Skin resurfacing, peel to CO₂ laser.

The series: pulsed CO2 with a defined protocol gave "predictable improvement in perioral and periorbital wrinkling and photodamage", all three severity classes "responded equally well", side effects were transient erythema and post-inflammatory hyperpigmentation and "one instance of an isolated hypertrophic scar" (Fitzpatrick 1996); the long-term CO2 assessment found "facial rhytids were almost completely ablated at the 3 and 6 month follow-up", "some relapse" at one year with the perioral region recurring most and the cheeks lasting best, infection and scleral show in 6% each, hyperpigmentation in 21%, hypopigmentation in 8% and scarring in 1% (Schwartz 1999); erbium resurfacing of perioral rhytides in 45 patients gave "a statistically significant score improvement of 2.2 gradations" at an average of 13 months and "no cases of hypopigmentation at the 6-month postoperative visit" (Sanniec 2019). Against the older method: the controlled comparison of dermabrasion and CO2 for perioral wrinkles found more redness at one month and "a small but significantly greater improvement in perioral wrinkles at 6 months" with the laser, biomechanically a skin "more similar to skin in younger patients", and patients split evenly on which they would recommend (Kitzmiller 2000). The systematic review favours CO2 for efficacy and erbium for complications (Chen 2017).

Strong, as the lip lines and wrinkles guides grade it; the perioral deep peel and dermabrasion are graded beside it there and in the aging smile guide. This is the treatment for the line a filler cannot fill and a toxin cannot relax; it is bought once, with the eyes of a clinician who has seen the six-month hypopigmentation and knows which skin gets it.

The profilometry: "wrinkles were significantly reduced in all facial areas, and the best results for wrinkle size and depth were found for the cheeks (−58% and −51%) and the periorbital area (−35% and −31%)", with investigators rating mottled pigment improvement at 51–75% (Kohl 2014); the five-year follow-up of 30 Asian patients found photoaging scores "significantly changed at one month, one year, and five years" with minimal adverse events (Tan 2014); the 490-treatment safety series in skin types I–IV found 67 adverse events (13.6%) — acneiform eruption 5.3%, herpes 2.2%, bacterial infection 1.8%, yeast 1.2%, hyperpigmentation 1.2%, prolonged erythema 0.8% — and "no reports of scarring or hypopigmentation" (Shamsaldeen 2011). Lower fractional energy "produces similar molecular changes and clinical outcome with fewer side effects" (Hsiao 2012); ablative fractional photothermolysis gives "significantly greater improvement than nonablative FP in reducing acne scarring and skin redundancy and laxity associated with photoaging" (Tierney 2009). The medium peel: Jessner's solution followed by 35% TCA "produces a medium-depth peel for photoaging skin, actinic keratoses, and rhytides" (Monheit 1989).

Strong, as the laser guide, sun damage guide and wrinkles guide grade fractional ablation, and strong for the Monheit peel in the peels guide. The randomised comparison of fractional erbium against non-ablative 1,550 nm in Asian skin is the trade-off in one study: erbium won on pigment and tone, the non-ablative laser on wrinkle score and overall impression, and erbium caused fewer adverse events (Moon 2015).

The meta-analyses: ultra-pulse fractional CO2 scored higher for skin smoothness than other methods (standardised mean difference 0.49) across six studies and 467 patients (Lin 2022); erbium-based fractional lasers were "associated with a lower probability of >50% clinical response than fractional CO2" (risk ratio 0.69), with CO2 costing 1.86 more pain points and 3.67 more days of downtime and no difference in hyperpigmentation (Song 2026); fractional radiofrequency was "as effective as the laser group in treating atrophic acne scars" with hyperpigmentation at a risk ratio of 0.12 and shorter erythema (Li 2022); fractional picosecond lasers showed "no difference" from other fractional lasers with less hyperpigmentation and pain (Li 2023). In skin types IV–VI, the non-ablative 1,550 nm laser improved scar scores at 16 and 24 weeks at both densities, with mild-to-moderate hyperpigmentation in five of seven patients at the higher density (Alexis 2016). The Cochrane review of 24 trials found most at high risk of performance bias and, in one study, fractional laser more effective than non-fractional non-ablative laser (Abdel Hay 2016); the non-energy review found TCA CROSS gave more than 70% improvement in 73% for ice-pick scars, microneedling 31–62%, and microdermabrasion "the least significant results" (Kravvas 2017); the evidence-based management review grades the ladder (Kim 2023).

