Who Is a Good Candidate for Laser Skin Resurfacing? CO2 vs Erbium

Short answer

A good candidate has sun damage, fine lines or acne scars, skin that is not very dark, and no active infection, cold sore or acne. CO2 lasers reach deeper and need longer recovery than erbium lasers, while non-ablative lasers are gentler but often need a series. Recent isotretinoin and darker skin change the plan, and 94% of a 2025 expert panel expect only a moderate improvement.

Who is a good candidate for laser skin resurfacing?

A good candidate has sun damage, fine lines, uneven pigment or acne scars, and healthy skin without active infection or irritation. Cleveland Clinic lists those concerns, and a 2025 expert panel of 21 dermatologists and plastic surgeons described the ideal fractional CO2 patient as 40 to 60 years old, with Fitzpatrick type I to III skin and moderate to advanced wrinkles.

Cleveland Clinic names scars from acne or chickenpox, uneven pigmentation, age spots, sun-damaged skin, and fine lines around the eyes, forehead or mouth. It lists deep wrinkles and excessive or sagging skin as poorer fits, and EyeWiki adds that resurfacing is no substitute for a facelift or eyelid surgery. The panel described Fitzpatrick types I and II as fair skin and called types III to VI more susceptible to pigment problems. The panel also favored thin to moderate skin thickness and mild to moderate pigment changes. Treat that profile as expert opinion from experienced users of one manufacturer's CO2 device, identified through that company's list, not as a trial result.

In that panel, 94% of experts said they expect a moderate improvement from fractional CO2 treatment. ANEWU's laser resurfacing page describes candidates as people with sun damage, fine lines, uneven tone or texture, or acne scarring, with no active infection or irritation in the treatment area, and says Dr. Arshia Payman, MD reviews your skin type and history at a free consultation before anything is scheduled.

Who is not a good candidate for laser resurfacing?

Cleveland Clinic lists active acne, very dark skin, deep wrinkles, and excessive or sagging skin as signs you may not be a good candidate. Clinicians also hold off for active cold sores or infection, recent sunburn, pregnancy or breastfeeding, a history of keloid scarring, past radiation to the area, or recent isotretinoin. Most of these are cautions to discuss, not automatic bans.

The word possible matters. The EyeWiki list also includes Fitzpatrick types IV to VI, so it mixes firm stops with cautions that depend on the laser, the settings and the clinician. Cleveland Clinic advises telling your doctor about any history of cold sores or shingles in the treatment area, and 95% of the 2025 panel recommend antiviral prophylaxis. Follow the written instructions from your surgeon on any medicine. ANEWU's page says laser resurfacing is not the right fit for every skin type.

• Active herpes lesions in the treatment area: 95% of the 2025 panel named this a contraindication.
• Recent sunburn or heavy sun exposure, and pregnancy or breastfeeding: each named by 67%.
• Keloid history, prior radiation therapy and recent oral isotretinoin: listed as possible contraindications by EyeWiki.

Does isotretinoin rule out laser resurfacing?

Not automatically, but it changes the plan. Many clinicians wait 6 to 12 months after isotretinoin, a habit a 2017 JAMA Dermatology review traced to three small case series from the mid-1980s. That review found insufficient evidence to delay fractional lasers, but did not recommend fully ablative lasers during isotretinoin treatment. Tell your clinician about any past or current use.

The 2017 review covered 32 publications and 1,485 procedures. A 2026 retrospective study of 106 patients with Fitzpatrick type III to VI skin (188 fractional CO2 sessions) found abnormal scarring in 3 patients (2.8%), with no significant difference between timing groups, from concurrent isotretinoin to more than 180 days after stopping. Healing took longer than 14 days in 11 patients (10.4%), most often among those treated during isotretinoin (6 of 31), though that difference was not statistically significant.

Pigment was the exception: treatment within 90 days of stopping carried about six times the odds of post-inflammatory hyperpigmentation at 3 months (adjusted odds ratio 6.03, 95% confidence interval 1.55 to 23.52). These are single-center, retrospective findings, and the authors still advise conservative density settings and careful counseling. Timing is a decision for your prescriber and your laser clinician together, so follow the written instructions from your surgeon.

What is the difference between CO2, erbium, fractional and non-ablative lasers?

