Topical Carboxytherapy for Skin Rejuvenation

J Clin Aesthet Dermatol. 2025;18(1):55–57.

by Ava Shamban, MD; Wendy E. Roberts, MD; Vivian Bucay, MD; Suneel Chilukuri, MD; Eva Simmons-O’Brien, MD; and Diane Orlinsky, MD

Dr. Shamban is with AVA MD in Beverly Hills, California. Dr. Roberts is with Generational and Cosmetic Dermatology in Rancho Mirage, California. Dr. Bucay is with the Bucay Center for Dermatology and Aesthetics in San Antonio, Texas. Dr. Chilukuri is with Refresh Dermatology in Houston, Texas. Drs. Simmons-O’Brien and Orlinsky are with Simmons-O’Brien & Orlinsky, LLC, in Towson, Maryland.

FUNDING: Funding for the roundtable event and creation of this article were provided by Lumisque, Inc.

DISCLOSURES: Dr. Roberts is a consultant for Lumisque, Inc. The remaining authors have no conflicts to disclose. 

ABSTRACT: Driven by public demand, new safe and effective approaches for achieving dermal rejuvenation are continuously being developed. Recently, there has been growing interest and advances in carbon dioxide therapy, or carboxytherapy. Based on the Bohr effect, carboxytherapy enhances the release of O₂ from the blood into the surrounding tissues in response to increased blood CO₂. Injections of CO₂ promote wound healing, reduced scar tissue, and increase collagen turnover, making it a useful tool for achieving a broad range of aesthetic benefits. A significant advancement in CO₂ technology is the development of a topical gel for the transcutaneous release of carbon dioxide (CO₂ Lift. Lumisque, Inc., Weston FL). Similar to the changes observed following CO₂ injections, the application CO₂ gel increases microcirculation and capillary growth. For example, applying a CO₂ gel mask after skin rejuvenation procedures, such as nanofractional radiofrequency therapy, is a safe and effective means to improve clinical outcomes and reduce treatment-related adverse events. The following manuscript is a review and discussion based on a roundtable discussion conducted at the Generational Dermatology Symposium in Rancho Mirage, California, on February 16–19, 2023. The use of carboxytherapy using a CO₂ gel represents a new multi-purpose new for medical, aesthetic, pediatric, and female health practitioners for improving patient skin health and appearance.

Keywords: Carboxytherapy, transdermal carbon dioxide, wound healing, aesthetic dermatology, roundtable

With an increasingly aging population and driven by public demand, new safe and effective approaches for achieving noninvasive dermal rejuvenation are continuously being developed. While not a new technology, there have been recent advances and growing interest in carbon dioxide therapy, or carboxytherapy, especially in the fields of dermatology and aesthetic medicine.¹ The same technology is also being applied medically for treating conditions such as nonhealing diabetic lesions. The following manuscript is a review and discussion based on a roundtable discussion conducted at the Generational Dermatology Symposium in Rancho Mirage, California, on February 16–19, 2023. 

Background

The scientific basis for carboxytherapy is known as the Bohr effect, first described by the Danish physiologist Christian Bohr in 1904.² In response to increased blood CO₂ and decreased pH, there is a rightward shift of the oxygen-hemoglobin dissociation curve which enhances the release of O₂ from the blood into the surrounding tissues. Conversely, a decrease in CO₂ and increase in pH results in a leftward shift in the oxygen-hemoglobin dissociation curve, increasing O₂ binding.

Injections of carbon dioxide gas into tissues were originally used to achieve the Bohr effect which stimulates an acute inflammatory reaction with peripheral vasodilatation and increased cutaneous microcirculation with enhanced oxygenation and improved tissue perfusion.^3,4 Based on this principle, for example, injections of CO₂ were used to promote wound healing^5,6 and scar tissue reduction.⁷ Carboxytherapy also increases collagen turnover,⁸ making it a useful tool for treating cellulite⁹ and achieving facial rejuvenation and other aesthetic benefits,^4,10 such as improving skin laxity, atrophic scars, striae distensae, and cellulite.^11–15

For example, several studies have described the beneficial effects of carboxytherapy for periocular rejuventation.^16,17 In one study, subjects received a series of five weekly CO₂ injections treatments,¹⁸ resulting in increased elasticity and flexibility of the periorbital skin with visible improvements in the number and depth of wrinkles. Adverse events were confined to pain resulting from carbon dioxide gas spreading under the skin, stinging and transient erythema and edema in the treatment area.¹⁸ CO₂ injections appear to be as effective as weekly applications of trichloroacetic/lactic acid gel for treating dark periorbital circles.¹⁹

Another benefit of carboxytherapy is achieved when used in combination with other dermatology procedures. Carboxytherapy improves the duration of aesthetic outcomes when used in conjunction with a hyaluronic acid filler for correcting nasolabial folds,²⁰ and enhancing the aesthetic outcomes following liposuction.²¹

