Q: What are the alternatives to CO2 laser treatments?

When it comes to laser resurfacing , CO2 lasers are considered old-school heavy hitters. Since their initial widespread use in the ‘80s, various laser technologies have been developed, including Fraxel , Halo , and CoolPeel . These newer lasers tend to be fractional or non-ablative, with fewer risks and easier recovery. For skin rejuvenation, you can look beyond lasers to improve many common concerns (wrinkles, hyperpigmentation, scarring, etc.). Other treatments that help shed damaged cells from the skin surface and prompt collagen production include chemical peels, microneedling , and microdermabrasion . The best skin rejuvenation treatment for you will depend on your concerns, desired results, skin type and tone, expendable downtime, and budget. A qualified dermatologist or plastic surgeon can walk you through your options.

Question 1

What is the CO2 laser?

Accepted Answer

A carbon dioxide laser (CO2 laser) resurfaces skin with targeted beams of light. As the first type of laser designed for skin resurfacing, it’s been a popular choice since the 1980s for the rejuvenation of aging and damaged skin.

So how does a CO2 laser work? Electricity runs through a gas-filled tube to produce a specific wavelength of light. The light is emitted in short, concentrated beams, which target water molecules and vaporize skin cells. The laser removes surface cells of the epidermis, making way for fresh, clear new skin.

At the same time, it penetrates the skin's deeper dermis layer to stimulate new collagen production, which firms and smooths skin over time.

CO2 laser treatments can address fine lines and wrinkles; discoloration (including sun damage and age spots); acne scars; stretch marks; and uneven skin texture on the face, neck, and chest.

It can also treat benign skin growths like warts, birthmarks, and seborrheic keratosis, as well as some skin cancers.

The skin condition rhinophyma, which increases skin thickness on the nose, also responds well to CO2 laser treatment.

CO2 laser resurfacing procedures, like the popular UltraPulse, can treat the full face or work as a spot treatment for isolated concerns like wrinkles or scars.

The downside of the CO2 laser? "It's an aggressive laser and should be used cautiously in all skin types," says Dr. Jason Emer, a dermatologic surgeon in West Hollywood, California.

Dr. A. David Rahimi, a board-certified dermatologist in Los Angeles, underscores this point. He says that an inexperienced provider who performs this treatment at inappropriately high settings can leave patients with post-inflammatory hyperpigmentation (a side effect seen in about 5% of patients, Dr. Rahimi notes), keloids, or permanent hypopigmentation.

Because of these risks, fully ablative CO2 laser treatments aren’t recommended for patients with Fizpatrick skin types IV-VI. However, Dr. Rahimi says fractional CO2 laser resurfacing can be safely performed on people with olive and brown skin tones, provided their skin is prepped in advance with a specialized protocol like Retin-A, hydroquinone, and glycolic acid.

Question 2

What are the pros and cons of CO2 laser treatments?

Accepted Answer

Pros

Invented in 1964, CO2 lasers have a long history of use and plenty of evidence to attest to their effectiveness and safety on fair to light skin tones.
Doctors can customize CO2 laser skin resurfacing treatments to best suit your skin type and concerns. There are several CO2 lasers on the market, and your provider will recommend the device, treatment intensity, and number of sessions that are right for you.
Laser resurfacing addresses a wide range of concerns beyond just aging and damaged skin. When it's performed by an experienced provider, a good candidate will see smoother, clearer, brighter skin once they’ve healed.

Cons

CO2 lasers, like most resurfacing lasers, can be risky for people with medium to deep skin tones because the light beam targets pigment. Gentle treatment may be possible, but consult with a doctor who’s experienced in treating olive, brown, and deep skin tones to ensure this is the right treatment choice.
These lasers can be intense. At their most aggressive (fully ablative, with all skin from the treatment area removed), you may need general anesthesia to mitigate pain and weeks of downtime while you heal.
Recovery time is lengthy. "Typically, redness is the most intense the first 10 days," says Dr. Warren Schutte, a plastic surgeon in Loveland, Colorado. "However, it takes weeks after that for the skin to fade from bright red through shades of pink and then back to natural skin pigmentation."
Laser treatments provide mild firming benefits, but they aren't the best option for treating moderate to severe skin laxity. If sagging or loose skin is your primary concern, you’re better off pursuing a surgical facelift or neck lift, both of which actually remove excess skin. If you’re committed to a nonsurgical option, consider radiofrequency or ultrasound energy treatments that focus on remodeling skin below the surface.

Question 3

How much does treatment with a CO2 laser cost?

Accepted Answer

Your cost will depend on your provider’s experience level, their practice location, and which laser is used.

Cosmetic procedures like this one aren't covered by most medical insurance plans. However, exceptions may be made if it’s being done to treat scars or remove precancerous growths.

You can finance your treatment with CareCredit.

See our complete guide to CO2 laser treatment costs

Question 4

CO2 laser before and after pictures

Accepted Answer

The CO2 laser photos in our gallery have been shared by the provider who performed the procedure, with the patient's consent.