Ablative lasers, including CO2 and erbium (Er:YAG), vaporize the outer layers of skin and can improve wrinkles significantly, with a few weeks of downtime, according to the American Society for Laser Medicine and Surgery (ASLMS). Non-ablative lasers heat the skin without vaporizing it, so recovery is shorter. Fractional lasers treat a grid of microscopic columns and leave the skin between them intact.

Treat these ranges as a guide, because depth, density and your own healing change them. Cleveland Clinic gives single figures: up to two weeks for CO2, and one full week for erbium and fractional treatment. ASLMS says aggressive ablative resurfacing can show results after one treatment, while lighter non-ablative resurfacing often takes a series to reach an optimal outcome. EyeWiki describes non-ablative resurfacing as giving modest improvements in tone, texture and pigmentation, which suits photoaging when quick recovery matters.

Is erbium laser better than CO2 laser for skin resurfacing?

Neither wins on every measure. A 2026 meta-analysis of head-to-head studies in acne scars found erbium-based fractional lasers were less likely than fractional CO2 to reach more than 50% improvement (relative risk 0.69), but fractional CO2 was associated with 1.86 more points of pain on a 10-point scale and about 3.7 more days of downtime. Erbium-based lasers may suit people who put shorter recovery first.

The analysis covered five studies from 2010 to 2023 with 130 participants, four with usable response data, and follow-up of 1 to 6 months. Three compared fractional CO2 with ablative Er:YAG lasers and two with nonablative erbium-glass lasers. Only two studies had usable downtime data. The result was fragile: limited to randomized studies, the relative risk was 0.76 with a 95% confidence interval of 0.54 to 1.08, which includes no difference. Pigment problems did not differ significantly between the two laser families (odds ratio 1.75, 95% CI 0.67 to 4.57).

So the idea that erbium is automatically kinder to pigment is not settled by head-to-head trials, even though Cleveland Clinic says erbium may be a good choice for a darker skin tone. Skin thickness, the area treated, how much downtime you can take and your skin tone all change the choice. ANEWU's laser resurfacing page does not name a laser type or wavelength, so ask which device would be used and why.

Is laser resurfacing a good option for darker skin tones?

Sometimes, but the risk of dark patches rises with deeper skin tones. Cleveland Clinic lists very dark skin among reasons laser resurfacing may not suit you, and over 90% of a 2025 expert panel suggested changing treatment settings for Fitzpatrick types III and IV.

The dark patches are called post-inflammatory hyperpigmentation (PIH). The background section of a 2026 network meta-analysis describes PIH as involving heightened melanocyte activity and extra melanin production, and says the more intense the laser injury and the inflammation that follows, the higher the risk. It cites earlier work linking ablative fractional lasers to more PIH than non-ablative ones, and higher treatment density to higher risk.

The 2025 panel called PIH a concern for every skin type, with Fitzpatrick types III to VI more susceptible, and advised all patients to prepare, with sun avoidance as the key step. Most panelists favored one higher-intensity session for types I and II but several milder sessions for types III and IV. If your skin is deeper, ask how often the clinician treats your skin tone, what settings they would use, and what happens if pigment changes. ANEWU's page says suitability depends on the individual.

Can laser resurfacing remove acne scars?

It can soften some indented (atrophic) acne scars, but the evidence for how much is limited. A 2016 Cochrane review of 24 trials with 789 adults found a lack of high-quality evidence and did not support any single treatment as first-line. Expect improvement, not removal, and discuss realistic goals before you book.

Newer data compare laser with needling directly. A 2026 meta-analysis of 17 studies and 1,068 patients compared fractional CO2 laser with needling treatments such as microneedling. In four trials against radiofrequency microneedling, treatment success was higher with CO2 (relative risk 1.10, 95% CI 1.01 to 1.20), but average scar-score reductions did not differ significantly, and the studies varied widely in design. Against standard microneedling, CO2 carried about three times the risk of PIH (relative risk 3.04, 95% CI 1.49 to 6.21).

Treatment choice generally follows scar type and severity, skin type, expected downtime and personal preference, according to the 2026 CO2 versus erbium review, and combinations are common. Most of those trials came from Asia and the Middle East, and follow-up was short, so long-term durability and late complications are unknown, the authors say. Ask which scar types you have and what improvement your clinician considers realistic.

