57. That is not reassurance, and in a clinic where most patients are Fitzpatrick type IV to VI it should not be quoted as such.
What actually governs pigmentary outcome in darker skin is not usually which device is in the room but how it is used: density, energy, number of passes, and the interval between sessions. A conservative first pass on a test area, photographed under fixed lighting, gives a patient-specific answer that no meta-analysis of predominantly lighter-skinned cohorts can.
The surrounding routine matters as much. Set expectations that a course will be longer and gentler than the manufacturer's protocol suggests, agree strict photoprotection before the first session rather than after the first pigmentary change, and be explicit that post-inflammatory hyperpigmentation is common and usually temporary - patients who are warned tolerate it, patients who are not stop the course.
- Test spot at conservative settings, photographed under fixed lighting, before committing to a course
- Plan lower density and more sessions rather than fewer aggressive ones in Fitzpatrick IV-VI
- Agree photoprotection before the first session, not after the first pigmentary change
- Warn about post-inflammatory hyperpigmentation explicitly; the warning is what keeps patients in the course
- Do not cite trial safety comparisons from lighter-skinned cohorts as reassurance about pigmentation risk
Why it matters
Safety data from predominantly lighter-skinned cohorts is routinely quoted as if it transferred.
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