Should You Consider CO2 Laser Treatment? An In-Depth Guide

Carbon dioxide laser treatment, or “CO2 laser” for short, is a highly effective procedure for getting rid of various skin blemishes like freckles, acne scars, unwanted tattoos, and wrinkles. In fact, this treatment produces superior cosmetic effects compared to other minimally invasive skin resurfacing procedures. Besides having inherent advantages, CO2 laser treatment may also be combined with other therapies for better results.

However, you may have heard that this procedure also has some downsides. And some patients do ask, “Is CO2 laser worth it?”

If you have lingering questions before booking your appointment, read on. This article discusses how CO2 laser skin resurfacing works and how it compares with other skin rejuvenation therapies. We shall also explain the things you can expect before, during, and after your session, the procedure’s contraindications, and the exciting breakthroughs combining CO2 laser surgery with new cosmetic treatments.

What Is CO2 Laser Skin Resurfacing, and What Does It Do for Your Skin?

The procedure takes advantage of powerful but target-specific laser energy harnessed from carbon dioxide particles, hence the name. CO2 lasers are invisible infrared light beams that selectively vaporize the outer layer of the skin by heating water in its cells.

When used by a highly trained laser specialist, CO2 lasers can remove the epidermis, a thin layer comprising the skin’s most superficial region, with minimal damage to deeper tissues. This “micro-injury” to the skin triggers the following processes that ultimately lead to skin healing:

• The intense laser heat burns away deranged collagen strands and contracts loose collagen tissue.
• Stripping the skin’s top surface is a powerful stimulator of the immune system and its inflammatory function. Inflammation results in the release of substances that activate the body’s natural repair mechanisms.
• As healing progresses, epidermal cells grow back, and the skin produces more collagen. The deeper skin layers also repair and renew.

CO2 laser therapy is a “resurfacing” treatment, as it strips off the old skin surface and replaces it with a new one with the following visible improvements:

• Superficial imperfections like unwanted pigment and fine lines go away, improving skin tone and texture.
• Deep blemishes like coarse wrinkles and acne scars are markedly reduced.
• The skin is tighter and firmer from enhanced collagen formation, contraction, and remodeling.

These dynamic skin changes may continue for up to a year after the treatment. So, at the end of your recovery and even beyond, your skin will look younger, smoother, and more even-toned.

What Is the Difference Between Conventional and Fractional CO2 Laser Resurfacing?

Traditional CO2 laser equipment produces wide beams of light, creating larger areas of skin injury and causing more inflammation. Although experts believe cosmetic improvement is greatest with increased inflammation, some patients may not tolerate some of the side effects of conventional CO2 laser resurfacing.

Meanwhile, fractional CO2 laser treatment is a gentler alternative that delivers thin columns of laser light to the skin instead of wide beams. A single pass of the CO2 fractional laser equipment creates multiple micro-sized injuries rather than one large area of damage. This approach reduces laser heat injury and its side effects. Additionally, the simultaneous activation of multiple mini-repair sites leads to faster recovery.

Both traditional and fractional CO2 laser treatments require pain medication to ensure patient comfort during sessions. Local anesthesia is often given, though some individuals need sedation or more potent forms of pain control. Treatment regimens usually require only 1-2 sessions, depending on problem severity.

For What Skin Conditions Is CO2 Laser Resurfacing Therapy Used?

CO2 laser resurfacing is the preferred treatment for severely sun-damaged skin, which typically exhibits fine and coarse wrinkles, unwanted pigmentation, spider veins, and sagging. This procedure is also highly effective for improving the following blemishes:

• Scars from surgery, chicken pox, and acne
• Stretch marks
• Pigmentation problems such as melasma, freckles, and uneven skin tone
• Rhinophyma, a condition marked by disfiguring pore enlargement of the nose from skin disorders like rosacea

CO2 laser therapy is an alternative option for removing benign skin lumps, such as warts, moles, actinic keratosis, and superficial non-melanoma skin cancers. Your dermatologist may recommend this treatment if you have a skin condition that does not improve with other remedies or if cosmetic surgery is risky for you.

How Does CO2 Laser Treatment Compare with Other Skin Resurfacing Procedures?

Various medical procedures may also be used for skin resurfacing, but not all share the same upsides as CO2 laser therapy. Below, we deep-dive into these treatments and compare them with CO2 laser resurfacing.

