What is laser skin resurfacing?
Laser skin resurfacing is a broad term for treatments that deliberately injure selected layers of skin with laser energy so that the skin repairs itself. Depending on the device and settings, the treatment may remove surface tissue, heat deeper tissue without removing it, or do both in microscopic columns.
That is why “laser resurfacing” can describe procedures with very different recovery times and risks. A light non-ablative fractional treatment and a fully ablative CO2 resurfacing are not simply weaker and stronger versions of the same appointment. They create different types of injury.
Why are CO2, fractional, Fraxel and non-ablative so confusing?
These words describe different things:
- CO2 describes a laser wavelength, about 10,600 nm. CO2 energy is strongly absorbed by water and can ablate skin.
- Er:YAG is another ablative laser, usually 2,940 nm. It removes tissue with less surrounding thermal injury than CO2 at comparable settings.
- Fractional describes the pattern. Instead of treating the entire surface, the laser creates microscopic treatment zones separated by untreated skin.
- Non-ablative means the laser heats tissue without vaporising comparable columns of surface tissue. Common fractional wavelengths include 1,550/1,565 nm erbium-glass and 1,927 nm thulium.
- Fraxel is a brand family, not a laser category. Different Fraxel systems use different wavelengths and are not all equivalent.
Most confusion comes from mixing these labels. Fractional does not mean non-ablative. Fractional CO2 is still an ablative treatment.
What are the main types of laser resurfacing?
For patients, the most useful division is by how much skin is injured.
- Fully ablative resurfacing: treats essentially the whole selected surface. Modern pulsed or scanned CO2 and Er:YAG lasers can produce substantial improvement, but recovery and pigment risk are greater.
- Ablative fractional resurfacing: usually fractional CO2 or fractional Er:YAG. Microscopic columns are ablated while intervening skin remains intact, allowing faster healing than full-field ablation.
- Non-ablative fractional resurfacing: heats microscopic columns without removing the epidermis in the same way. It usually means less downtime and lower pigment risk, but often more sessions and subtler change per session.
There is no universally “best” category. The right choice depends on the problem being treated, skin tone, acceptable downtime and how much risk you are prepared to accept.
What can laser resurfacing realistically improve?
The best-supported uses include atrophic acne scars, fine lines and wrinkles, rough texture, photoaging and selected pigment irregularities. Certain fractional lasers are also used for surgical or traumatic scars and some stretch marks.
Results depend heavily on the indication. Deep ice-pick acne scars, for example, often need focal techniques such as TCA CROSS or punch procedures rather than laser alone. Significant skin laxity is also not the same problem as surface photoaging. A laser can improve skin quality and some fine wrinkling, but it does not reposition deeper facial tissues like a facelift.
Which laser works best for acne scars?
Fractional CO2 has one of the strongest evidence bases for atrophic acne scars, but it is not automatically superior to every alternative.
A 2026 meta-analysis comparing fractional CO2 with needling-based treatments found no clear overall difference in scar-score reduction, with substantial variation between studies. Another 2026 meta-analysis comparing fractional CO2 with RF microneedling found better scar improvement and patient satisfaction with CO2, but more pain, longer erythema and a higher risk of post-inflammatory hyperpigmentation.
A separate 2026 meta-analysis comparing fractional CO2 with erbium-based fractional lasers found a somewhat higher chance of greater improvement with CO2, while erbium-based treatments generally had a more favourable recovery profile.
Scar type still matters. Rolling and shallow boxcar scars may respond well to resurfacing. Deep boxcar or ice-pick scars often need combination treatment. If a clinic promises that one laser will “erase” every acne scar type, the problem is the promise, not the laser.
How much can laser resurfacing improve wrinkles and sun-damaged skin?
Ablative and fractional lasers can improve fine lines, texture and photodamage, but the magnitude varies with treatment intensity. Fully ablative resurfacing can produce a stronger single-session change, with correspondingly greater recovery and risk. Non-ablative fractional treatment usually trades intensity for easier recovery.
Recent evidence continues to support fractional approaches for photoaging. Reviews of 1,550-nm erbium-glass and 1,927-nm thulium systems report improvement in dyschromia, fine lines and selected photoaging changes, while ablative lasers remain more aggressive options for deeper resurfacing.
