What Are Lasers and How Do They Work?
So what exactly is a laser? The word stands for light amplification by stimulated emission of radiation, according to NASA. As used in dermatology, a laser is “a skin-resurfacing modality that harnesses the power of light and heat to improve skin tone, texture, and coloration,” says Lara Devgan, MD, a plastic surgeon based in New York City. “It does that by creating a controlled injury in the tissue that stimulates the body to have a healing response that makes it look better.”
When you work out, you intentionally cause small tears to your muscles, which grow back stronger, research notes. Lasers work in a similar way: They use light and heat energy to cause controlled damage to the surface of the skin, so that your body reacts to heal the tissue by creating new skin.
The result? Revved production of collagen, says Rachel Nazarian, MD, a dermatologist with Schweiger Dermatology Group in New York City, which is confirmed by research. With age, collagen production wanes, leading to fine lines and wrinkles, according to the Cleveland Clinic.
If you’ve seen Chelsea Handler’s viral Instagram post of her “before and after” laser treatment, you’re probably already sold on the benefits. Other celebrity influencers have been touting the effects of their own laser treatments on social media — Drew Barrymore’s makeup-free mug looked angelic as she raved about the benefits of Clear + Brilliant, for example. No wonder laser resurfacing is more popular than ever.
According to a report, from 2000 to 2018, laser resurfacing procedures increased by 248 percent, from 170,951 to 600,000.
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Still, lasers can pose risks to your skin health. Here’s what you need to know to avoid getting burned.
1. Don’t Assume the Person Operating the Laser Is a Trained Professional
In the era of med spas and Botox bars, the lines between pampering, aesthetics, and medical treatments are increasingly blurred. Inconsistent legislation only compounds the problem.
Most med spas prefer that their aestheticians have some level of study, but the actual requirements can differ by state, according to a state-by-state analysis by HairFacts.com. It’s best to check the provisions in your state before you move forward.
As magical as they may seem, lasers aren’t toys. “The thing that makes lasers so powerful and also so dangerous is that tiny fluctuations in how light and heat are manipulated — and the exact wavelength and energy — can be the difference between giving you perfect skin and a catastrophic burn or hyper- or hypopigmentation,” says Dr. Devgan. “The laser itself means very little, compared with the person on the other end of the laser who’s programming the settings and manually putting it on your face.”
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So if you’re seeking treatment, it’s smart to see a board-certified plastic surgeon or dermatologist with significant experience in resurfacing laser treatments. “The majority of complications occur in the hands of people who are not derms or plastic surgeons — whether that’s your dentist or a person taking a weekend laser course and buying a laser — which is unfortunately becoming way too prevalent,” says the New York City–based dermatologist Sapna Westley, MD.
The key certifications to look for are from the American Board of Plastic Surgery (ABPS), the American Board of Dermatology (ABD), or the American Osteopathic Board of Dermatology (AOBD).
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2. Know the Basic Categories of Resurfacing Lasers
There are several key categories of lasers, including ablative and nonablative (the former wounds the skin, while the latter doesn’t), as well as fractional, which means that the laser beam is pixelated and only a fraction of the skin surface is affected. Other therapies, such as light therapies, are gentler options for skin resurfacing.
These are the most powerful lasers. They remove the epidermis (the top layer of your skin) and part of your dermis (the second layer of your skin) by superheating water in the skin. This causes controlled vaporization of skin cells, says Manish Shah, MD, a plastic surgeon in Denver. “The body responds by making new, younger-looking skin,” he says. “The skin gets tighter, while the fine lines are removed and the wrinkles are softened. Sunspots are lightened, and benign skin growths are destroyed.” This treatment can help reduce the appearance of age spots, fine lines, hyperpigmentation, and uneven skin tone.
Recovery time with ablative lasers is about a week, says Dr. Shah. And because skin can be sensitive in the immediate weeks following the procedure, it’s a good idea to use a physical sunscreen for protection. “Patients can expect final results in about six months,” he adds, but “stubborn skin conditions might need several treatments to get the best results.”
Examples of ablative lasers are the carbon dioxide laser (CO2) and the newer erbium YAG (Er:YAG), which provides similar benefits but with fewer side effects than the CO2 laser, Dr. Nazarian says. Many healthcare professionals prefer the erbium for aggressive resurfacing with fewer side effects and shorter downtime, according to a research review.
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Almost all ablative lasers used these days are also fractional, which means tiny fractions of the epidermis and some of the dermis are injured while intervals of healthy skin are left intact. “The fractionated laser delivers heat and light in a pixelated fashion,” says Paul Jarrod Frank, MD, a cosmetic dermatologist based in New York City “So instead of burning 100 percent of the skin, there are almost these digital pixels of laser that destroy the target, allowing for quick healing without causing trauma to 100 percent of the skin at one time,” he says.
“The idea is that you can get a lot of the benefits of an ablative laser, but a little bit less downtime [recovery time] because there are small islands of dermal elements that help the tissues heal a little bit faster,” Devgan says.
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Dubbed “nonwounding” lasers by the Mayo Clinic, nonablative lasers are gentler than their ablative counterpart. “While ablative lasers direct their energy at the top layer of skin to renew the most superficial parts, nonablative lasers work by directing their energy much lower into the deeper tissue,” Nazarian says.
According to a research review, while the results of nonablative lasers are mild, they are better for people with darker skin because they pose a lower risk of hyper- or hypopigmentation in the right hands. If you’re okay with getting slower results over a longer period of time and undergoing more sessions, this is the laser for you.
