Do Non Ablative Laser Peels Really Work for Acne Scars?

And therefore, they must "work" at "least a little," right?

Please check my answer elsewhere on this forum for "What is the best laser for skin resurfacing?" I will include edited parts of the answer here for your review.

I have taught laser surgery, including resurfacing, for over twenty years, nationally and internationally (Korea, Canada, Caribbean), and have performed thousands of laser cases in my practice. (I am in private practice, and do not have academic affiliation, rarely publish, but have taught nearly a hundred laser courses and thousands of physicians of various specialties over these years). Now, just the facts, Ma'am.

Ablative CO2 laser resurfacing came first, gave great (dramatic) results for both wrinkles and acne scars, but fell somewhat out of favor as hypopigmentation (skin color lightening) occurred a year or so after treatment. Wrinkles, spots, and sun damage still gone, but line of demarcation where treatment stopped, and lighter skin color where treatment was done. Bummer!

Ablative Erbium-YAG laser resurfacing came next, but treated much more superficial layers, so skin healed faster, with less redness, but with less dramatic changes, especially for deeper issues such as acne scars. If the doctor promoted this as "better than CO2" and charged as much, patients were unhappy, but not because the laser had a "problem" other than milder results. Bad doctor "marketing!" These lasers are now being "repurposed" as "micro laser peel" machines because of the superficial nature of the tissue removal.

By the time that third-generation combination CO2/erbium-YAG lasers came along about ten years ago, the herd of dermatologists, plastic surgeons, and other laser doctors had moved on to the "non-ablative" lasers or therapies such as Thermage, N-lite, Cool-touch, Smoothbeam, and many others. These all "worked" to varying degrees, but usually with very minimal results, and virtually NO improvement with acne scars. Prices dropped, and so did most of the hype, and "the herd" of doctors that need the "latest and the greatest" moved on to Fractional lasers. (Very few of us--usually the experienced instructors--bought the third-generation CO2/Erbium YAG resurfacing lasers. Even though they work the best of the three generations of lasers discussed thus far, slow sales = company bankrupt.) The rest of the herd was at the fractional laser rodeo!

Fractional lasers started with Erbium wavelengths, and treated the skin in tiny polka-dots. Bridges of intact skin were left untreated, which is said to promote faster healing and less down-time (partially true). Actually, less skin treated = less result, which required multiple treatments, which = more procedures, more healing and MORE cumulative downtime. Oh, and the total cost adds up to a tidy sum usually! The results are real, but with superficial layer and polka-dot treatment came mild results. More, give us more!

The next fractional lasers returned to CO2 wavelengths, which penetrate deeper, and still treated skin in tiny polka-dots. Fortunately, unless the energy was turned up too much, or the polka-dot density too tight, hypopigmentation changes were limited, and the results were indeed better. Still only in the fraction of the skin treated, still requiring more than one treatment for results that could approach that of well-performed third-generation combination CO2/Erbium-YAG ablative resurfacing (which very few doctors even had then, or have today), and still adding up to a tidy sum for only "fractional" results. BTW, it still takes a week to heal fractional laser treatments, and if you add up the time for multiple procedures, doctor's visits, and cost, HOW can this be "LESS DOWNTIME"?

So at the risk of being contrarian, I would submit that a properly-performed ablative CO2/Erbium-YAG full-face laser resurfacing remains the BEST one-time laser resurfacing procedure available, especially for acne scars. With proper skin care, I routinely have patients healed in 7-10 days, and with minimal (truly) redness easily covered with standard make-up. I even purchased a second CO2/Erbium-YAG laser for parts--they are no longer available. But the marketplace delivers what the public (and their doctors) demand. I know from all the courses I have taught over the years, that many, if not most, of the doctors that use lasers don't even understand the basic laser biophysics of how laser energy interacts with tissues--they just want to know "what is the basic setting, where is the trigger, and how much can I charge?"

