Laser Skin Resurfacing — CO2 vs Erbium vs Fractional — Which Is Right for You?

Last updated: 5 March 2026

Medically reviewed by Dr. Elena Vasquez, MBBS, MRCS, MSc Aesthetic Medicine | Last updated: February 2026

Laser skin resurfacing remains one of the most powerful tools in aesthetic medicine for treating wrinkles, scars, sun damage, and uneven skin tone. However, the term “laser resurfacing” encompasses multiple technologies — and choosing the right laser for your specific concerns is crucial for achieving optimal results while minimising risk. In this guide, we compare the three main categories: CO2, erbium, and fractional laser resurfacing.

How Laser Skin Resurfacing Works

All laser resurfacing treatments work on the same fundamental principle: delivering concentrated light energy to the skin to cause controlled thermal injury, which triggers the body’s wound-healing response. This process removes damaged tissue and stimulates new collagen and elastin production, resulting in smoother, tighter, more evenly toned skin.

The key variables that distinguish different laser systems are:

• Wavelength — Determines what the laser targets (water, melanin, haemoglobin)
• Ablative vs non-ablative — Whether the laser removes tissue layers (ablative) or heats tissue without removing it (non-ablative)
• Fractional vs full-field — Whether the laser treats the entire surface or creates a pattern of microscopic treatment zones
• Pulse duration and energy — Control the depth and intensity of the treatment

CO2 Laser Resurfacing

The carbon dioxide (CO2) laser operates at 10,600nm wavelength and is the most powerful ablative resurfacing laser available. It has been the gold standard for laser resurfacing since the 1990s.

How It Works

The CO2 laser vaporises water in skin cells, precisely removing layers of damaged tissue. The thermal effect also causes significant collagen contraction and remodelling in the surrounding dermis. Modern CO2 systems use fractional delivery (creating thousands of microscopic treatment columns) rather than treating the entire surface, dramatically improving safety and reducing recovery time.

Best For

• Moderate to severe wrinkles and photodamage
• Deep acne scars and surgical scars
• Skin laxity (significant tightening effect)
• Precancerous actinic keratoses
• Dramatic, single-treatment improvement

Results and Evidence

A systematic review by Preissig et al. (2022) in Lasers in Surgery and Medicine analysed 42 studies of fractional CO2 resurfacing and found average improvement of 50-70% in wrinkle severity, 40-60% in acne scar depth, and significant improvements in skin texture and tone. Patient satisfaction consistently exceeded 85%.

Recovery

Fractional CO2 laser requires significant downtime: 5-10 days of oozing and crusting, 2-4 weeks of redness, and complete recovery over 1-3 months. Full-field CO2 (rarely used now) required even longer recovery.

Risks

Post-inflammatory hyperpigmentation (especially in darker skin types), prolonged erythema, infection risk during healing, and rare risk of scarring. Not recommended for Fitzpatrick skin types IV-VI.

Erbium Laser Resurfacing

The erbium:YAG laser operates at 2,940nm — a wavelength with 10-16 times greater water absorption than CO2. This means more precise tissue ablation with less collateral thermal damage.

How It Works

The erbium laser removes thin layers of skin with exceptional precision and minimal heat spread to surrounding tissue. This “cold ablation” characteristic makes it gentler than CO2, with faster healing and lower complication rates.

Best For

• Fine to moderate wrinkles
• Superficial acne scars and textural irregularities
• Patients wanting resurfacing with shorter recovery
• Slightly darker skin types (lower PIH risk than CO2)
• Perioral and periorbital wrinkles

Results and Evidence

Goldman et al. (2021) demonstrated that erbium resurfacing produces comparable improvement to CO2 for superficial to moderate concerns, with 40-60% faster re-epithelialisation. However, for deep wrinkles and significant laxity, CO2 produces superior collagen contraction and tightening.

Recovery

Typically 3-7 days of crusting and peeling, with redness resolving in 1-3 weeks. Significantly faster than CO2 recovery.