Strong, in line with the microneedling guide's grade for radiofrequency microneedling and the peels guide's TCA CROSS — with the Cochrane caveat that the comparisons are weak. Rolling scars want fractional ablation or subcision, boxcar scars fractional lasers or radiofrequency, ice-picks TCA CROSS; darker skin wants radiofrequency or picosecond first. A randomised trial found microneedling plus a chemical peel beat either alone on the objective scale (Pakla-Misiur 2021).

The evidence: collagen fibres up 6.68% at four months with the growth-factor signalling to match (de Sica 2016); "wrinkle score reduction was significantly greater after Er:glass NAFR" than after fractional erbium ablation, with physician and patient overall assessments also favouring it (Moon 2015); the 1,927 nm diode periorbital trial found lightness and pigment improved in both arms and pores and wrinkles improved with the four-week interval, side effects "resolving within 7 days" (Huang 2025); the 1440/1927 nm review found reactions "mild to moderate and self-limited" with safety "demonstrated in patients with skin of color" (Geronemus 2025); experienced users of the dual 1550/1927 nm device treat "patients of all ages and skin types" for photoaging, periorbital wrinkles, lentigines and scars on face and body (Friedman 2021). The meta-analysis of randomised trials could not show ablative lasers outperformed non-ablative ones in 124 people (Seirafianpour 2022). Same-session IPL plus non-ablative fractional treatment beat either alone in a split-face study without added downtime (Kearney 2012).

Moderate, as the laser guide, wrinkles guide and dull skin guide grade it. This is the resurfacing for someone with a job, a tan, or a darker skin type; it does over five sessions what fractional CO2 does in one, and does not touch an etched line.

The trials: 40 patients with photopigmentation, overall improvement "moderate to very significant in 82% of subjects at one month and in 69% of subjects at three months after the second treatment", lentigines improved in approximately 68% and then 51%, blinded photographic assessment "a durable response at three month follow-up" (Brauer 2014); 27 women with diffuse dyspigmentation, spots, UV spots and brown spots improved at one month, brown spots still improved at three, and "an increase in pigment toward baseline at 3 months" (Vingan 2023); the low-energy, low-density 1,927 nm laser gave marked improvement in about 55% for photodamage, melasma and post-inflammatory pigmentation (Brauer 2015). The comparison: the 755 nm picosecond laser "can yield superior results with less pain and side effects" than the 1,927 nm for photopigmentation and aging in a randomised single-blind study (Serra 2018), and a fractional 1,064 nm picosecond laser outperformed IPL on periorbital fine lines and pores with equal pigment results (Zhang 2026).

Moderate, as the dark spots guide and sun damage guide grade the 1,927 nm laser; the Q-switched and picosecond pigment lasers are strong for discrete lentigines in the laser guide. Resurfacing evens a blotchy field; a spot is removed by a spot laser, and everything on this row comes back without sunscreen.

The thulium study found "a significant reduction in AK count (p < 0.001) and photoaging parameters", histologically an improvement in the vertical extension of keratinocyte atypia, "increased dermal thickness" and fibroplasia, and no severe adverse effects, calling it "promising" as a field-directed therapy (Salviano 2026). The medium peel's original indications include actinic keratoses (Monheit 1989); full-face CO2 resurfacing for widespread keratoses is where the "striking leukoderma" of alabaster skin was documented six months later (Laws 1998).

Moderate, as the peels guide grades TCA for keratosis fields and the sun damage guide its lasers. Actinic keratoses are a medical diagnosis first: the dermatologist decides between field treatments — photodynamic therapy, topical agents, a peel or a laser — on the basis of the field, and the cosmetic improvement is the bonus.

The eyelid series: "excellent post-treatment improvements were noted for eyelid skin rhytidosis and redundancy, which improved 53.1% and 42.0%, respectively", with a favourable recovery profile, treating "areas within the boundaries of the orbital rim" (Kotlus 2010); the profilometry (Kohl 2014); the 1,927 nm periorbital trial (Huang 2025). The harm: "erosions and swelling of the right lower eyelid 2 days postoperatively, which developed into scarring and an ectropion" after fractional CO2 (Fife 2009); scleral show in 6% of the long-term full-field CO2 series (Schwartz 1999).