Even when I "gave away" free treatments with non-ablative laser devices when I evaluated them years ago, barely one third of patients saw even minimal improvements. If you like the emperor's clothes, I suspect that you may well be one of the minority who like the results you see on acne scars by non-ablative laser treatments!

Enough said, my soapbox is sagging! Caveat emptor!

Palomar (Lux 1540) really
makes a difference in the skin. It would be one of best options to treat acne
scarring. This treatment penetrates deep into the dermal layer of the skin, so it
can rebuild collagen and elastin in the scar tissue.

Thank you for your question.  We usually treat acne scars with profractional laser.  We have seen significant improvement in the skins tone and texture along with the appearance of the acne scarring.  Our patients have been extremely happy post a few profractional treatments.  The skin, is however, not 100% smooth with no acne scarring.  The skin does, however, improve in texture significantly about 40-50% in improvement.

Successful treatment of acne scars often requires a combination of treatment options to obtain an optimum result.  Non ablative fractional resurfacing will improve mild acne scars after multiple treatments.  More significant scars such as deeper rolling scars, pitted scars, hypertrophic and keloid scars, pigmented and red scars all take a different approach.  It is important to see and expert who understands the best way to treat all of these scar type.  One treatment does not fit all acne scar needs.

The acne scars are scars of various shapes and depth. Any collagen stimulation by non-ablative lasers are minimal and the improvement achieved are hardly noticable. Acne scars need to be removed by any means such as surgical dermabrasion, deep chemical peels or Co2 laser in order to get a noticable improvement. Minimal treatments produce minimal results.

While ablative lasers like erbium , regular Co2, or fractional in various combinations may give the most dramatic results, they all have significant downtime. Our group has treated many hundreds of satisfied acne patients with non ablative lasers. The two most commonly used have been the smooth beam laser and Fraxel repair ( which technically is partially ablative). You need a doctor who is well trained with these lasers and feels comfortable with using the higher energies required to see the desired changes. Our patients are usually quite happy with the results. Other non ablative lasers that we have used include the pulsed dye and the KTP lasers.

fractional Lasers (CO2 or Erbium) are more efficient. There will be more crusting though with these lasers. 

Laser Peels are an option to improve acne scarring.  However, it is a slow process and require multiple treatments.  Ablative lasers such as profractional or erbium laser resurfacing may be better for acne scars, espcially if the scars are deeper.

Over time, non-ablative laser treatments repair and improve acne scars by the remodeling of collagen under the scars - old collagen is broken down and new collagen formed. This process does take time to occur - typically about 3 months - AND a series of non-ablative treatments are needed to produce enough collagen remodeling to be clinically evident in most scars -so the real improvement seen with the non-ablative lasers can take some time to be apparent. For many acne scars, especially the depressed or rolling type that look worse with shadowing light, the non-ablative fractional erbium laser, Fraxel restore, is my treatment of choice even though I have more aggressive devices that I could use. One of my favorite treatments is to alternate non-ablative smoothbeam treatments with non-ablative Fraxel restore treatments.

In our opinion, depth of penetration is the key to results. This is true regardless of the technology used be it laser, chemical or mechanical.
The skin is composed of 2 basic layers: the epidermis and the dermis. The dermis is the foundation and where thinning occurs with aging and scarring with acne.
The key to any skin tightening procedure is how it affects the underlying foundation. The greater the effect on the dermis, the greater the result.
All treatments technically cause a controlled injury to the dermis. If this injury is minor, as the dermis heals, you will see minor improvement. If the injury is deeper and more significant, healing will produce greater results. If the injury is catastrophic, healing produces visible scarring.
In our own practice, for there to be any visible, quatifiable and photographic improvement with acne scarring, the treatment needs to be significant. For our patients, we will typically recommend either microneedling, thermage, or laser resurfacing depending upon the patients problem, there expectations, and the treatment they are willing to go through.
One general rule of thumb: the greater the severity of the treatment, the longer the recovery, and the greater the result.