Learning Center: SKIN RESURFACING

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WHAT SKIN RESURFACING CAN (AND CAN’T) DO

In brief

Skin resurfacing removes or injures the outer layers of the skin in a controlled way so that the skin heals with a smoother surface, more even color, and new collagen. The three main tools are chemical peels, lasers, and mechanical methods such as dermabrasion and microneedling. The deeper the injury, the larger the improvement, and the longer the recovery and the higher the risk of complications, especially pigment changes in darker skin. Resurfacing improves the quality of the skin surface; it does not lift sagging tissue or relax the muscles that cause expression lines. Choosing the right method depends on what you want to change, your skin type, and how much downtime you can accept.

How the skin is built, and why depth matters

The skin has two main layers. The epidermis is the thin outer layer that holds the pigment cells (melanocytes) and forms the barrier. Beneath it is the dermis, which contains the collagen and elastic fibers that give skin its firmness. The dermis is further divided into a thin upper papillary dermis and a thicker reticular dermis. Hair follicles and oil glands extend into the dermis, and new surface skin grows back from these structures after resurfacing.

Every resurfacing method works by the same principle: a controlled wound followed by healing. Superficial treatments affect only the epidermis, medium-depth treatments reach the papillary dermis, and deep treatments reach the upper reticular dermis [1, 2]. Wound healing in the dermis lays down new, more organized collagen, which is what softens wrinkles and scars. The trade-off is consistent across all methods: deeper injury produces more improvement, but also more days of peeling, longer redness, and a higher chance of infection, pigment change, and scarring [3, 4].

What resurfacing treats

Fine lines and wrinkles that are present at rest, especially around the eyes, the cheeks, and the upper lip, where vertical "lipstick lines" respond well to resurfacing [5, 6].
Sun damage (photoaging): rough texture, uneven tone, brown spots, enlarged pores, and loss of the skin's normal glow. Chronic sun exposure causes most of these visible changes [2].
Dyschromia, meaning uneven pigment such as sun spots and mottled color. Some pigment problems, particularly melasma, can worsen with aggressive treatment and are better approached with a medical skin care regimen first.
Acne scars and other atrophic (depressed) scars, which usually need a series of treatments and often a combination of methods [7, 8]. Our scar treatment page covers surgical and injectable options as well.
Precancerous spots (actinic keratoses). In a randomized trial of patients with prior skin cancer or severe sun damage, CO2 laser resurfacing, a 30% TCA peel, and 5-fluorouracil cream each reduced actinic keratoses by 83% to 92% and were associated with fewer new non-melanoma skin cancers than in untreated controls [9]. Resurfacing is not a substitute for evaluation of a suspicious spot; see skin cancer.

What resurfacing does not treat

Deep folds, sagging skin, and jowls. These come from descent of the deeper soft tissues and loss of facial support, not from the skin surface. Resurfacing can tighten skin modestly, but it cannot reposition tissue. A facelift, neck lift, or brow lift addresses laxity; resurfacing is often combined with these operations or performed afterward to improve the surface.
Dynamic lines, the creases that appear with expression, such as frown lines and crow's feet when smiling. These are driven by muscle activity and respond best to neuromodulators; volume loss responds to fillers. See injectables.
Excess eyelid skin and under-eye bags, which are structural and are treated with blepharoplasty. Resurfacing of the thin eyelid skin is often a useful complement.
Broken blood vessels and diffuse redness, which are better treated with light- or vascular-laser devices such as intense pulsed light (IPL) that target color without removing skin.

Skin type and the risk of pigment change

The Fitzpatrick scale classifies skin by how it responds to sun: type I always burns and never tans, and type VI is deeply pigmented and rarely burns [10]. It is the single most useful predictor of resurfacing risk. Darker skin (types IV through VI) has more active pigment cells, which respond to injury and inflammation by making excess pigment. This produces post-inflammatory hyperpigmentation (PIH), a temporary but sometimes persistent darkening of treated skin. Darker skin is also more prone to hypopigmentation (lightening) after deep injury and to hypertrophic and keloid scarring [2, 11].