Moderate, as the eye bags guide grades lower-lid resurfacing, and strong for crow's feet outside the lid in the crow's feet guide. Crepey lid skin tightens a little and smooths a lot; excess lid skin is a blepharoplasty, and a bag is fat. Metal eye shields, a conservative depth, and a clinician who has treated lids are the conditions.

The user survey for the dual-wavelength non-ablative device reports treatment of "both facial and non-facial areas, including neck, chest, hands, arms, abdomen, legs, and buttocks" with adverse effects "rarely reported" and "mild and transient" (Friedman 2021); the 1440/1927 nm diode review found the same off-face tolerability (Geronemus 2025); the fractional photothermolysis review lists "dyschromia and fine wrinkling of photoaging on the face, chest, neck, and hands" and poikiloderma among the non-ablative indications (Tierney 2009); the 1,927 nm pigment trials included the same patients' photodamage pattern (Brauer 2014).

Moderate, as the neck, décolletage and aging hands guides grade the non-ablative lasers off the face; those guides also grade the peels and the pigment lasers for spots on the hands and chest. Density and energy are turned down off the face, sessions go up, and the ablative lasers stay on the face for the reason in the next row.

The randomised pilot: 46 mostly type IV patients, "significant improvement from baseline was seen in both the MI and mMASI scores for both the TXA and control sides at 3 months, with no statistically significant difference between sides", with a repeat regimen "every 3 months" suggested for recurrence (Wanitphakdeedecha 2020); the low-energy 1,927 nm series included melasma among its favourable outcomes (Brauer 2015); the skin-of-colour review found laser-assisted drug delivery with low-density 1,927 nm or diode lasers "reduce[s] the number of treatments required for significant clearance of melasma" (Sanyal 2024); the Asian resurfacing review names "post-inflammatory hyperpigmentation (PIH) and rebound worsening of melasma" as the predominant complications (Wat 2017).

Emerging, as the dark spots guide grades lasers for melasma. Melasma is a hormonal, light-driven condition; sunscreen, oral or topical tranexamic acid and the triple cream are graded moderate to strong there, and a laser is the thing that can make it worse.

The observation (Fitzpatrick 1996), the fractional comparison (Tierney 2009), the eyelid redundancy figure of 42% (Kotlus 2010) and the fractional-laser review's list of laxity among its improved parameters (Carniol 2015) are the evidence, and none of them measured a jowl or a neck against a control.

Emerging, as the sagging skin guide grades it. Resurfacing rebuilds the dermis of crepey skin, and a rebuilt dermis lies flatter; descent of fat and ligament is the tightening guide's subject, and a facelift's.

The evidence-based review concluded that microdermabrasion "appears to be a procedure that can produce changes in dermal matrix constituents and result in improvement in skin contour irregularities", may improve transepidermal delivery, and has a "limited" role in pigment and acne (Karimipour 2010); in the acne-scar review it "achieved the least significant results", with "27.3% patients did not achieve any benefit despite eight treatment sessions, and only 9.1% achieved good results" (Kravvas 2017); the randomised, double-blind, placebo-controlled trial of a 5% retinoic-acid peel with microdermabrasion found "slight but statistically significant improvements" for all photoaging parameters at one to two months, with mild transient side effects (Faghihi 2017).

Emerging, as the dull skin guide grades microdermabrasion and hydradermabrasion and the dry skin guide the hydrating facials. The mechanism is exfoliation of the dead layer, which a retinoid or an acid does at home for the price of a tube; the machine's advantage is the afternoon it produces, before an event.

The cases: "as with traditional ablative CO2 laser resurfacing, hypertrophic scarring is a potential complication of ablative fractional CO2 laser resurfacing, particularly on the neck", reversible in one case with early steroids and unresolved in another at a month (Avram 2009); "linear erosions and beefy red swelling on the right side of the neck which developed into a tender, band-like scar", a neck with "stinging and yellow exudate" that grew MRSA and scarred in streaks, and a neck whose eschar "developed into horizontal scars and a vertical platysmal band" (Fife 2009); the complication reviews of laser resurfacing, peels and dermabrasion put the neck among the sites where "excessive treatment" scarred (Hamilton 2020; Duplechain 2023).

Limited, as the neck guide grades fractional ablation on the neck and the décolletage guide keeps the chest at emerging with the same warning. Necks get non-ablative sessions at their own settings, a peel graded for body skin, and the pigment laser for spots; a clinic that offers the face's fractional CO2 settings on the neck is offering the case reports.