Deeper folds caused by volume loss, bone change or tissue descent should not be presented as a laser problem. Resurfacing may soften the skin surface without correcting the underlying anatomy.
Is laser resurfacing a good treatment for pigmentation or melasma?
Sometimes, but this needs careful diagnosis. Sun spots and some superficial dyschromia may improve with selected fractional wavelengths. Melasma is different: it is biologically prone to recurrence and can worsen after inflammation.
In darker skin tones, laser treatment for pigmentation needs particular caution because post-inflammatory hyperpigmentation (PIH) is more common. A 2024 review of non-ablative fractional lasers in Fitzpatrick IV-VI skin found useful evidence for several conditions, including melasma and atrophic scars, while emphasising careful parameter selection.
Laser should also not be used simply to remove an undiagnosed pigmented lesion. A suspicious or changing lesion needs medical assessment first.
Can darker skin tones have laser resurfacing?
Yes, but the treatment choice and settings matter more. Darker skin is not a blanket contraindication.
Melanin competes for light and inflammation can trigger PIH. For that reason, non-ablative fractional lasers are often preferred when a lower pigment risk is important. Ablative fractional treatment can also be performed in darker phototypes by experienced clinicians, but the margin for error is smaller and pretreatment or post-treatment pigment control may be considered.
Recent reviews continue to identify PIH as one of the most frequent laser complications, particularly in Fitzpatrick IV-VI skin. The exact percentage cannot be reduced to one honest number because studies combine different wavelengths, settings, skin types and indications.
How much do the laser settings change the result?
A lot. The device name alone does not tell you how aggressive the treatment will be.
Energy, density, pulse duration, spot size, stacking and number of passes all change treatment depth, thermal injury and surface coverage. With fractional devices, two clinics can use the same machine and deliver very different treatments.
More energy is not automatically better. A treatment should be designed around the target: scar depth, wrinkle severity, skin thickness, pigmentation risk and acceptable recovery.
What happens during a laser resurfacing treatment?
The skin is cleaned and eye protection is mandatory. Anaesthesia ranges from topical numbing cream for lighter fractional treatments to local blocks, sedation or occasionally general anaesthesia for aggressive full-face ablation.
The clinician passes the laser over selected areas according to the treatment plan. Immediately afterward, the skin may feel hot and look red and swollen. Ablative procedures can ooze and crust as the surface re-epithelialises. Non-ablative fractional treatments usually leave redness, swelling and a rough or bronzed appearance rather than an open wound.
How many sessions will I need, and when do results appear?
A fully ablative treatment may be planned as a single major session. Fractional ablative and non-ablative protocols are more often performed as a series, although the number varies widely.
Early changes in pigment and texture can appear as the skin heals. Collagen remodelling is slower and can continue for months. That means a final result should not be judged a few days after treatment.
Repeated sessions are not automatically better. Treatment interval and intensity should reflect the biology of healing, not simply a clinic package.
What does the downtime really look like?
There is no single “laser resurfacing downtime.”
- Fully ablative CO2 or Er:YAG: re-epithelialisation commonly takes around one to two weeks, while redness can persist for weeks and sometimes longer.
- Ablative fractional: redness, swelling, crusting or bronzing often last several days, but aggressive settings can require a longer recovery.
- Non-ablative fractional: redness and swelling are usually shorter and the skin surface remains more intact, although several treatment sessions may be needed.
Your clinic should describe the expected recovery for the exact device and settings it plans to use. “Fractional laser” alone is not enough information.
How should I prepare for laser resurfacing?
Preparation depends on treatment depth, skin type and medical history. A proper consultation should cover active acne or infection, tendency to pigment, scarring history, medications, previous procedures and any history of cold sores.
For ablative resurfacing, clinicians may prescribe antiviral prophylaxis when herpes simplex reactivation is a concern. Strict sun avoidance and daily broad-spectrum sunscreen are important before and after treatment. Some patients with higher pigment risk may receive a pigment-control protocol.
Do not improvise by stopping prescription medication or applying strong acids or retinoids without instructions. Preparation should match the procedure you are actually having.
What aftercare matters most?