In a review of 2,010 facial laser treatments, PIH was the most frequently reported complication and was concentrated in Fitzpatrick types IV to VI [11]. In a series of 500 patients treated with traditional CO2 laser, hyperpigmentation occurred in 37% overall and more often in darker phototypes [12]. People with darker skin can still be excellent candidates, but the choice usually shifts toward superficial peels, nonablative lasers, and microneedling, with conservative settings and pretreatment of pigment [13, 14, 15].

Who is a good candidate

Good candidates have realistic goals, sun damage, fine wrinkles, or scars limited to the skin surface, and the ability to protect healing skin from the sun for several months. Factors that raise risk or change the plan include:

Isotretinoin (Accutane). The drug label has long advised waiting 6 months after isotretinoin before resurfacing, based on a few small case series from the 1980s. A systematic review with expert consensus found insufficient evidence to delay superficial chemical peels or fractional ablative and nonablative laser treatment, but still advises against mechanical dermabrasion and fully ablative laser in patients taking isotretinoin [16]. The American Society for Dermatologic Surgery reached similar conclusions [17]. Timing for deeper procedures is individualized.
Cold sores (herpes simplex). Resurfacing the face can reactivate the virus, and an outbreak on freshly treated skin can delay healing and cause scarring. In the 500-patient CO2 series, herpes infection occurred in 7.4% of patients, regardless of whether they reported prior cold sores [12]. With prophylactic valacyclovir started the day before laser resurfacing and continued for 10 to 14 days, no outbreaks occurred among 120 patients [18]. For this reason, antiviral prophylaxis is routine for medium and deep resurfacing.
Other factors: smoking, prior radiation to the face, active skin infection or acne in the treatment area, a history of keloids, and melasma, which can flare after treatment.

Most plans begin with daily sunscreen and topical skin care to prepare the skin, and strict sun protection afterward, because new skin is especially prone to pigment change.

CHEMICAL PEELS (SUPERFICIAL, MEDIUM, AND DEEP)

A chemical peel is the application of an acid or other caustic solution that destroys a predictable thickness of skin. The depth depends on the agent, its concentration, how the skin is prepared, and how the solution is applied. Peels are among the oldest and most cost-effective resurfacing tools, and superficial peels in particular remain very widely used [1]. Peels are usually grouped by depth, and each level addresses a different degree of photoaging [3].

Superficial peels

Superficial peels remove part or all of the epidermis. Common agents are alpha-hydroxy acids (glycolic, lactic, and mandelic acid), salicylic acid (a beta-hydroxy acid), Jessner's solution, and low-strength trichloroacetic acid (TCA) [1].

What they treat: dull or rough texture, mild sun spots, acne and post-acne discoloration, and very fine lines. They do little for established wrinkles.
Recovery: redness and light flaking for a few days; most people return to work immediately.
Number of treatments: usually a series of 3 to 6 peels a few weeks apart, then periodic maintenance. For atrophic acne scars, glycolic acid, TCA, and Jessner's peels have supportive evidence, typically as a series or in combination with other procedures [7].
Skin of color: superficial peels are generally the safest peels for darker skin. In patients with skin types V and VI pretreated with hydroquinone, a series of 20% to 30% salicylic acid peels produced moderate to significant improvement in 88%, with mild side effects in 16% [13]. A 2026 scoping review found favorable results for glycolic and salicylic acid peels in skin types IV to VI, while noting that the studies are small and short [14].

Medium-depth peels

Medium-depth peels extend through the epidermis into the papillary dermis. The standard is the combination peel described by Monheit: Jessner's solution is applied first to break down the outer layer so that 35% TCA penetrates evenly [19]. Higher concentrations of TCA used alone are avoided because they are less predictable and more likely to scar.