Chemical Peel Therapy

This time-tested procedure entails the application of a concentrated exfoliating agent, such as trichloroacetic acid and phenol, that peels off the skin at varying depths, depending on the complexity of the skin condition being treated. Like CO2 laser resurfacing, chemical peeling induces skin repair mechanisms, with inflammation intensity determining its effectiveness.

CO2 laser therapy is more effective in removing various skin blemishes than superficial and medium-depth peels, which cause only mild-to-moderate inflammation. However, deep chemical peeling, which often uses Baker phenol, has been found to be superior to CO2 laser resurfacing in treating upper lip wrinkles, as it produces greater inflammation.

Still, a huge limitation to the use of deep skin peeling is that Baker phenol can enter the bloodstream, disturb the heart’s rhythm, and impair the latter’s ability to pump blood. In contrast, the side effects of CO2 laser treatment are usually only skin-deep.

Dermabrasion and Microdermabrasion

Dermabrasion requires the use of a rotor device to strip off the top surface of the skin, starting with the epidermis. Like CO2 laser therapy, dermabrasion requires pain medication when performed.

However, dermabrasion is ineffective in treating deep acne scars. This procedure depends heavily on the skill of the practitioner and comes with a higher risk of side effects, including pain, redness, skin discoloration, potential scarring, and long recovery periods. Fractional CO2 laser treatment has mostly replaced dermabrasion for treating acne scars due to these drawbacks.

Microdermabrasion is a similar physical skin exfoliation procedure that uses a device with a pump to release a stream of fine crystals. A handpiece and vacuum then remove these crystals along with dead skin cells.

Unlike dermabrasion, microdermabrasion is painless, requires no anesthesia, and has minimal risk of complications. This procedure may be performed more frequently but is even less effective than CO2 laser treatment for deep scars or significant skin concerns.

Microneedling

Microneedling entails using a roller device with tiny, sharp needles to create small punctures in the skin. The treatment site is cleaned, and a numbing cream is used about an hour before the procedure starts. The roller is then moved back and forth over the target site, with the needles going just deep enough to reach beneath the epidermis. Pinpoint bleeding may be observed during the session.

This procedure is also popularly known as “collagen induction therapy.” The micro-punctures kickstart inflammation and natural healing processes, boosting collagen production to improve skin texture.

Microneedling may be performed safely on any skin color or type, with a reduced risk of abnormal pigmentation post-treatment compared to procedures like dermabrasion, chemical peels, and CO2 laser resurfacing. However, laser therapy is more effective than microneedling when used on skin texture issues like acne scars.

Platelet-Rich Plasma

Platelet-rich plasma (PRP) treatment, which also goes by “vampire facial,” relies on blood’s natural ability to heal damaged tissues, including those in the skin. Plasma is the watery component of blood that transports nutrients and blood cells throughout the body. Platelets, a type of blood cell, are critical to the healing process as they seal wounds and release substances that repair injured tissues.

PRP is made by isolating platelets from a small blood sample. Injecting PRP into the skin activates platelets to release chemicals that repair damaged tissue, stimulate skin cell growth, and increase collagen and hyaluronic acid production. The treatment improves scarred and wrinkled areas by adding volume and enhancing texture.

PRP produces modest results when used alone for skin rejuvenation compared to CO2 laser resurfacing. However, combining with microneedling or CO2 fractional laser treatment improves PRP’s effectiveness.

Non-Ablative Laser and Intense Pulsed Light

Non-ablative lasers like the Vbeam and less energetic forms of radiation such as intense pulsed light (IPL) are also used for skin resurfacing like CO2 lasers. However, non-ablative light-based procedures work only in deep skin layers and leave the epidermis intact. These gentler treatments cause only mild discomfort during sessions, which a cooling mist or gel can minimize in most cases.

In terms of efficacy, CO2 laser treatment still bests non-ablative laser and IPL procedures in removing wrinkles, scars, and stretch marks. However, hair and tattoo removal, which requires less light energy, is better accomplished with non-ablative lasers and IPL to reduce inflammation and the risk of scarring.

Radiofrequency

Radio waves are related to lasers and ordinary light in that they are all “electromagnetic” forms of energy—the kind of energy created by electric and magnetic forces working together. However, radio waves have much less power and are entirely invisible. Additionally, radiofrequency resurfacing uses a non-ablative device that delivers electric energy instead of light energy.