For ablative treatment, wound care is part of the procedure. The skin barrier is temporarily disrupted, so products applied immediately afterward matter. Follow the clinic's instructions for cleansing, ointment or dressings and do not pick crusts.
Sun protection is essential during healing because UV exposure can worsen erythema and pigmentation. Avoid introducing active skincare too early. Retinoids, exfoliating acids, scrubs and fragranced products are usually restarted only when the clinician considers the barrier sufficiently recovered.
Contact the clinic promptly for increasing pain, spreading redness, pus, new blisters, grey or dark areas, or delayed healing rather than assuming every reaction is “normal purging.”
What are the common risks?
Expected short-term effects include redness, swelling, burning, crusting, dryness and temporary pigment darkening. More significant risks include prolonged erythema, PIH, hypopigmentation, acneiform eruptions, milia, bacterial or viral infection, scarring and visible treatment borders.
A 2026 review of 2,010 facial laser cases found PIH to be the most frequently reported complication, especially in darker skin types. Ablative CO2 and Er:YAG carried the highest risks of scarring and infection in that review, while non-ablative fractional treatments were more often associated with erythema and textural change.
Serious ocular injury is uncommon but potentially severe, which is why appropriate wavelength-specific eye protection is non-negotiable, particularly around the eyelids.
Is there a reliable percentage for serious complications?
Not one that applies to all “laser resurfacing.” Published rates vary too much because fully ablative CO2, fractional CO2, Er:YAG and non-ablative fractional systems create different injuries. Skin tone, treatment density, indication and aftercare also change risk.
For example, a 2026 meta-analysis comparing fractional CO2 with RF microneedling for acne scars found the relative risk of PIH was 4.44 times higher with fractional CO2 in the included trials. That does not mean every patient has a 4.44% risk; it is a relative comparison between two treatments.
A clinic that quotes one universal “less than 1% complication rate” for every laser and every setting is oversimplifying the evidence.
Do I really need to wait six months after isotretinoin?
The old rule is more nuanced than many websites suggest.
Recent systematic reviews and a 2024 randomized split-face trial do not support an automatic six-to-twelve-month delay for fractional ablative or non-ablative laser treatment in every patient taking or recently finishing isotretinoin. In the randomized trial, fractional CO2 treatment performed concurrently with isotretinoin did not show the feared increase in abnormal scarring.
That does not make every procedure equivalent. Fully ablative resurfacing is still treated much more cautiously, and individual wound-healing or pigment risk matters. Tell the clinician exactly what dose you take and when you started or stopped it.
Who may need another treatment instead?
Laser resurfacing is most useful when the target is skin texture, selected scars, fine lines or photodamage. It is less logical when the main problem is deep tissue descent, major volume loss, a very deep tethered scar or a pigment disorder that is likely to flare with heat or inflammation.
Alternatives can include RF microneedling, conventional microneedling, chemical peels, subcision, TCA CROSS, injectable treatments, pigment-specific lasers or surgery. The correct comparison depends on the problem, not on which device a clinic happens to own.
How does laser resurfacing compare with RF microneedling?
Both create controlled injury and collagen remodelling, but they deliver energy differently. Fractional CO2 can produce stronger surface resurfacing and may offer somewhat greater acne-scar improvement in some comparative studies. RF microneedling leaves more of the epidermal surface intact and may carry a lower PIH risk in some skin types.
Neither is automatically better. Scar morphology, skin tone, pain tolerance, recovery time and operator experience should drive the choice.
What should I ask before agreeing to treatment?
- What exact device and wavelength are you using?
- Is it fully ablative, ablative fractional or non-ablative fractional?
- Why is this treatment appropriate for my specific concern and skin tone?
- What settings or treatment intensity are you planning, and what recovery does that normally produce?
- What is your protocol for herpes prevention and post-treatment wound care?
- What pigment changes do you see in patients with my skin type?
- If I have acne scars, which scar types are you treating with laser and which need another technique?
- What should I do if I develop worsening pain, infection signs or delayed healing?
A good consultation should leave you knowing exactly which resurfacing procedure you are having. “CO2,” “fractional” or “Fraxel” on its own is not a complete treatment description.
