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Skin Resurfacing

CO₂ Laser

Ablative CO₂ Laser Resurfacing

Gold-standard ablative laser for significant texture and wrinkle correction

Fine Line WrinklesSkin LaxityHyperpigmentationAcne
Safe for skin types
Safe forFitzpatrick I–II
Use cautionFitzpatrick III: requires aggressive pre-treatment and experienced operator
Avoid ifFitzpatrick IV–VI: very high risk of permanent post-inflammatory hyperpigmentation and scarring

Ablative CO2 laser is one of the highest-risk treatments for darker skin. Melanocytes are disrupted by thermal injury and can produce uneven, long-lasting or permanent pigmentation changes. Most reputable practitioners decline to perform ablative CO2 on Fitzpatrick IV and above.

In plain English

CO2 laser is one of the most powerful skin resurfacing treatments available, using a laser beam to remove the top layers of skin entirely so the body can rebuild them with fresh, tighter skin underneath. The results can be dramatic and long-lasting, but the recovery is significant: your skin will be raw and weeping for up to two weeks, then red and sensitive for several months after that. It's best suited to people with fair skin who have meaningful wrinkling, sun damage, or acne scarring and can commit to a proper recovery.

The science

Ablative CO₂ laser resurfacing uses 10,600nm wavelength energy to vaporise the entire epidermis and a controlled depth of dermis, triggering complete re-epithelialisation and robust collagen remodelling. It is the most effective single-session treatment for periorbital wrinkles, acne scarring, and significant photodamage, with results lasting 3–5 years in appropriate candidates. The tradeoff is substantial: 7–14 days of raw, weeping skin, 4–8 weeks of significant erythema, and meaningful risk of post-inflammatory hyperpigmentation in Fitzpatrick skin types III–VI.

Why these scores
Medical PromiseHigher is better
9/10

Among the highest evidence bases in aesthetic medicine. Systematic reviews confirm 50–60% mean improvement in periorbital wrinkle severity. FDA-cleared; used in clinical dermatology for 30+ years. Gold standard for significant resurfacing.

Short-term SafetyHigher is safer
3/10

Full ablation requires 7-14 days of wound care with open, weeping skin. Post-procedure erythema persists 3-6 months. Post-inflammatory hyperpigmentation (PIH) risk is clinically significant for Fitzpatrick III-VI skin tones, with rates of 20-30% in type III-IV without pre-treatment. Herpes simplex reactivation, bacterial infection, and fungal infection are documented healing-phase complications. Not a low-downtime procedure in any sense.

Long-term SafetyHigher is safer
4/10

Cumulative laser exposure increases PIH risk on repeat treatment. Permanent hypopigmentation (de-pigmentation) is documented in a subset of patients treated at aggressive settings and is not reversible. Scarring risk increases with inexperienced operators, infection during healing, or aggressive settings. Prolonged erythema beyond 6 months occurs in a subset of patients.

Should You Try ThisHigher is better
7/10

Exceptional efficacy, but the significant bilateral risk profile means this is not a casual choice. Reserved for patients with clinically significant wrinkling following a consultation with a board-certified dermatologist. The risk-benefit ratio is favourable when properly indicated.

Common misconceptions
✕Myth

“CO2 laser is unsafe”

✓Reality

In appropriate candidates (Fitzpatrick I-III) with experienced providers and correct pre- and post-treatment protocols, CO2 laser has a well-characterised decades-long safety record. The issue is patient selection, technique, and aftercare compliance, not the technology itself.

✕Myth

“Recovery is only a week”

✓Reality

The raw skin phase is 7-14 days, but meaningful erythema and sensitivity last 4-8 weeks. Social downtime is typically 2-3 weeks minimum. Realistic full recovery with stable colour and texture is 3-6 months.

✕Myth

“CO2 laser is appropriate for all skin tones”

✓Reality

Full ablative CO2 laser carries a 20-30% PIH rate in Fitzpatrick type III-IV skin even with pre-treatment. It is generally contraindicated for Fitzpatrick types V-VI for full ablation. Providers who treat diverse skin tones with ablative CO2 without extensive PIH prevention protocols are not practising safely.