Question 5

Ablative vs. fractional CO2 laser: What’s the difference?

Accepted Answer

There are two types of CO2 laser: fully ablative and fractional. The main difference between them is how much skin they remove, or ablate.

Fully ablative CO2 lasers completely ablate the treatment area, as their name implies. They strip away all superficial skin hit with the laser beam and heat up the deeper dermal layer to trigger a regenerative healing response that includes new collagen and elastin production.

The treatments can be intense, usually requiring general anesthesia, and downtime is a minimum of two weeks. Paradoxically, these lasers can cause more pigmentation issues—and they’re recommended only for fair or light skin tones.

To mitigate risks, doctors often recommend preparing the skin in advance with Retin-A or hydroquinone. On the plus side, one treatment usually suffices for desired results.

Fractional CO2 lasers, on the other hand, deliver a partial beam of light that targets only a fraction of the skin, in a pixelated pattern. Doctors can adjust the percentage of the area treated and the depth of treatment to suit your skin concerns.

With only some skin removed, treatments are considerably less aggressive than those with a fully ablative laser.

They may trigger some deeper remodeling and regeneration, but fractional treatments are usually better for surface-level improvement. Downtime can be only a matter of days, but most people need a series of treatments for best results.

Fractional CO2 laser resurfacing technology is newer, and it’s increasingly popular with doctors and patients alike, given the minimized pain, downtime, and risks.

Related: The Return of the CO2: Why These Next-Level Lasers are Making a Comeback

Question 6

Who’s a good candidate for CO2 laser treatments?

Accepted Answer

For fully ablative treatments, the ideal candidate has a fair to light skin tone and wrinkled, sun-damaged, or scarred skin. (People who just have fine lines or mild discoloration don't need such an intense laser as the CO2.)

Fractional CO2 laser treatments, which remove only a fraction of the skin's surface, may be an option for people with medium to deep skin tones (Fitzpatrick skin types IV-VI). Talk with your provider about whether they recommend a pre-treatment protocol to help mitigate the risks of hyperpigmentation, hypopigmentation, or keloids.

Fractional CO2 lasers can treat mild to moderate signs of aging and damage, including fine lines, rough texture, and hyperpigmentation. An experienced provider can increase or decrease the intensity as appropriate, to safely treat a range of skin types and tones.

RealSelf Tip: Laser resurfacing treatments work best to target pigment-based discoloration—think sunspots, age spots, and post-inflammatory hyperpigmentation. CO2 lasers won’t do much for redness or rosacea, which originate within the vascular system. If flushing, ruddiness, or visible blood vessels are your main concerns, talk to a doctor about IPL or pulsed dye lasers for treatment.

Question 7

What happens during a CO2 laser treatment?

Accepted Answer

CO2 laser resurfacing is an outpatient procedure. Appointments last from 30 minutes to two hours, depending on the size of the treatment area and aggressiveness of treatment. Here’s what to expect:

If you’re having a fractional CO2 laser treatment, your doctor will first numb you with local anesthesia and may also provide an oral sedative to help you relax.
For a fully ablative treatment, you’re likely to be put under general anesthesia so that you’re completely asleep. (Arrange for a ride home if you’re going to be sedated for the procedure.)
Once you’re numb or unconscious, your provider begins moving the handheld laser device across the treatment area as it emits its powerful light beam. The beam is usually a square, so the provider carefully moves the device section by section, lining up each ablated square in a grid-like pattern until the full area has been treated.
You won’t feel or be aware of anything if you’re under general anesthesia. If you have just numbing cream or an injected local anesthetic, the sensation can feel like a snapping rubber band.
After your provider has applied the laser beam to the full treatment area, they’ll cover your skin with a thick ointment and dressings.

Question 8

How long does CO2 laser recovery take?

Accepted Answer

Social downtime (when you won’t want to leave the house) can stretch for several days for fractional treatments to more than two weeks for fully ablative treatments.

During that recovery time, your skin will be swollen and develop scabs or crusting. You’ll first notice that your skin is raw, which can feel itchy and painful. You may also have some pinpoint bleeding, particularly following a more ablative treatment.

“It will feel like an exaggerated sunburn, but ice packs will help take down the sting within one to two hours,” says Dr. Paul Flashner, a physician in Boston. Over-the-counter pain relievers can offer some additional relief, and doctors may prescribe stronger pain medication for aggressive fully ablative treatments.

Swelling can be managed with prescription steroids and ice packs as well as keeping your head elevated while sleeping.

Follow your doctor’s precise instructions for gently cleansing and moisturizing the treated area. They may recommend or even provide specific medical-grade skin-care products for you.

It’s important to keep your skin protected and moist throughout the healing process—initially with ointments and thick creams, then with lighter creams and serums down the line. This encourages healthy cell turnover and prevents the forming of scabs, which can increase the chance of scarring and prolong healing time.

After the initial healing phase, your skin can remain pink for several weeks. You can apply makeup to conceal redness, but only after new skin grows in the entire treated area.

When you go out of the house, be especially mindful of sun exposure. Your fresh, new skin will be sensitive, so a broad-spectrum sunscreen with an SPF of at least 30 is a must.

