by Dr Daniel Sister

We are regularly told by the news media that we should all be trying to reduce our production of carbon dioxide or CO2 as it is considered to be a very destructive gas which is increasing the greenhouse effect of the planet and contributing to global climate change, yet it would seem that there is a bonus application for this invisible gas that we all breathe out daily – namely for skin rejuvenation and cellulite reduction.

Carboxytherapy, also referred to as carbon dioxide therapy or CDT is becoming more widely used within UK aesthetic clinics and in this month’s feature article we aim to explain this novel use for carbon dioxide.


Carbon dioxide is, as its molecular name states, made up of one carbon atom (C) and two oxygen atoms (O), hence CO2. It is an invisible and odourless gas produced by all humans and animals during respiration and by plants and trees for photosynthesis, which aids their growth and in turn produces more oxygen for us to breathe. CO2 is also produced by the burning of fossil fuels, such as in car exhaust fumes and in the production of electricity from coal fired power stations; hence the concerns regarding its over production and our so called ‘carbon footprints’, which have led many large producers to try and offset their carbon dioxide production via the planting of more forests.

Despite its often noted potential harmful effects in terms of being a greenhouse gas, it does have many uses and applications within the food, oil and chemical industries, such as in carbonated drinks, raising agents for baking, fire extinguishers, industrial and medical lasers and dry cleaning solutions.

It also has properties which make it useful to the medical community. One such property is its vasodilatory ability, i.e. the ability to relax the muscles in blood vessels and allow them to dilate or expand. The dilation of blood vessels leads to a decrease in blood pressure and a better flow of oxygen rich blood around the body.

The beneficial effects of carbon dioxide on health were first discovered in France in the 1930s when it was noted that bathing in the pools of carbon dioxide rich water at the Royat Spas helped to speed up wound healing.

Carboxytherapy, (the therapeutic and medical use of carbon dioxide), has now been used by the medical community in Europe for over 60 years, having been investigated in France in the 1950s by a group of cardiologists who used the therapy to treat patients with various illnesses caused by blood circulation and fat accumulation problems in their arteries.

Subsequently the therapy was applied to patients with cellulite problems, where circulation is known to be sluggish, and is now widely used for a variety of other aesthetic indications in Europe, and North and South America.

How Does Carboxytherapy Work?

Every time we breathe in oxygen via our lungs the oxygen is picked up by the red blood cells with each red blood cell carrying four oxygen molecules which it takes from the lungs to the heart via the blood vessels. As the heart beats it forces these blood cells into the arteries and on a journey around the body to where they’re needed. When they encounter an area with high levels of carbon dioxide, which has been created by cellular metabolism, the red blood cells release the oxygen molecules and pick up the carbon dioxide that they have produced.

Certain “imperfections” on our bodies such as dark under-eye circles, scarring and cellulite are thought to be caused, in part, by the poor circulation of blood to those areas, and therefore a poor supply of oxygen. Carboxytherapy is said to work simply by tricking the body, as by injecting a small amount of carbon dioxide gas into the area, it will increase the dispatch of oxygen laden red blood cells to the area to pick up the new ‘waste’ carbon dioxide which the body will then naturally eliminate via the lungs over time. By increasing the amount of oxygen getting to the area the cells will become more active and thus speed up any healing or new cell production required to rejuvenate the area.

What Happens During Carboxytherapy Treatment?

The most common aesthetic indications for treatment with carboxytherapy are for cellulite and localised fat reduction, stretch marks (striae), acne scars, skin laxity and wrinkle reduction. Treatments are generally performed on the face, neck, arms, abdomen and thighs.

Carboxytherapy, as performed in the aesthetic clinic setting, is similar in nature to the technique of mesotherapy, but is used to infuse tiny quantities of medical grade carbon dioxide gas below the skin’s surface rather than tiny quantities of a liquid formulation. It is done using a series of small injections with a thin needle attached to a hose which delivers the gas in a controlled flow and dose via a specially designed machine.
Depending on the area treated, it may be possible to see the gas as it travels within the surface layers of the skin as a minor protrusion. In the case of treating cellulite, the carbon dioxide is delivered deeper into the subcutaneous layer of the skin.