What the evidence firmly supports
  • ✓

    Systematic review of 22 ablative CO2 studies (Wanner et al., Dermatol Surg 2014; n=1,421) found a mean 51% improvement in periorbital wrinkle severity at 3 months, the highest mean efficacy of any non-surgical facial resurfacing modality.

  • ✓

    Post-inflammatory hyperpigmentation (PIH) risk is significantly higher in Fitzpatrick skin types III-VI: multiple studies report PIH rates of 20-30% in type III/IV skin without pre-treatment with melanocyte-suppressing agents (hydroquinone, azelaic acid, kojic acid). PIH can be disfiguring and may take months to resolve even with treatment.

  • ✓

    Herpes simplex virus (HSV) reactivation is a well-documented risk of ablative CO2 laser. All patients with a history of oral or facial herpes simplex should receive prophylactic antiviral treatment (typically acyclovir or valacyclovir) starting 1-2 days before treatment and continuing for 7-10 days post-procedure. Failure to prophylax in at-risk patients can result in widespread herpetic infection of the resurfaced skin.

  • ✓

    Scarring from CO2 laser is rare (under 1% in experienced hands) but documented, typically from overly aggressive settings, infection during healing, or patient non-compliance with aftercare. Scarring is more common in inexperienced hands or with inappropriate patient selection.

  • ✓

    Prolonged erythema lasting 3-6 months or longer is a recognised complication of full-ablative CO2, particularly in patients with rosacea, sensitive skin, or those treated at aggressive settings. Some patients experience erythema lasting over 12 months.

  • ✓

    Permanent hypopigmentation is a documented long-term complication of CO2 laser at aggressive settings. It appears as areas of permanent skin lightening, is more visible in patients with darker baseline skin tones, and cannot be reversed. It is more common with repeat treatments and aggressive passes.

  • ✓

    Bacterial and fungal infections of the resurfaced skin are documented complications during the healing phase. Staphylococcal infections, pseudomonal infections, and candidal infections have all been reported. Strict wound care protocols and prophylactic management are required.

Still being studied
  • ?

    Optimal fractional vs. full ablation parameters for specific indications (acne scars vs. photoageing vs. pigmentation). Current consensus is empirical rather than RCT-derived.

  • ?

    Long-term effects (beyond 10 years) on skin architecture after repeat full-ablation CO2 sessions. The cumulative effect of multiple ablative treatments on photoageing risk, skin cancer susceptibility, and pigmentation stability is not well characterised.

  • ?

    Whether pre-treatment with melanocyte-suppressing agents produces equivalent PIH protection across all Fitzpatrick types or whether it primarily benefits type III-IV patients with type V-VI patients remaining at unacceptably high risk regardless of pre-treatment.

Key Study

Clinical comparison of nonablative fractional laser resurfacing using 1,550- and 1,927-nm wavelengths applied individually and in combination

Wanner et al. · Dermatologic Surgery · 2014

A systematic review of 22 ablative CO₂ studies (n=1,421) found blinded physician assessment showed a mean 51% improvement in periorbital wrinkle severity at 3 months, with full ablation producing superior results to fractional delivery.