RealSelf Tip: Some over-the-counter pain relievers, like aspirin, can increase the risk of post-procedure bleeding. Be open with your doctor about any medications or supplements you’re taking so that they can advise on whether you should continue taking them as you heal.

Question 9

When will you see CO2 laser results?

Accepted Answer

How soon you’ll see results depends on the intensity of your treatment and how long healing takes. You won’t really see results until after your skin has completely healed and any lingering redness resolves, which can be several weeks for fractional treatments and a couple of months for fully ablative treatments.

Surface skin results will be apparent as soon as healing’s complete, but it takes a few months to see the firming effects of increased collagen as your body naturally produces new cells and structural proteins.

Question 10

How long do CO2 laser results last?

Accepted Answer

Results can last years. Their longevity will depend on the intensity of your treatment and how well you take care of your skin afterward. To avoid recurring damage, establish a hydrating, antioxidant-packed skin-care routine and strong sun protection habits with high-SPF sunscreen.

That said, your skin will continue to age with the rest of you.

You can help maintain your results with ongoing laser treatments or other skin rejuvenation treatments. According to Dr. Emer, “Fractional lasers should be done every quarter to maintain results, whereas the fully ablative CO2 laser can be done every one to two years.”

Question 11

What are the risks of CO2 laser treatments?

Accepted Answer

Fully ablative CO2 laser treatments come with the highest risk and most serious side effects, given that they actually remove all surface layers of skin. Burning and scarring can result from an overly aggressive or poorly performed treatment.

The healing process can also be intense, with weeks of swelling, scabbing, oozing, peeling, and redness. It’s important to precisely follow your doctor’s instructions for cleansing and moisturizing, to avoid infections that can lead to scarring, hyperpigmentation, or hypopigmentation. Many doctors prescribe antibiotics to take after CO2 laser treatments.

The same risks and side effects accompany fractional CO2 laser treatments, to a lesser degree. People with medium to deep skin tones remain at considerable risk of burning and scarring, due to the way laser beams target pigment. Again, find an experienced provider who knows how to choose a safe but effective setting for your skin tone. Then follow their recovery instructions closely, to ensure healthy healing and prevent infection.

The most common risks of CO2 laser treatments are pigmentation complications. The laser can zap away melanin and melanin-producing cells, leaving behind light spots of hypopigmentation. But it can also send those pigment-producing cells into overdrive, producing spots of excess pigmentation called hyperpigmentation. The more melanin in your skin, the higher your risk for pigmentation issues (including keloid scars) post-treatment. As we mentioned above, these risks can be mitigated by a pre-treatment protocol, like the combination of Retin-A, glycolic acid, and hydroquinone recommended by Dr. Rahimi.

Related: Top Cosmetic Treatments for Deep Skin Tones

Avoid CO2 lasers if you have active acne. The treatment relies on controlled damage, so further harming already inflamed skin (and potentially spreading bacteria) won’t be beneficial. AviClear, a laser treatment that’s FDA approved specifically as an acne treatment, may be a better choice.

On a related note, stay away from this laser if you currently take Accutane (or isotretinoin), which limits the skin’s healing abilities.

Milia, tiny white bumps or cysts, can also form in the treated area during the healing process.

If you have a history of cold sores, tell your doctor so that they can prescribe an antiviral medication ahead of your laser treatment, to prevent new flare-ups.

Question 12

What are the alternatives to CO2 laser treatments?

Accepted Answer

When it comes to laser resurfacing, CO2 lasers are considered old-school heavy hitters. Since their initial widespread use in the ‘80s, various laser technologies have been developed, including Fraxel, Halo, and CoolPeel. These newer lasers tend to be fractional or non-ablative, with fewer risks and easier recovery.

For skin rejuvenation, you can look beyond lasers to improve many common concerns (wrinkles, hyperpigmentation, scarring, etc.). Other treatments that help shed damaged cells from the skin surface and prompt collagen production include chemical peels, microneedling, and microdermabrasion.

The best skin rejuvenation treatment for you will depend on your concerns, desired results, skin type and tone, expendable downtime, and budget. A qualified dermatologist or plastic surgeon can walk you through your options.

Question 13

Sources & studies

Accepted Answer

Omi, Tokuya, and Kayoko Numano. “The Role of the CO2 Laser and Fractional CO2 Laser in Dermatology.” Laser Therapy, vol. 23, no. 1, Mar. 2014.

Preissig, Jason, et al. “Current Laser Resurfacing Technologies: A Review That Delves Beneath the Surface.” Seminars in Plastic Surgery, vol. 26, no. 03, Aug. 2012.

Sandeliv, H, and S Perkins. “CO2 Laser Resurfacing: Still A Good Treatment.” Aesthetic Surgery Journal, vol. 28, no. 4, July 2008.

CO2 LASER

Dr. A. David Rahimi

Kali Swenson

Dr. A. David Rahimi

Kali Swenson

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Dr. A. David Rahimi

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CO2 LASER QUESTIONS

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