Determinants of fractional CO₂ laser therapy utilization: Demographic, clinical, and psychosocial predictors

Fractional CO2 laser therapy (FCO2LT) is an effective treatment for hypertrophic scars (HTS); however, access and utilization remain low.

A retrospective cohort of 3282 patients initially admitted to or treated at an ABA-verified burn unit within a level 1 trauma center (2017-2025), including those referred to affiliated institutions, was analyzed. Demographic, clinical, and insurance data were compared between patients who received FCO2LT and non-laser controls. Multivariable regression analyses identified the predictors of treatment, time to initiation, and number of sessions.

A total of 3282 burn patients were included, of whom 290 (8.8%) received FCO2LT (mean age 31.6 years). Patients undergoing FCO2LT were younger (P < 0.01), more frequently female (P < 0.01), and more often Hispanic/Latino or Asian (P < 0.01), with the majority insured through Medicaid (P < 0.01). In the multivariable analysis, younger age, female sex, and insurance were associated with higher odds of FCO2LT, while non-White racial/ethnic groups collectively had lower adjusted odds compared with White/Caucasian patients (OR 0.939, P < 0.001). Among FCO2LT recipients, greater TBSA (P < 0.001), psychiatric history (P = 0.006), and insurance (P = 0.006) predicted more sessions, while younger age (P < 0.001) was associated with a longer time to initiation and psychiatric history (P = 0.003) with earlier initiation.

Psychiatric history was independently associated with earlier initiation and greater number of treatments, underscoring the psychosocial drivers of scar care. Consistent coverage policies, particularly through Medicaid, facilitate access, whereas variability among private insurers remains a barrier. Both clinical and insurance factors strongly influenced FCO2LT utilization, emphasizing that access is shaped by systems as much as patient needs.