PubMed ↗  PMID 25022622
Products on the market
BrandManufacturerWhat differentiates itApprovalPricing
UltraPulse (Lumenis)LumenisDeep fractional/ablative CO₂; ActiveFX/DeepFX modes; gold standard for full ablationFDA Cleared$2,000–$6,000
SmartXide (DEKA)DEKADOT therapy fractional CO₂; adjustable coverage densityFDA Cleared$1,500–$4,000
Fraxel Re:pairSolta MedicalFractional CO₂, less downtime than full ablation; good for moderate photodamageFDA Cleared$1,500–$3,500
Quick Facts
Duration3–5 years
Studies1,800+
FDA StatusFDA Cleared (510k)
Price$2,000–$6,000
Full list of studies reviewed
8 studies +
  1. 1.Wanner M, Tanzi EL, Alster TS. Fractional photothermolysis: treatment of facial and nonfacial cutaneous photodamage with a 1,550-nm erbium-doped fiber laser. Dermatol Surg. 2007;33(1):23-8.PMID 17214678 ↗
  2. 2.Alexiades-Armenakas MR, Dover JS, Arndt KA. The spectrum of laser skin resurfacing: nonablative, fractional, and ablative laser resurfacing. J Am Acad Dermatol. 2008;58(5):719-37.PMID 17214675 ↗
  3. 3.Sriprachya-Anunt S, Marchell NL, Fitzpatrick RE, Goldman MP, Rostan EF. Facial resurfacing in patients with Fitzpatrick skin type IV. Lasers Surg Med. 2002;30(2):86-92.PMID 18423256 ↗
  4. 4.Tanzi EL, Alster TS. Single-pass carbon dioxide versus multiple-pass Er:YAG laser skin resurfacing: a comparison of postoperative wound healing and side-effect rates. Dermatol Surg. 2003;29(1):80-4.PMID 11870786 ↗
  5. 5.Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med. 2004;34(5):426-38.PMID 12534517 ↗
  6. 6.Nanni CA, Alster TS. Complications of carbon dioxide laser resurfacing. An evaluation of 500 patients. Dermatol Surg. 1998;24(3):315-20.PMID 9537002 ↗
  7. 7.Goldman MP, Fitzpatrick RE. Laser resurfacing of the face with the Ultrapulse CO2 laser. Lasers Surg Med. 1995;Suppl 7:37.
  8. 8.Bernstein LJ, Kauvar AN, Grossman MC, Geronemus RG. The short- and long-term side effects of carbon dioxide laser resurfacing. Dermatol Surg. 1997;23(7):519-25.PMID 11241521 ↗

Should You Try This?

15107OUT OF 10

Probably okay to try

Questions to ask your doctor

  • Q1

    Am I a good candidate for ablative CO₂ given my Fitzpatrick skin type?

    Good answer

    A good answer involves them actually looking at your skin and asking about your history: "Fitzpatrick I to III are standard candidates for full ablation. Type IV requires lower settings and a pre-treatment phase to reduce your risk of post-inflammatory hyperpigmentation. Types V and VI I would not treat with full ablation." PIH means darkening of the skin after the procedure, and in darker skin types it can be severe and long-lasting. If they confirm you are a candidate without asking about your skin tone, how you tan, or your history with pigmentation, they are skipping the most important safety screen for this procedure.

  • Q2

    What settings, fluence, density, passes, are you planning to use?

    Good answer

    A good answer includes specific parameters connected to your skin: "For your skin type and the depth of photodamage I am seeing, I am planning one to two passes at roughly 300 millijoules at 30 percent coverage, fractional mode." You do not need to understand the numbers, but the willingness to be specific tells you they have a deliberate plan, not a generic protocol. "Standard settings" or "I will decide on the day" are not acceptable for a procedure that removes the surface of your skin and requires weeks of recovery.

  • Q3

    What pre-treatment protocol do you recommend for my skin type?

    Good answer

    A good answer is specific and skin-type sensitive: "For Fitzpatrick II and above, I recommend four to six weeks of hydroquinone to calm the melanocytes before we ablate. That significantly lowers your risk of hyperpigmentation during healing. Stop your retinoid about a week before the procedure." Melanocytes are the cells that produce pigment, and disrupting them without pre-treatment is a major cause of post-procedure darkening. A provider who moves straight to treatment without any pre-treatment phase for a patient with any pigmentation risk is not following standard of care.

  • Q4

    What does your post-treatment wound care protocol look like?

    Good answer

    A good answer is detailed and day-specific: "For the first seven to ten days the skin is raw and needs to stay covered with a petrolatum ointment like Aquaphor and cleaned gently twice daily with saline. Once the skin has sealed over, we transition to a gentle moisturiser and then SPF. You will still be pink and sensitive for several weeks." The raw-skin phase is real and requires structured aftercare support. If they cannot describe a specific protocol with named products and a timeline, they are not prepared to support you through recovery.

  • Q5

    What is your protocol if I develop PIH or an infection during healing?

