Fractional CO2 Laser in Lichen Sclerosus: A Dual Mechanism for Combination Therapy

Lichen sclerosus is a chronic inflammatory dermatosis with anogenital predilection and a recognized risk of malignant transformation. Ultrapotent topical corticosteroids remain the standard of care, yet a clinically relevant proportion of patients shows partial response, early recurrence, or corticosteroid intolerance. Ablative fractional CO2 laser has been increasingly investigated as a second-line option, with growing clinical evidence supporting its efficacy on symptomatic and quality-of-life outcomes. This narrative review examines the mechanistic basis and the clinical evidence for fractional CO2 laser in lichen sclerosus. It sets out a dual-mechanism framework. Preclinical and histological studies show an intrinsic biological effect on the skin. This includes neocollagenesis, neoangiogenesis, local immunomodulation and re-epithelialization of atrophic tissue. The same treatment also increases the cutaneous delivery of co-applied topical agents through laser-assisted drug delivery. These two mechanisms support combining fractional CO2 laser with topical corticosteroids as an add-on strategy, rather than a head-to-head alternative to the standard of care. Current evidence is reviewed across monotherapy and combination protocols, alongside the largely unexplored male form of the disease, and further comparative studies are needed to confirm this rationale.