Evidence shows that, like other non-ablative procedures, radiofrequency is less effective than the CO2 laser in removing the signs of sun damage when used alone. In terms of side effects, radiofrequency is less likely to cause pigmentation problems from light- and inflammation-induced skin damage than the CO2 laser. However, radiofrequency equipment can reach and inadvertently burn fat under the skin, potentially creating visible volume loss.

Radiofrequency is best combined with other skin resurfacing procedures, including CO2 laser surgery and microneedling. You may read further about radiofrequency microneedling from one of our previous articles to learn more.

Plasma Skin Resurfacing

Plasma skin resurfacing is a new technique that uses a special gas that is also called “plasma” but is unrelated to blood. Plasma used in these procedures is typically derived from nitrogen gas.

Plasma releases heat that removes oxygen from the skin, reducing oxidative stress and helping to eliminate damaged tissue and stimulate collagen production. Plasma skin resurfacing forms a layer of dry epidermis that creates a natural barrier, which speeds up healing and helps new skin grow.

This procedure is FDA-approved for treating facial wrinkles and benign skin conditions like actinic keratosis. It can also improve skin tone, texture, pigmentation, and sagging. At low-energy settings, plasma resurfacing is non-ablative, producing noticeable effects only after multiple treatments, though adverse reactions are mild. In its ablative form, plasma resurfacing yields cosmetic effects comparable to CO2 laser therapy, but recovery takes longer.

Facelift

The facelift is a plastic surgery procedure involving the repositioning of facial soft tissues to create a younger look. Facelifts are typically performed under general anesthesia, so patients undergoing this treatment must be in optimal physical condition.

The facelift is still considered the most effective procedure for rejuvenating the aging face. However, besides its potential for serious side effects, this treatment does not always improve wrinkled areas in or around the forehead, eye, and lip areas.

Meanwhile, CO2 laser therapy produces comparable cosmetic results, with added advantages that include precision and less risk of complications. Dermatologists can use this treatment to target areas that are challenging to remedy with facelifts.

What Are the Proven Benefits of CO2 Laser Resurfacing Treatment?

Overall, the most important benefits of CO2 laser skin resurfacing are the following:

Superior cosmetic outcomes for a minimally invasive procedure
Effectiveness against skin conditions that facial plastic surgery cannot address, such as clustered blemishes in the forehead, eyelid, and lip areas
Ability to get rid of various severe lesions
Long-lasting cosmetic effects
Treatment efficiency, as only a few sessions are required

This versatile procedure may be combined with other therapies to improve effectiveness, safety, or both.

What Can You Expect from the CO2 Laser Therapy Experience?

During your initial consultation, your laser dermatologist will perform a complete medical assessment to determine if CO2 laser resurfacing is suitable for you. They will schedule an appointment for your therapy if you’re a good candidate. You will also be given preparation instructions.

Before Your Session

Your laser specialist may recommend the following measures before your CO2 laser appointment:

• Discontinue skin-sensitizing treatments, such as hydroxy acids, isotretinoin (Accutane), and certain acne antibiotics, to reduce the risk of laser burns.
• Avoid drugs and supplements that slow down healing, including blood thinners, ibuprofen, and vitamin E.
• Refrain from smoking and drinking to aid the skin’s repair process.
• Begin regular sun protection and avoid tanning beds and sun exposure.

• Take cold sore medication to prevent outbreaks that may be triggered by the procedure.
• Use topical tretinoin or hydroquinone to help recovery and prevent pigmentation issues.
• Clean your face and avoid makeup before checking in for your appointment.

Keep in mind that proper skin preparation helps minimize complications and produce the best aesthetic results. Besides the above, you may also be advised to wear loose buttoned or zipped clothing—so you can easily change into or from a clinic gown—and have a companion for assistance.

During Your Session

Before starting, your laser dermatologist or their medical assistant will ask you to change into a gown and wear eye protection. Once you’re comfortable, the specialist will give you numbing medication and wait for 30 minutes before applying the laser in pulses. The session typically lasts 1 or 2 hours, depending on the severity of the skin problem. Most patients are fully awake or mildly sedated during surgery and experience little to no pain.

After Your Session

After the procedure, your specialist shall clean the treated skin area and apply a generous amount of moisturizing ointment to it. They may place an airtight dressing for added protection and provide you with detailed aftercare instructions.

Recovery times vary. The downtime after a non-fractional CO2 laser therapy session takes 1-2 weeks for many patients, though redness may linger for weeks to months in some individuals. In contrast, fractional CO2 laser treatment typically requires only 4-10 days for recovery.

