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CO2 Laser: Review, Downtime, Recovery, Side Effects

We will review CO2 Fractional laser in terms of uses, recovery and side effects in this article.

We will also compare the different fractional resurfacing energy devices that focus on treating uneven acne scars, reducing the appearance of wrinkles and pores.

The treatments discussed in this article focuses on lasers that targets on achieving a smoother texture, treating common conditions such as

  • Reducing of pores size
  • Minimising appearance of fine lines
  • Improving appearance of depressed acne scar like rolling scars and box scars and atrophic in particular
  • Anti-aging/skin rejuvenation

How does CO2 Fractional laser work?

For the fractional CO2 laser at 10600nm wavelength, the target chromophore of the laser energy is water in your skin.

The CO2 beam is fractionated into thousands of treatment zones that targets a fraction of the skin at a time, leaving a gap of healthy skin for effective healing.

Fractional CO2 laser remains the gold standard treatment of photo-aged skin and for treating acne scars as this bridges the gap between the ablative and non-ablative laser technique, which works on both the epidermal and dermal layer.

CO2 Fractional Laser Review: Comparison with Pico, Erbium and Radiofrequency energy

Apart from CO2 Fractional Laser, other technology like Erbium, Pico and radiofrequency are commonly used treatments for skin resurfacing.

Compared to CO2 Fractional Laser, Erbium:yag laser at 2940nm wavelength, is a newer technique that decreases the thermal damage observed with CO2 laser, translating to a treatment that is safer for individuals with darker skin tones and with less downtime. However, the depth of penetration is lesser and the results are less visible with the same number of passes.

Fractional Pico laser uses Micro lens Array (MLA) for Laser Induced Optical Breakdown (LIOB). In PicoPlus, the dual-focus dots handpiece can be adjusted so that LIOB can be achieved at the different depths, from the epidermis to the dermis. Once LIOB is induced, a cavitation is created, where an inflammatory healing response is triggered. This increases collagen and elastin that improves skin texture. The major difference in this technology is that the superficial layer of the skin is intact. This means that there is almost ZERO downtime. However, this is mainly used for skin rejuvenation. Although fractional Pico has is also used to treat acne scars, fractional CO2 remains the gold standard.

Fractional Radiofrequency is also known as RF microneedling. INFINI, Secret RF, Intracel are examples of fractional RF. This is a not to be confused with fractional lasers. The mechanism of action is very different. Fractional RF combines 2 mechanisms – 1. Microneedling, 2. Radiofrequency.

  1. Microneedling – During a microneedling treatment, small needles are punctured into the skin. By doing so, it physically breaks scarring tissue and simultaneously causes controlled injury to the skin. This creates a healing response in the body that promotes collagen production.
  2. Radiofrequency – radiofrequency via the tip of the microneedles heat up the surrounding tissue and induce the same kind of inflammatory response that encourages collagen production.

The combined effects of these mechanisms work well together with laser as they work on the different layers of the skin with different ‘pathways’ to stimulate collagen. Depending on the indication of use, fractional radiofrequency can be adjusted to target the appropriate depth at an appropriate energy.

Are CO2 Fractional Laser treatments painful?

Lasers are generally felt as burst of heat on the skin, which is very well tolerated with topical anaesthesia routinely applied prior to procedure. Some patients find that fractional RF is slightly more painful as the needles advance through the skin. However, a machine such as INFINI has very fine, well made, ultra-fine needles designed to improve overall comfort.

After treatment, you may still feel some heat on the skin especially for fractional CO2 and erbium where the skin barrier is breached. The skin feels very raw and it can be painful when you wash your face!

Is there downtime for CO2 fractional laser?

Depending on your skin concerns, the duration of downtime varies. For an intense fractional CO2 laser, where the skin is ablated till scabs are formed, it can take up to 10 days for the scabs to fade away! Improved version of fractional CO2 laser has dramatically reduced the duration of downtime to only about 3-5 days. The beams emitted are finer, and that result is about 80% less carbonization (charring) of the skin.

Fractional CO2 laser downtime is generally minimal, although at a higher setting, petechiae can surface as the area of cavitation disrupts underlying blood vessels. You may find that it is exceptionally useful that the most superficial layer of the skin is not ‘charred’– managing any possible downtime with concealers can be easily achieved.

In the treatment of acne scars, many patients prefer the use of fractional RF as the downtime is minimal! And there is no pain, no discomfort, no residual heat on the felt post-procedure. However, as the treatment involves needle penetrating into the dermis, bruising can be a major downside.

What can I do to speed up the recovery time of CO2 laser treatment?

For semi-ablative fractional CO2 laser and Erbium:yag, where the superficial layer of the skin is charred, moisturizing intensively is extremely important. Dexpanthenol-containing petroleum jelly is recently proven to hasten the recovery process. Moisturisers containing healing compounds like PDRN and ceramides have also shown to help to minimse the downtime. When there is swelling of the treated area, cold compress can be applied to reduce the redness and immediate inflammation.

What are the possible side effects of CO2 fractional laser?

When used according to parameters, fractional CO2 laser is a very safe procedure. The performing doctor must have a thorough knowledge of the physiology of the skin and experience in treating post-laser complications will prevent long-term complications.

Fractional CO2 laser disrupts the skin barrier, which is a natural defense against infection. The organism causing the infection can be viral, fungal, or bacterial. It is important to recognize and treat accordingly to prevent delayed healing.

Scarring is extremely rare. This can result from infection or a consequence of excessive intensity, or too many passes. If the skin is heated beyond the ability to repair itself, scarring can result. The setting for the neck and chest should be lowered as these areas tend not to heal as well as the face.

Post inflammatory hyperpigmentation is common with previous generation fractional CO2 laser in Fitzpatrick skin types IV and V, which take months to recover. In newer technology Edge pulse laser, the risk of PIH is reduced drastically. Apart from hyperpigmentation, hypopigmentation can occur when fractional laser damage the skin too much to cause excessive fibrosis and disrupts formation of melanin. Hypopigmentation is usually a non-reversible change.

Sensitive skin and prolonged redness are more common side effects which usually resolves with time.

What should I do to decrease the risk of complications from CO2 Laser?

During consultation, please notify your doctor if you suspect that you have a tendency to develop keloid scars.

After the procedure, follow post-laser care instructions strictly. This would usually involve

  • application of moisturizer,
  • avoiding sun exposure,
  • applying sunblock,
  • prophylactic use of antibiotic cream
  • do not pick on scabs

Should complications arise, notify your doctor the soonest possible as treating a complication early can drastically improve the cosmetic outcome and minimize manifestation of long term complications.


Medical Director

After graduating from the National University of Singapore, Dr Boey’s journey in aesthetics brought him to esteemed institutions such as Harvard Medical School, American Academy of Aesthetic Medicine and Queen Mary University of London in diverse cities like Seoul, London, Boston and New York.