Treatment is generally said to be fairly painless, although some people will feel a slight discomfort, pressure or stinging sensation as the gas is delivered to the tissues, sometimes described as a ‘crackling’ sensation, depending on the area treated. A topical anaesthetic can be applied to the skin if required. Side effects include minor swelling, redness (caused by the vasodilation), bruising and pain at the injection sites lasting anywhere from 1 – 5 days, depending on the area treated, and in the case of cellulite treatment a warm sensation in the region for up to 24 hours. Bathing or swimming should be avoided in the first few hours after carboxytherapy treatment.

In the case of treating stretch marks, it is said that these respond better to treatment when they are most recent and still red in colour, rather than when older and of a more faded, silvery appearance. Newer striae will most likely require to be treated once a week for 2 – 4 weeks, although in some cases a single session is enough, depending on their severity. Older stretch marks will need 3 or 4 treatment sessions at 3 – 4 weekly intervals.

The results for treating stretch marks and scarring are claimed to be permanent.

In the case of cellulite reduction, the introduction of the CO2 under the skin is combined with manual massage to help evenly distribute the gas and make it circulate within the tissues. When it comes into contact with the fat cells, it is claimed that it can literally kill them by stimulating a metabolic reaction or fat burning mechanism within the body. The vasodilatory effect in the small blood vessels surrounding the fat cells increases the amount of oxygen and blood flow to the area which eliminates the build up of fluids and toxins between the cells causing lymphatic drainage, and also improves the elasticity of the deeper skin areas by stimulating the production of new collagen, leading to a rejuvenation in the upper layers which reduces the tight, cottage cheese or orange peel look to the skin associated with cellulite.

Results are said to be seen immediately, with an improved and smoother look to the skin. As the blood circulation improves and the natural fat burning continues, the area becomes firmer over time with a reduced circumference, although multiple treatment sessions and top-up maintenance sessions every 6 months will be required.

Depending on the area being treated, consumers should expect to pay approximately £100 per session of carboxytherapy, with reduced fee packages available from most providers.

Clinical Data

Clinical data on the use of carbon dioxide for aesthetic indications is currently quite limited, although there are some key studies emanating from Europe and South America which shed significant light on its efficacy in the treatment of fatty tissue.

In 2001, a study from the University of Siena in Italy looked into the treatment of localised fat deposits on the thighs, knees and/or abdomen in 48 women using carbon dioxide therapy. The CO2 was administered subcutaneously twice weekly for 3 consecutive weeks, i.e. a total of 6 treatment sessions.

Results showed that on average the women lost 2cms of circumference from their thighs, 1cm from the knees and almost 3cms from the abdomen. The skin in the treated areas also presented a thicker appearance than before treatment, with cellulite appearing smoother. Few side effects were observed; although of those noted, such as the presence of a crackling sensation under the skin (reported by all patients), pain at the injection site (reported by 70% of patients) and slight haematomas (reported by 30% of patients), all resolved very quickly.

A later study from the same University published in 2004 looked at the effects of carbon dioxide on skin irregularity and its use as a complement to liposuction. It evaluated the treatment of 42 patients treated for fatty tissue accumulations on the thighs and knees. The group of patients were divided into three groups, in one group only liposuction was performed, in the second carbon dioxide therapy was administered 3 weeks after liposuction was performed in twice weekly applications for 10 consecutive weeks, and in the third group carbon dioxide therapy alone was administered, again twice weekly for 10 consecutive weeks.

The results were then analysed by reporting on variations in circumference measurements and skin elasticity after 2 months. The authors noted that liposuction alone did not generally have a positive enough effect on skin irregularity and could in fact cause uneven areas, however the addition of carbon dioxide therapy provided an improvement in skin smoothness and elasticity, meaning that in their opinion it offers a good complement to liposuction procedures. CO2 therapy also showed positive results in reducing fat accumulation as the circumferential measurement results of those treated with liposuction and carbon dioxide were better than for those treated with liposuction alone.

A study from Brazil published in March 2008 looked at whether the intradermal and subcutaneous injection of carbon dioxide into the skin of rats would increase the turnover of collagen.

Following biopsies it was noted that collagen turnover had indeed increased as compared to the control animals (which were injected with saline) and that the collagen formations were more pronounced in the areas where the gas was injected intradermally as compared to where it was injected subcutaneously.

The authors noted that the results obtained corroborated clinical observations of aesthetic improvements in human facial skin injected with carbon dioxide but that future clinical studies were needed to address the comparison between intradermal and subcutaneous injection methods as well as the volume of gas to be used and the frequency of treatment sessions.