What they treat: moderate photoaging, including fine and moderate wrinkles, sun spots, rough texture, and actinic keratoses [19]. In a randomized trial, a 30% TCA peel reduced actinic keratoses about as effectively as CO2 laser resurfacing [9].
Recovery: the skin darkens and tightens over the first few days and then peels over roughly 5 to 7 days; pinkness fades over several weeks.
Risks: infection, cold sore reactivation, PIH, milia (small white cysts), acne flares, and, uncommonly, scarring. Antiviral prophylaxis and strict sun protection are standard.
Repeat treatment: a medium-depth peel can be repeated, typically no more than once or twice a year [3].

Deep peels

Deep peels use phenol combined with croton oil and reach the upper reticular dermis. They produce the most dramatic improvement in deep wrinkles of any peel, along with genuine skin tightening, and have long been considered the standard for heavy perioral and periorbital lines [3, 20].

Modern formulas: the classic Baker-Gordon formula was known for leaving the skin very pale ("alabaster") and waxy. Hetter's work showed that croton oil, not phenol, is the main driver of peel depth, and that depth can be adjusted by varying the croton oil concentration [21]. Laboratory work supports this: croton oil drives the inflammatory and collagen-building response [22]. Today's lower-concentration formulas allow the surgeon to tailor depth by area and give more natural results with less risk of permanent lightening [20].
Results: deep peels produce long-lasting improvement. In a multicenter series of 55 phenol-croton oil peels for constitutional dark circles under the eyes, mostly in Fitzpatrick type III and IV skin, 89% of peels produced more than 50% improvement, with a median duration of 24 months and no scarring [23].
Recovery: the skin is raw and weeping for about 1 to 2 weeks and requires occlusive dressings or ointment and close follow-up. Pinkness lasts for weeks to months.
Risks specific to phenol: phenol is absorbed through the skin and can cause heart rhythm disturbances. Full-face deep peels are therefore performed with cardiac monitoring, and the face is typically treated one segment at a time with pauses between segments. In 181 patients monitored during full-face deep peels, arrhythmia occurred in 6.6%, more often in patients with diabetes, hypertension, or depression; all were controlled, 8 with intravenous lidocaine [24]. Other risks include permanent hypopigmentation, a visible line of demarcation between treated and untreated skin, prolonged redness, and scarring.
Candidates: deep peels are best suited to fair-skinned patients (types I to III) with heavy wrinkling. They are used selectively in darker skin.

Lasers have replaced deep peels for many indications, but the deep phenol peel remains an effective, durable option in experienced hands, particularly for deep lines around the mouth and eyes [1, 20]. Peels of different depths can also be combined in one session, for example a deeper peel to the upper lip and a medium-depth peel to the rest of the face.

Laser resurfacing, dermabrasion, and microneedling

Resurfacing lasers deliver energy absorbed by water in the skin and either vaporizes tissue (ablative) or heats it without removing the surface (nonablative). A second distinction is whether the laser treats the entire surface (fully ablative or "traditional") or only a fraction of it in a grid of microscopic columns (fractional).

Fully ablative lasers: CO2 and erbium

The carbon dioxide (CO2, 10,600 nm) and erbium:YAG (Er:YAG, 2,940 nm) lasers remove the epidermis and a controlled layer of dermis across the whole treated area. They produce the greatest single-treatment improvement in wrinkles and sun damage of any laser, along with visible tightening, but they also have the longest recovery and highest complication rates [4, 11].

CO2 versus erbium: in a split-face trial, the CO2 side showed somewhat greater wrinkle improvement, but the erbium side healed faster, had less redness at 2 and 8 weeks, and developed hypopigmentation far less often (5% versus 43% of treated sides) [25]. CO2 heats the surrounding tissue more, which accounts for both its greater tightening and its greater risk.
Recovery: the skin is raw for roughly 1 to 2 weeks and needs constant ointment care. In a 500-patient series, redness occurred in every patient and lasted an average of 4.5 months; hyperpigmentation occurred in 37%, and acne flares, milia, and dermatitis in 10% to 15%. Scarring and hypopigmentation each occurred in less than 1% in that series [12].
Late lightening: longer follow-up showed that permanent hypopigmentation can appear months after CO2 resurfacing, a risk not apparent in early reports [26].