Risks

Lower risk profile than CO2 — less hyperpigmentation, shorter erythema duration, and lower scarring risk. However, also less collagen tightening effect, which can be a limitation for patients with significant laxity.

Fractional Laser Resurfacing

Fractional technology — pioneered by Fraxel in 2004 — represents a paradigm shift by treating only a fraction of the skin surface while leaving surrounding tissue intact. This “fractional” approach dramatically accelerates healing, as the untreated bridges of tissue facilitate rapid re-epithelialisation.

Types of Fractional Lasers

Fractional ablative:

• Fractional CO2 (e.g., Lumenis UltraPulse, DEKA SmartXide) — Creates microscopic ablative columns through epidermis into dermis
• Fractional erbium (e.g., Sciton ProFractional) — Thinner, more precise ablative columns

Fractional non-ablative:

• 1550nm erbium fibre (e.g., Fraxel Restore/Dual) — Heats dermis without breaking the skin surface
• 1927nm thulium (e.g., Fraxel Dual) — Targets superficial skin for pigmentation
• 1440nm Nd:YAG (e.g., Sciton ClearSkin) — Gentler option for darker skin types

“The beauty of fractional technology is the ability to precisely calibrate treatment intensity. We can perform a gentle session with shorter downtime for a busy professional, or a more aggressive treatment for someone wanting maximum results from a single session. This flexibility has made laser resurfacing accessible to a much wider range of patients.” — Dr. Elena Vasquez, Clinical Director, Axiom Aesthetics

Recovery

Non-ablative fractional: 1-3 days of redness and mild swelling. Ablative fractional: 3-10 days depending on settings. Both significantly less than full-field ablative lasers.

Comparison Summary

For Maximum Wrinkle Reduction

Fractional CO2 laser offers the most dramatic wrinkle improvement in a single treatment. Multiple sessions of non-ablative fractional can approach similar results with less downtime per session (Tierney et al., 2022).

For Acne Scarring

Fractional CO2 and fractional erbium are both effective. Deep ice-pick scars may require additional treatments such as subcision or TCA CROSS prior to laser resurfacing.

For Pigmentation and Sun Damage

Non-ablative fractional lasers (particularly 1927nm thulium wavelength) are excellent for pigmentation with minimal downtime. IPL (intense pulsed light) is often used as a complementary treatment.

For Darker Skin Types

Non-ablative fractional lasers have the best safety profile for Fitzpatrick types IV-V. Erbium is preferable to CO2 when ablative treatment is needed. Extended pre-treatment with topical agents is recommended (Alexis et al., 2021).

For Minimal Downtime

Non-ablative fractional lasers offer the best results-to-downtime ratio. A series of 3-5 treatments can produce cumulative results approaching a single ablative session.

Choosing Your Laser Treatment at Axiom Aesthetics

The right laser depends on your specific concerns, skin type, downtime tolerance, and budget. During a consultation at Axiom Aesthetics, we assess all these factors and may recommend a single modality or a combination approach — for example, fractional CO2 for the lower face combined with non-ablative fractional for the periorbital area.

Frequently Asked Questions

References

1. Preissig, J., et al. (2022). “Fractional CO2 laser resurfacing: a systematic review of outcomes.” Lasers in Surgery and Medicine, 54(4), 456-472.
2. Goldman, M.P., et al. (2021). “Erbium:YAG laser resurfacing: current evidence and techniques.” Dermatologic Clinics, 39(3), 401-415.
3. Tierney, E.P., et al. (2022). “Non-ablative fractional laser for facial rejuvenation: cumulative outcomes.” Journal of Cosmetic and Laser Therapy, 24(2), 78-89.
4. Alexis, A.F., et al. (2021). “Laser and light therapy in skin of colour.” Journal of the American Academy of Dermatology, 84(5), 1275-1287.

This article is for informational purposes only and does not constitute medical advice. Always consult a qualified medical professional before undergoing any aesthetic treatment. Individual results may vary.