As this treatment becomes more popular in the UK, and perhaps the USA, it is hoped that more studies of this kind will be done on the various potential aesthetic indications for carboxytherapy.

Case Studies

Treatment with carboxytherapy is still very new in the UK in terms of the number of practitioners offering the treatment and those suitably skilled and trained to carry out the procedure. In general, as this treatment is more popular in Europe and has origins in France, many of those doctors practicing in the UK are indeed French. Two such doctors, Dr Daniel Sister ( and Dr Cyrille Blum (, both with clinics based in London, have kindly provided some case studies to illustrate the wide range of treatment indications and results achievable with the aesthetic application of carbon dioxide therapy.

Carboxytherapy Devices

A variety of devices exist in the marketplace for the controlled delivery of carbon dioxide into the skin. Here we will highlight some of the more commonly encountered machines targeted at those practitioners treating aesthetic indications. It is anticipated that such devices will become more mainstream and available within the UK supply chain in the coming years.

CO2 Riojuvenation System (Rioblush)

The CO2 Riojuvenation System from Rioblush, which hails from Brazil, is said by the manufacturers to be widely distributed in Europe and South America, with 5000 machines currently in use. It is currently in the process of gaining US FDA approval for use.

The gas can be set to flow either continuously or in pulses of 0 – 150ml/mn and the operator can also adjust the temperature of the gas from room temperature to 50 degrees Celsius depending on the size of the area and condition that is being treated.

The manufacturers note that their system is the only one on the market which provides a heated gas solution which they claim dramatically reduces any discomfort felt by the patient.


The Carbomed device, manufactured by Italian company LED Spa (distributed by Carbossi Terapia Italiana SRL), was European CE mark approved in 2002 for the treatment of circulatory and vascular pathologies, including the treatment of diabetic ulcers, vascular ulcers, treating burns, reducing cellulite and aesthetic body contouring.

This is the device used in the initial clinical evaluations carried out at the University of Siena in Italy.

CDT Evolution

The CDT Evolution device, also available from Carbossi Terapia Italiana SRL from Italy is a European CE mark approved medical device.

This device includes a microprocessor which controls the purity and quantity of carbon dioxide delivered, as well as the speed with which it is administered.

Using electronic sensors which measure the variation in resistance within the tissues as the gas it delivered it analyses the best protocols and pain control parameters.


Despite the wide variety of indications which carboxytherapy is able to turn its hand to, it seems that the vast majority of data collected and treatments performed are for the reduction in the appearance of cellulite and fatty tissue.

The market for cellulite and fat related body contouring treatments is one of the largest growth areas within the aesthetic arena. In fact a report from Medical Insight Inc, published just this August predicted that the global medical aesthetic market, currently estimated to be worth $5.2billion, will see growth reach $8.9billion by 2012 due mainly to the expansion in body shaping and skin tightening technologies. It predicts that body shaping will grow by 22.7% in annual supplier sales and skin tightening by 18.9%.

This is also corroborated at ground level by the huge variety of body contouring treatment types and devices now available on the market, offering everything from mechanical massage to heat induced lipolysis via lasers, ultrasound and radiofrequency. Add to that mesotherapy and carboxytherapy techniques and the number of available treatment options for flabby bums and tums which now bombard the consumer is quite mind boggling.

So what’s the attraction of carbon dioxide therapy?

One could argue that criterion such as treatment time, the number of sessions required, pain during treatment and post-treatment downtime and recovery are fairly similar across the board with most available non-invasive body shaping techniques. Most aim to be as painless as possible (although some may require topical or local anaesthesia), with little to no downtime or recovery required and often with the body doing most of the hard work of fat metabolism and collagen renewal in-between treatment sessions.

However, carboxytherapy has the advantage that it’s generally cheaper for the consumer than a course of say Endermologie®, Smartlipo®, Ultrashape®, Velasmooth®, Thermage® or Accent®, as well as being a much cheaper capital investment for the clinic business, in terms of equipment, clinical environment and per patient accessories.

Anecdotal results and clinical data are certainly proving promising and replicable, which unfortunately has not been the case with some of the various modalities targeting this treatment indication.

As experience with this technology evolves and more clinical data becomes available you can be sure that we will be here to update you with the facts as they emerge.

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