Aftercare

Aftercare regimens vary by provider, but the following measures are widely recommended:

• Remove dressings after 24 hours and replace as instructed.
• Cleanse the treated skin twice every day and keep it moist with ointment to prevent scabbing.
• Protect the healing skin from trauma, pressure, and irritants.
• Apply ice packs to the treated skin or take acetaminophen to relieve pain.
• Sleep with your head elevated to minimize facial swelling.
• Use sun protection and avoid alcohol and smoking while in recovery.
• You may start wearing mineral makeup a week after healing or as advised by your specialist.
• Apply vinegar soaks to the treated area or take oral antimicrobials, if advised, to prevent infection.

Like good pre-treatment preparation, good post-treatment care also helps avoid complications and hasten recovery.

Potential Side Effects of CO2 Laser Resurfacing

CO2 laser resurfacing is generally safe. However, unwanted side effects that have been reported following this treatment include the following:

• Laser burns, especially when the wrong equipment settings are used or the patient’s skin is light-sensitive
• Acne and skin lumps called “milia” due to dressings or ointments
• Contact dermatitis as a reaction to cleansers, moisturizers, or medications
• Persistent redness if incorrect laser settings are used
• Pigmentation abnormalities, especially in patients with darker skin
• Increased infection risk due to the skin barrier being compromised
• Bad scars, which may develop when the patient is scarring-prone or the procedure is performed with poor technique
• Aggravation of a previous lower eyelid surgery
• Visual problems if eye protection is inadequate

The thing is, these complications have been reported far more frequently when an inexperienced or unlicensed individual performs CO2 laser therapy—a complex medical procedure. In contrast, dermatologists rarely cause such issues due to their advanced medical training. You can reduce your risk of developing unwanted side effects by entrusting this facial rejuvenation treatment only to a board-certified dermatologist with extensive laser expertise.

Who Should Not Receive CO2 Laser Resurfacing Treatment?

Modern CO2 laser equipment and techniques make the procedure adaptable. While patients with fair complexion are the ideal candidates, a laser specialist can skillfully adjust instrument settings to make the treatment suit various skin types.

Still, not everybody is a good candidate for CO2 laser resurfacing. The following conditions or situations can make this therapy inappropriate for you:

• Ongoing inflammation or infection in the treatment area
• Continuing oral isotretinoin therapy
• Tendency to scar badly
• Having skin of color and a positive CO2 laser spot test, indicating an increased risk of inflammation-induced hyperpigmentation
• Conditions that impair healing, such as collagen disorders, immunodeficiency, diabetes mellitus, and malnutrition
• Recent chemical peel or UV exposure

Your specialist may recommend other treatments in the presence of these factors and other concerns they may elicit during your medical evaluation.

What New Skin Treatments Work Excellently with CO2 Ablative Laser Therapy?

As mentioned, CO2 laser skin resurfacing is a versatile procedure that may be combined with various other cosmetic treatments to ensure the best outcomes. That long list includes chemical peeling, plasma skin resurfacing, and even plastic surgery—a discussion that is beyond the scope of this article. However, research has shed new light on the potential benefits of combining new treatments with CO2 laser therapy, discussed below.

PRP

Methods combining fractional CO2 laser resurfacing with PRP treatment differ between studies. In some regimens, the fluid is immediately applied topically to the laser-treated skin. In others, PRP injection and CO2 laser surgery are performed separately.

Various studies have shown that this combination can create a dramatic improvement in pitting acne scars and vitiligo-related depigmentation. However, little evidence shows any extra benefit from combining fractional CO2 laser therapy with PRP for treating facial wrinkles.

Nanofat

One of the characteristics of the fresh, youthful look is adequate facial volume. Conversely, aging-related bone and soft tissue changes that thin out various parts of the face make people look tired or older.

Autologous fat transfer is a popular procedure that involves harvesting fat from one region of the body to another that needs volume enhancement. Old methods used large, minimally altered fat particles that sometimes produced visibly uneven contours in injected areas. Nanofat is essentially harvested fat tissue that is refined to leave only fat stem (young) cells and small fat particles, which helps avoid contour imperfections after injection.

Fat stem cells in nanofat release tissue growth and healing factors upon injection, promoting the repair of damaged skin in the graft area. If the procedure is performed properly, fat grafts can remain viable for longer than 5 years due to their ability to establish blood circulation in the graft area and adapt to their new environment.