What are the downsides and risks of laser skin resurfacing?

Expected effects include redness, swelling, itching and, with ablative lasers, raw or oozing skin that crusts and peels. Risks include dark or light patches, cold sore reactivation, infection, small white bumps called milia and, rarely, scarring. Complication reporting varies from study to study, so be wary of any single rate.

Cleveland Clinic says skin looks red and feels sunburned at first, may look raw, ooze and blister, then peels around 5 to 7 days, with pinkness fading over two to three months. It calls scarring very rare, but says fractional CO2 light penetrates more deeply than other lasers, so there is a greater risk of complicated healing and scarring. In the 2025 panel, 95% of panelists had seen hyperpigmentation after fractional CO2 treatment, 62% local infection and 33% scarring. Those figures count panelists who have seen an event, not how often it happens.

Older technology shows what lasting problems can look like. In a 2008 follow-up of full-face CO2 resurfacing, 4 of the 46 patients (8.7%) who completed 10 years of follow-up had hypopigmentation that did not resolve. That small, retrospective study used older equipment, so it cannot predict results with today's devices. Cleveland Clinic also notes that smoking slows healing. For a day-by-day view of healing, see our laser resurfacing recovery guide.

How long do laser resurfacing results last?

Improvement can keep building for up to a year and may last several years, but normal aging continues, so lines can return. Cleveland Clinic says new wrinkles can be treated again and advises daily sunscreen on treated skin. A 2008 study that followed full-face CO2 patients for 10 years found some of the early benefit was lost over time.

In that 2008 study, 159 patients were treated and 46 completed the 1-, 5- and 10-year visits. At 5 and 10 years, 32% and 20% still had good skin texture, 22% and 19% kept corrected pigmentation, and 88% and 98% needed correction of recurring wrinkles, jowling or loose skin.

How often to repeat depends on the laser and your skin. ASLMS says aggressive ablative treatment can show results after one session, while lighter treatment often needs a series. In the 2025 panel, 57% recommended waiting 3 to 6 months before repeating treatment around the eyes. ANEWU's laser page says the plan for one session or a short series is set at the consultation, and a follow-up is used to plan any further sessions. You can book a free consultation to talk through your goals.

Sources and further reading

1. Comparative efficacy and safety of fractional carbon dioxide and erbium-based fractional lasers for atrophic acne scars: A systematic review and meta-analysis Lasers in Medical Science, 2026
2. Expert Consensus on Clinical Recommendations for Fractional Ablative CO2 Laser, in Facial Skin Rejuvenation Treatment Lasers in Surgery and Medicine, 2025
3. Laser Skin Resurfacing: Lasers Types, Skin Conditions, What to Expect Cleveland Clinic, page last updated March 2021
4. Laser Resurfacing (patient information) American Society for Laser Medicine and Surgery, updated November 2025
5. Laser Resurfacing of the Eyelids and Face EyeWiki, American Academy of Ophthalmology, page edited July 2026
6. Isotretinoin and Timing of Procedural Interventions: A Systematic Review With Consensus Recommendations JAMA Dermatology, 2017
7. Ablative Fractional CO2 Laser Resurfacing for Atrophic Acne Scars During and After Oral Isotretinoin: A Single-Center Retrospective Cohort Study in Fitzpatrick III-VI Patients Dermatologic Surgery, 2026
8. Interventions to Prevent Postinflammatory Hyperpigmentation After Laser and Energy-Based Device Treatments: A Systematic Review and Network Meta-Analysis Lasers in Surgery and Medicine, 2026
9. Interventions for acne scars Cochrane Database of Systematic Reviews, 2016
10. Comparing fractional CO2 laser and needling-based modalities in facial acne scar treatment: a comprehensive systematic review and meta-analysis Lasers in Medical Science, 2026
11. Full-face carbon dioxide laser resurfacing: a 10-year follow-up descriptive study Plastic and Reconstructive Surgery, 2008
12. 2023 Average Surgeon/Physician Fees (Internet Archive copy of the ASPS statistics release) American Society of Plastic Surgeons, 2023 data

This article is general information about dental and facial procedures, not a diagnosis or medical advice. Every jaw and every health history is different, so the right plan for you can only be set after an exam and imaging with a surgeon.