Fractional lasers

Fractional photothermolysis treats the skin in thousands of microscopic columns while leaving the skin between them intact. The untreated bridges of skin speed healing dramatically; in the original studies, the surface was healed within a day after nonablative treatment [27]. The trade-off is that most patients need more than one treatment to approach the result of a single fully ablative session.

Nonablative fractional lasers (for example, 1,550-nm erbium-glass) heat columns of dermis under an intact surface. Recovery is usually a few days of redness and swelling. In 50 patients treated 3 times, 73% of treated faces showed at least 51% to 75% improvement in photodamage at 9 months, with no prolonged pigment change or scarring [28]. In 961 consecutive treatments, complications occurred in 7.6%, most often acne flares (1.9%) and cold sore outbreaks (1.8%); all were temporary, and PIH was more frequent in darker skin [29].
Ablative fractional lasers (fractional CO2 or erbium) vaporize microscopic channels and give stronger results with about a week of recovery. Six months after a single fractional CO2 treatment, blinded assessment showed about 52% improvement in wrinkles, 48% in uneven pigment, and 56% in texture [30]. After 3 fractional CO2 treatments, measured wrinkle size decreased by 58% on the cheeks and 35% around the eyes, showing that response varies by facial area [6].
Acne scars: in a meta-analysis of 8 comparative studies, fractional CO2 was more effective than fractional Er:YAG for atrophic acne scars, with longer redness but no difference in PIH [31]. Combination treatment generally outperforms any single method; in a network meta-analysis of 56 randomized trials, fractional CO2 combined with subcision or platelet-rich plasma gave the most consistent benefit for moderate to severe acne scars [8]. Ablative fractional lasers also have an established role in improving the texture and flexibility of traumatic and burn scars [32].

Complications of fractional lasers are less common and usually milder than with fully ablative lasers, but prolonged redness, PIH, infection, and, rarely, scarring do occur, particularly on the neck, in darker skin, and with aggressive settings [4]. Cold sore reactivation is also less frequent but still occurs, so antiviral prophylaxis is commonly used for ablative fractional treatment.

Lasers in darker skin

The risk of PIH rises with skin type and with the aggressiveness of treatment. In Chinese patients with skin types III and IV, PIH occurred in 56% of patients 1 month after a single fractional CO2 treatment and persisted in 11% at 6 months [33]. In practice, darker skin is treated with nonablative fractional devices or lower-density ablative settings, longer intervals between sessions, and pretreatment and posttreatment pigment control [11].

Dermabrasion

Dermabrasion removes the epidermis and upper dermis mechanically with a rapidly rotating diamond burr or wire brush, or by hand with sterile abrasive paper (dermasanding). It predates lasers and remains useful in experienced hands, especially for the upper lip and for surgical and acne scars, where the surgeon can feel and see the depth directly. In a randomized split-face trial for perioral wrinkles, dermabrasion and CO2 laser produced no significant difference in wrinkle improvement at 4 months, but the dermabraded side healed faster, crusted less, was less painful, and had shorter redness [5]. Risks are similar to other deep resurfacing: pigment change, infection, cold sore reactivation, and scarring. Mechanical dermabrasion is not recommended while a patient is taking isotretinoin [16].

Dermabrasion is different from microdermabrasion, a superficial exfoliation with a much smaller effect.

Microneedling

Microneedling (collagen induction therapy) uses a pen or roller with fine needles to make thousands of tiny punctures into the dermis. The epidermis remains largely intact, so recovery is short and the risk of pigment change is lower than with lasers or peels [34, 15].

Evidence: reviews report improvement in acne and surgical scars, fine wrinkles, and texture, usually after a series of 3 to 6 sessions [34, 15]. A 2025 meta-analysis of 21 studies (723 patients) treated for facial aging found 83% patient satisfaction, with transient redness in 6.8% and scaling in 1.7% [35]. The authors noted that outcome measures were not standardized, so the size of the wrinkle effect is less certain than for lasers.
Compared with fractional laser for acne scars: a meta-analysis of 17 comparative studies found similar overall improvement, a slightly higher rate of treatment success with fractional CO2, and a 3-fold higher risk of PIH with fractional CO2 than with standard microneedling [36]. For this reason, microneedling is often preferred in darker skin.
Variations: microneedling is often combined with platelet-rich plasma, and radiofrequency microneedling adds heat to the needle tips for more tightening [8].