An important medical application of carboxytherapy is the treatment of nonhealing wounds, such as diabetic ulcers. In one randomized double-blind study, 20 of 30 nonhealing diabetic wounds healed following treatment with CO₂ injections versus none in the control group.²² Similar results have been reported by others treating diabetic foot ulcers^6,23 and pressure sores.²⁴

A significant advance in CO₂ technology is the development of a topical gel for the transcutaneous release of carbon dioxide (CO₂ Lift; Lumisque, Inc., Weston FL). When applied to facial skin, the CO₂ gel results in increased microcirculation and capillary growth,²⁵ similar to the changes observed following CO₂ injections.²⁵ Subsequent studies have shown that carboxytherapy applied as a gel mask after skin rejuvenation procedures, such as nanofractional radiofrequency therapy, is a safe and effective means to improve clinical outcomes and reduce treatment-related adverse events.²⁶

A presentation of clinical data showed considerable evidence of the effectiveness of this novel carboxy gel. Applied topically, microcirculation increased 28 percent in the treated area and tissue oxygenation increased in a manner similar to hyperbaric oxygen.²⁷ It improved hydration by 117 percent after a single application. It also increased mean luminosity and radiance of the skin by 39 percent and 42 percent, respectively, decreased mean skin sagging and pigmentation by 30 percent and 27 percent, respectively, and decreased mean fine lines and wrinkles by 24 percent and 20 percent, respectively. It improved mean skin elasticity by 26 percent after six applications over a one-month period.²⁷

In one study, carboxytherapy gel was applied as a single treatment following nano fractional radiofrequency treatment for improving facial skin quality and photoaging.²⁶ Blinded investigator ratings showed significant improvement of dryness, erythema, edema, crusting, and percent healing after 24 hours and one degree improvement in investigator global assessment for photodamage, pigmentation and wrinkles in all patients one week after using the CO₂ gel mask. When used to treat symptoms of vulvovaginal atrophy, Female Sexual Function Index scores improved, and tissue biopsies revealed a regenerative effect on vulvovaginal tissues.²⁸

Discussion

A roundtable discussion on the use of carboxytherapy gel was conducted following a presentation on the development of carboxytherapy in aesthetic dermatology at a national dermatology symposium (Generational Dermatology Palm Springs Symposium, February 15-18, 2023; https://generationaldermatology.com/).²⁹ The presentation was preceded by a live demonstration of carboxytherapy gel applied to a volunteer following facial microneedling.

Product demonstration: The CO₂ gel was prepared immediately prior to applying to a volunteer by mixing with the CO₂ activator. An applicator is provided with the product. Unlike other mask products, the lips and eyes can also be covered with the gel. The product remains on the skin for 45 minutes to one hour. It can be applied anywhere on the body, including hands, knees, neck or décolleté. It can also be applied immediately following laser resurfacing or dermal filler procedures to soothe post-treatment discomfort and reduce erythema.²⁶ The product is nonreactive and is also safe for use following chemical peels.³⁰ The product can also be sent home with the patient for additional home use.

Among many of the panelists, CO₂ gel was found to improve skin hydration and barrier function and seen to be therapeutic for patients with xerosis and on the spectrum of dry skin disorders such as atopic dermatitis. Panel members were in strong agreement regarding the benefits of CO₂ gel for dry skin. For children with atopic dermatitis, it was cited as an alternative to corticosteroids (Roberts). Some panel members use it immediately following dermal filler injections to decrease procedural discomfort, then send additional product for home use so their patients need not return to clinic as soon for routine post filler wellness checks (Bucay). One member applies it following injection of a variety of dermal fillers, including hyaluronic acid, calcium hydroxylapatite, poly-L-lactic acid, and polymethylmethacrylate. Its post-procedure use improves the benefits achieved from CO₂ laser resurfacing and helps minimize post-surgical bruising and inflammation. One member always tries to include treatment of the hands (Shamban).

The discussion included the use of CO₂ gel for vaginal rejuvenation. There were many clinical scenarios discussed and panelists shared their patient experiences: These were of a generational nature falling into post-menopausal group with a particular subgroup of breast cancer affected females, who are reluctant to use topical estrogen products (O’Brien). There was a middle age group with vulvar disorders, such as lichen sclerosus et atrophicus, and a younger population of postpartum women who received an episiotomy during delivery (Orlinsky). All of these groups experienced relief of dyspareunia and post-coital discomfort after four weeks of use. In one such case, it alleviated emotional distress caused by incontinence. 

Vascular compromise is a potentially serious complication after soft tissue filler injections. Immediate treatments include hyaluronidase in the case of hyaluronic acid fillers, massaging the area, and applying 2% nitroglycerin paste to promote vasodilatation.³¹ One panelist indicated CO₂ gel was useful for resolving an instance of vascular occlusion, suggesting that topical application of CO₂ gel may also prevent necrosis following vascular occlusion due to misplaced dermal filler injections by oxygenating tissues. It provides the benefits of hyperbaric oxygen without the risk of cataract formation. 

Acknowledgement

The authors acknowledge the editorial assistance of Dr. Carl S. Hornfeldt, Apothekon, Inc., during the preparation of this manuscript. 

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