Fractional Laser: How Suitable Is It for Acne Scars, Wrinkles and Skin Texture?

What is fractional laser and how does it work?

The word «fractional» means that the laser light is delivered not to the whole of the skin but to many small, separate points. At these points, microscopic treatment zones form within the skin; the intact skin left between them speeds up healing.

As the body repairs these small areas, it produces new collagen (the supporting protein that gives skin its firmness), and the skin surface renews itself over time. In this way the texture may become smoother, and fine wrinkles and some scars may become less noticeable.

Fractional lasers work at different wavelengths and with different settings. Even with the same type of laser, a light or an intensive treatment can be given; recovery time and risk depend largely on these settings.

What is it used for?

• Depressed (atrophic) acne scars
• Fine and moderately deep wrinkles, especially around the eyes and mouth
• Rough, uneven skin texture and visible pores
• Sun-related skin damage and some pigmentation
• Surgical and injury scars (where the physician considers it appropriate)

Laser treatment does not remove scars completely; it aims to reduce their appearance. For deep and wide scars, laser is often planned together with other methods.

Who is it suitable for?

Those who usually respond well to fractional laser are people whose problem is suited to this method, who have no active skin disease and who can follow the aftercare and sun protection during the recovery period. In fair skin, both ablative and non-ablative types can be used.

Treatment can also be given to medium and dark skin; however, the risk of darkening after the procedure is higher in these skin tones. For this reason, more cautious settings, non-ablative types and a careful plan to prevent pigmentation before and after the procedure are usually preferred. Physicians often use the Fitzpatrick classification to assess your skin type.

Who is it not suitable for, and what should you watch out for?

• Postponing it during pregnancy and breastfeeding is generally recommended.
• Active infection, an open wound, an active cold sore or inflamed acne in the treatment area
• Recently sun-exposed or tanned skin: the risk of pigmentation and burns increases.
• A tendency to keloids (excessive scarring)
• Conditions that can flare after skin injury, such as vitiligo or psoriasis
• Use of an oral vitamin A derivative acne medicine (isotretinoin): be sure to say if you are currently taking it or have recently stopped. Whether a waiting period is needed is assessed by your physician according to the type and extent of the laser treatment.
• Conditions that impair wound healing or treatments that suppress the immune system
• A history of cold sores: preventive medication may be needed, especially for ablative treatments on the face.

During the consultation, clearly mention all the medicines and skin products you use, when you were last in the sun and any scarring or pigmentation problems you have had before. Suitability can only be decided after a physician's assessment.

Who should perform it, and where?

Fractional laser, especially the ablative types, is a medical procedure that can cause burns, permanent scarring and discolouration at unsuitable settings. It is recommended that it be carried out under the responsibility and supervision of a physician who can assess skin type and scar type and who can recognise and treat complications.

Eye protection suitable for the device must be available where the treatment is given, and your eyes must be protected during the procedure. With ablative treatments, follow-up during the recovery period is as important as the procedure itself.

Preparing for the procedure

• Avoid sunbathing and sunbeds in the weeks before the procedure; your physician will tell you the right period for you.
• If you are prone to pigmentation, your physician may recommend using a cream to prevent pigmentation for a while before the procedure.
• You may be asked to pause products containing retinoids and acids for a few days before the procedure.
• If you have a history of cold sores, ask whether preventive medication is needed, especially before an ablative treatment.
• If an ablative treatment is planned, arrange your work and social schedule for the recovery period accordingly.

The day of the procedure, step by step

1. Your medical history, medicines and expectations are discussed; your skin type and the problem to be treated are assessed.
2. The informed consent form is read; the recovery process and risks are discussed and the form is signed.
3. The area is cleaned, and a numbing cream is usually applied some time beforehand. For ablative and intensive treatments, additional pain-control methods may be discussed.
4. You and the practitioner put on eye protection suitable for the device.
5. The laser handpiece is moved over the skin area by area. You may feel heat, prickling or a sensation like needle pricks; cooling systems can reduce the discomfort.
6. At the end of the procedure the area is cooled, a soothing product is applied and detailed aftercare advice is given.

After the procedure: the first 24 hours and the first week

After non-ablative treatments, redness, swelling and a feeling similar to sunburn are common; within a few days the skin may become dry and peel finely, or take on a darker colour. After ablative treatments there may be oozing, crusting and marked swelling; healing of the surface usually takes around a week, and redness may last longer.

• Follow the cleansing and moisturising instructions your physician gives you; do not let the skin dry out.
• Do not pick off crusts or peeling skin.
• In the first days, avoid make-up, saunas, Turkish baths, swimming pools and intense exercise.
• Do not use retinoids, acid-containing or irritating products until your physician allows it.
• Protect yourself strictly from the sun: stay in the shade, wear a hat and start a broad-spectrum sunscreen when your physician allows.
• Sleeping with your head slightly raised can reduce swelling in the first days.

Expected side effects

• Redness and swelling: may last a few days with non-ablative and weeks with ablative treatment.
• Dryness, peeling and itching
• Oozing and crusting with ablative treatments
• Small white cysts (milia) or an acne flare
• Temporary darkening of the skin: more common especially in medium and dark skin and in sun-exposed skin.

There are also less common but important risks: bacterial, fungal or cold sore (herpes) infection, prolonged redness, scarring and lightening of the skin (whitening). Lightening of the skin can sometimes appear months later and may be permanent; it has been reported more often with ablative and intensive treatments. With intensive ablative treatments around the eyelids, a change in eyelid shape may rarely occur.

When is the result seen, and how long does it last?

As the skin surface heals, the texture may look smoother in the first weeks; however, improvement linked to collagen production continues over months. For this reason, the result is usually better assessed a few months after treatment ends.

Non-ablative treatments usually require more than one session a few weeks apart. With ablative treatments, a noticeable change may be seen with fewer sessions; however, the recovery time and risk are higher. Your physician will suggest a plan according to the condition of your scars and skin.

The improvement achieved in acne scars is usually maintained for a long time. With wrinkles and sun damage, however, new changes may appear over time because ageing and sun exposure continue; sun protection is important for preserving the result.

Realistic expectations: what can fractional laser not do?

• It does not erase scars completely; it aims to reduce their appearance.
• It does not correct marked sagging or excess skin.
• On its own, it does not correct hollows caused by volume loss.
• In most cases one session is not enough; several sessions are needed, especially with non-ablative types.
• Some pigmentation, such as melasma, may get worse after laser; treating pigmentation requires a separate assessment.
• Everyone responds differently.

Alternatives