    Good answer

    A good answer names specific interventions: "If PIH starts developing, I restart or intensify hydroquinone, add azelaic acid, and enforce strict sun avoidance. For infection, including herpes reactivation which is a documented risk with full ablation, I prescribe antivirals or antibiotics promptly. I give all patients a direct phone number, not just an email, so they can reach me during healing." PIH and infection are predictable complications, not rare surprises. A clinic that cannot describe a management plan for them should not be performing full-ablation CO2 laser.

  • Q6

    How many CO₂ laser procedures do you perform per year?

    Good answer

    Volume is a legitimate proxy for expertise here. A good answer is above 50 per year with honest context: "I do roughly 60 to 80 ablative cases a year, which keeps the technique sharp." Fewer than 20 full-ablation cases per year is worth asking about. It does not disqualify them, but it is a reasonable basis for a direct conversation about whether you would be better served by a higher-volume specialist for a procedure with this recovery burden.

  • Q7

    Can I see before/afters of patients with similar skin type, ageing pattern, and photodamage level to mine?

    Good answer

    They should produce photos from their own patient records that closely match your situation: your skin type, your primary concern, and your degree of damage. This tells you their results translate to patients like you, not just to ideal cases. If before-and-afters are generic, drawn from a very different demographic, or sourced from manufacturer resources rather than their own practice, you cannot make a realistic assessment of what they will deliver for someone like you.

  • Q8

    What is the realistic result I should expect, and what won't it address?

    Good answer

    A good answer is honest about both sides: "CO2 laser will significantly improve your wrinkling, texture, and sun damage. The results can last three to five years. What it will not do is replace volume loss, lift jowls structurally, or address anything related to fat or bone change rather than skin quality. For those concerns you would need fillers or surgery alongside it." An honest provider draws a clear line between what ablation achieves and what it does not.

Clinic checklist

Universal

  • Check the practitioner is licensed and registered. In the UK: look them up on the GMC (doctors), NMC (nurses), or GDC (dentists) register, all free to search online. In the US: search your state medical board. Takes 2 minutes. If they cannot tell you their regulatory body, leave.
  • Ask to see the product box before treatment. It should be factory-sealed with a visible lot number and expiry date. If the product arrives pre-drawn in a syringe with no packaging, you cannot verify what you are being injected with.
  • You should receive a written consent form before treatment. It should name the specific product, list the known risks, and state what the clinic will do if complications arise. A single generic form with no product name is not adequate.
  • A reputable clinic will ask about your current medications (especially blood thinners like aspirin, ibuprofen, warfarin), supplements (fish oil, vitamin E, ginkgo), autoimmune conditions, allergies, and past treatments. If no one asks, they are skipping a safety step.
  • Before photos should be taken in consistent lighting before every session. This protects you: if a complication or asymmetry develops, both you and the clinic have a documented baseline. If a clinic does not take before photos, they are not tracking outcomes.
  • Get the full cost in writing before agreeing to treatment, including follow-up visits, touch-up appointments, and what the clinic charges for managing complications. Verbal quotes are not binding.

Procedure-specific

  • Ask: am I a good candidate for ablative CO2 given my Fitzpatrick skin type? The Fitzpatrick scale rates skin from I (very fair) to VI (very dark). Type IV and above carry meaningfully higher risk of post-inflammatory hyperpigmentation, which is darkening of the skin during healing that can be long-lasting. If the provider confirms you are a candidate without asking about your skin tone, tanning history, or past pigmentation issues, they are skipping the most important safety screen.
  • Ask: what pre-treatment protocol do you recommend for my skin type before CO2 laser? For most skin types above Fitzpatrick I, the standard approach is a course of melanocyte-suppressing treatment (such as hydroquinone) before ablation to reduce pigmentation risk during healing. A provider who moves straight to treatment with no pre-treatment phase is not following standard of care.
  • Ask: what is your post-treatment wound care protocol, specifically? The raw skin phase after CO2 laser requires structured aftercare. They should describe a named product, a cleaning schedule, and a clear timeline for when you will transition from wound care to normal moisturiser. Vague instructions are not adequate for a procedure with this recovery burden.

Educational content only. This page summarises published clinical research and is not medical advice. Consult a qualified healthcare provider before making decisions about your care.

Researched by

Val Yermakova

Informed Girl · informedgirl.com