Combining nanofat injection with CO2 laser resurfacing has proven effective in improving depressed acne scars, an effect that is attributed to the synergy between the two treatments in promoting skin renewal. Meanwhile, the combination of CO2 laser treatment (La), microneedling (Mi), and nanofat transfer (Na) has been used successfully for facial rejuvenation in the LaMiNa study.

Fat Stem Cell-Derived Exosomes

Exosomes are tiny particles released by cells that carry important proteins and genetic material. Fat stem cell-derived exosomes can help promote the repair of damaged tissue like fat stem cells themselves do.

The advantages of using exosomes instead of stem cells include better graft results, reduced potential for cancer formation, and quality control. Additionally, exosomes have a longer shelf life, can be sterilized through filtration, and are easier to mass produce compared to other treatments using a patient’s own cells.

The combination of CO2 laser resurfacing and subsequent topical application of fat stem cell-derived exosomes has proven effective in improving deep acne scars. Furthermore, fat stem cell-derived exosomes appear to speed up recovery from laser surgery.

CO2 Laser Treatment Is Certainly Worth It, But…

CO2 laser resurfacing therapy has many advantages as a standalone procedure, including optimal aesthetic outcomes, even for certain severe skin conditions. Fractionation allows providers to reduce patients’ laser heat exposure and the risk of unwanted side effects. Combining this therapy with other procedures further enhances its effectiveness and safety.

However, CO2 laser surgery is not for everyone, which makes patient examination crucial. While adhering to the recommended pre- and post-treatment care measures is critical to your therapy’s success, the fact of the matter is that the outcomes of your cosmetic procedures greatly depend on your provider’s skill, not only in performing these treatments but also in determining your suitability, monitoring your recovery, and addressing potential complications.

Bottom line, a huge part of the success of your CO2 laser resurfacing therapy depends on who you entrust it to. So trust only a highly trained laser specialist to ensure the best results.

Frequently Asked Questions

Can CO2 Laser Surgery Cause Skin Cancer?

CO2 laser therapy is unlikely to cause skin cancer. Although one study from more than a decade ago reported squamous cell carcinoma as a rare complication of the procedure, an overwhelming amount of research contradicts the possibility that CO2 laser exposure causes skin malignancies. On the contrary, animal studies show that repeated CO2 laser treatment of UV-damaged skin delays squamous cell carcinoma formation.

Who Can Perform Laser Resurfacing Procedures?

Primary care physicians identify dermatologists as the most qualified medical professionals to perform cosmetic laser surgery. Board-certified dermatologists have exhaustive formal training in cosmetic dermatology, spend years perfecting their technique under heavy supervision, and are required to take a certification exam before obtaining their license to practice. Clearly, the best choice to ensure your laser therapy’s success is to see a board-certified dermatologist.

Meanwhile, evidence indicates that non-physicians, especially in spa settings, who often have no formal cosmetic dermatology education, perform procedures that result in more adverse events like burns and discoloration. Non-physician cosmetic treatment providers include aestheticians, nurses, physician assistants, and nurse practitioners who treat patients without physician supervision.

What Is the Average Cost of CO2 Laser Skin Resurfacing Therapy?

The cost of your CO2 laser resurfacing treatment depends on many variables, including but not limited to your geographic location, the severity of your skin condition, your provider’s expertise, your insurance coverage, and the type of facility where your treatment will be performed. You may discuss the matter with your laser specialist or call their office for more information.

Need the Best in Laser Care? Trust LA’s Leading Laser Experts

Yes, the success stories are real—CO2 laser resurfacing therapy has helped many people get back their radiant glow. But achieving the best results requires the expertise of a true specialist. If you’re wondering where to start your treatment journey, you’ve come to the right place.

BHSkin Dermatology has some of California’s top laser dermatologists. Countless patients have achieved healthier-looking skin and renewed confidence thanks to our highly skilled laser care providers. Visit us at our Glendale or Encino clinic, or use our telederm portal for your first consultation.

Book your appointment today!

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Author: Don Mehrabi

Don Mehrabi, MD, FAAD, is LA’s leading board-certified dermatologist who treats patients, builds the BHSkin clinics, and raises three kids. This blog builds on medical studies combined with Dr. Mehrabi's first-hand experiences from practicing in Encino-Tarzana, Glendale, and online