Choosing among methods

Mild sun damage, uneven tone, any skin type: superficial peels, nonablative fractional laser, or microneedling, usually in a series.
Moderate wrinkles and sun damage: medium-depth peel or ablative fractional laser.
Deep wrinkles, especially around the mouth and eyes, in fair skin: fully ablative laser, deep phenol peel, or dermabrasion.
Acne scars: fractional laser or microneedling, often combined with subcision, fillers, or platelet-rich plasma.

The comparison of these treatments is limited by small trials, different devices and settings, and inconsistent outcome measures, so recommendations rely partly on experience. More information about our skin treatments is on the aesthetic skin services page, and related conditions are described under skin conditions and aging and aesthetics.

COST OF SKIN RESURFACING

The cost of skin resurfacing varies widely, and a specific fee is quoted at consultation once the treatment plan is clear. The main factors are:

The method and depth. Superficial peels and microneedling cost the least per session. Medium-depth peels, fractional lasers, and dermabrasion cost more. Fully ablative laser resurfacing and deep phenol peels are surgical procedures that cost the most per treatment, but often give in one session what lighter treatments achieve over several.
The number of sessions. Superficial peels, microneedling, and nonablative fractional lasers are usually done as a series of 3 to 6 treatments, and acne scars commonly need several sessions and combined methods [28, 7, 8]. A fair comparison looks at the cost of the whole course rather than a single session. In an economic analysis, fractional CO2 laser had similar effectiveness and cost to alternative lasers for acne scars and rejuvenation [37].
The area treated. Treating a single area such as the upper lip or the lower eyelids costs less than a full face; the neck, chest, and hands are priced separately.
Setting and anesthesia. Light treatments are done in the office with topical numbing. Fully ablative laser, deep peels, and dermabrasion often require local anesthesia with sedation, and deep phenol peels require cardiac monitoring [24]; facility and anesthesia fees add to the cost.
Combination with surgery. When resurfacing is performed at the same time as a facelift or blepharoplasty, some facility and anesthesia costs are shared.
Aftercare. Antiviral medication, ointments, and sunscreen, plus a maintenance skin care regimen, add modest ongoing costs.

Cosmetic versus covered treatment

Resurfacing for wrinkles, sun damage, uneven pigment, and acne scars is considered cosmetic and is not covered by health insurance. There are limited exceptions in which part of the care may be covered, depending on the plan and documentation:

Treatment of precancerous actinic keratoses, when resurfacing or a medium-depth peel is used as field therapy for extensive lesions [9].
Laser treatment of scars that cause functional problems, such as contracture, pain, or itching after burns or trauma [32].
Selected reconstructive scar revision after skin cancer surgery or injury.

Prior authorization is usually required, and cosmetic components of a combined procedure are billed separately. Our office can review what is likely to be covered before treatment.

Summary

Skin resurfacing uses a controlled injury, from a chemical peel, laser, dermabrasion, or microneedling, to produce smoother texture, more even color, and new collagen. It treats fine lines, sun damage, uneven pigment, actinic keratoses, and scars, but not sagging skin, jowls, or expression lines. Deeper treatments (fully ablative laser, deep phenol peel, dermabrasion) give the largest single-treatment improvement with 1 to 2 weeks of healing and months of pinkness; lighter treatments (superficial peels, nonablative fractional laser, microneedling) need a series of sessions but have little downtime. Skin type is the key risk factor, because darker skin is more prone to pigment change. Antiviral prophylaxis, attention to isotretinoin use, and strict sun protection reduce complications. Cosmetic resurfacing is not covered by insurance, and cost depends on method, area, number of sessions, and anesthesia.

Last reviewed: October 4, 2026

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