Among fractionated lasers (which, to review, can be both ablative or nonablative), the brand Fraxel has become like Xerox or Kleenex — almost synonymous with the category. Examples of this type of laser are the Fraxel Restore and the Clear + Brilliant laser, though there are many others. Fraxel lasers can be divided into many types, based on how ablative or nonablative the treatment is. For example, there’s Fraxel Restore, a nonablative option; Fraxel Repair, an ablative fractionated CO2 laser; and Fraxel Dual, a nonablative option with two lasers: one to target pigmentation and sun damage and the other to target wrinkles and acne scarring.
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Another popular nonablative treatment, as the Mayo Clinic notes, is light therapy, also known as intense pulsed light (IPL) or broad-based light (BBL). They aren’t lasers, nor do they resurface skin. Instead, they’re a “rejuvenating” therapy, Dr. Westley says.
They achieve many of the same results that lasers do, but in a more targeted, gentler way. “Instead of using one laser that focuses on your skin, [light therapy] uses several wavelengths of light at once,” says Sheel Desai Solomon, MD, founder of Preston Dermatology and Skin Surgery in the Raleigh-Durham area of North Carolina.
Just keep in mind that because it’s gentler, you’ll need more sessions to see serious results, Devgan says.
To avoid possible complications, it’s best to get IPL done with an experienced physician.
It’s important to note there are many other types of lasers that are not resurfacing lasers, but instead specifically target coloration, such as redness or pigment, as well as treating everything from rosacea, spider veins, sun spots, and melasma to the removal of scars, hair, and tattoos. Some of these include Q-switched, pulsed dye, Nd:YAG, alexandrite laser, diode laser, KTP laser, and Picosecond. The PicoSure and Enlighten lasers fall in this relatively new and promising category. Each laser company has its own branded name, but many of the lasers have the same basic technology behind them.
3. Don’t Get Hung Up on Laser Brand Names
One problem with the surging popularity of laser treatments is that you may think you’re already an expert in this field because you saw an Instagram post or have peers who’ve undergone laser treatments themselves. But Westley says the brand names of the lasers are less important than the wavelengths used and the knowledge level of the health professional performing the treatment. “There are parameters, and we need to know what settings to use, and everyone comes with a different skin type. And with darker skin, you have to be more cautious with the settings,” Westley says. “I’ve seen a lot of people end up with burns and scarring post lasers because wrong wavelengths were used, or they were undertreated and they didn’t get the results that they could have gotten.”
The focus on brands instead of the overarching wavelengths or categories, and their capabilities and limitations, can leave you uninformed and prone to limited, if not unwise, choices. “It’s sort of like if you only knew Coca-Cola, but you weren’t able to put it in the category of dark-colored sodas,” Devgan says.
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4. Work With Your Dermatologist to Choose the Right Laser for You
It’s wise to get treatment from someone who has experience operating a range of lasers, says Westley. “Doctors with several machines are able to customize the treatments in terms of what wavelengths of lasers they would do the best with, and sometimes it’s a combination of various lasers and wavelengths.”
Dr. Frank agrees. “The current and future of noninvasive cosmetic dermatology is in combining a lot of small things to get big results, so you can’t just go to someone who only offers one device,” he says.
So if you’re considering getting a laser treatment, make sure you understand the pros and cons, and be sure to ask about recovery time.
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5. Come to Your Consultation Armed With Questions
“The basic rule of thumb with lasers is that the more aggressive the treatment, the more downtime and the better the result,” says Devgan. “The less aggressive the treatment, the less downtime and also the less dramatic the result and the more treatments you’ll need to get a nice outcome.”
Before you meet with a doctor, make a list of the top three things that are bothering you about your skin. Ultimately, your dermatologist can help you weigh the factors against one another to help you identify the right laser or light therapy.
6. If You Have a Dark Skin Tone, Approach Lasers With Caution
Not all skin colors react to lasers the same way. Dermatologists utilize the Fitzpatrick scale, a system of classifying human skin color, to estimate the response of different types of skin to ultraviolet (UV) light. According to this system, there are six basic categories, with 1 being the lightest and 6 having the most melanin, as noted by DermNet.
“It’s possible to use any type of laser on any skin tone, but you have to be very mindful,” says Devgan. “The risk with more pigment in the skin is hyperpigmentation, which paradoxically means you’re risking making someone have more blotchiness or darkness or brown spots on their skin as an unwanted side effect, when maybe that’s exactly what they’re trying to treat.”
“Overall, my approach is to be very conservative when lasering Fitzpatrick skin types 4, 5, 6,” Devgan says.
But that doesn’t mean darker skin tones need to shy away from lasers completely. Instead, practice caution, and find a provider who has experience using the laser that is best for your skin type and who can best assess the value versus risks. “A common misconception is that laser resurfacing is only safe for light skin types,” says Dr. Solomon. “While it’s true that certain lasers pose a higher risk for cell damage or discoloration in darker skin, there are safe and effective resurfacing options. For lighter-toned African American, Hispanic, or Asian skin tones, erbium lasers can sometimes be a good option, posing less risk for discoloration.”
Nonetheless, Solomon says sometimes patients with “darker brown or black skin may need to consider other skin resurfacing options, such as radio-frequency treatments or microneedling.”
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7. Know That Lasers Can Help Treat Acne Scars, but They Aren’t Good for Active Acne
“Lasers and other light therapies may seem like the perfect acne treatment — just beam a light to make the acne disappear,” Solomon says. But it’s not that simple.
Lasers can be effective for resurfacing acne scars, but for active acne, you’ll want to opt for treatment with blue or blue-red light, advises the American Academy of Dermatology (AAD).
Devgan says she often treats patients with acne scars by using an erbium laser for resurfacing. “If someone has active acne, I would do something more like an intense pulsed light with an acne reduction filter,” she says.
According to one study, IPL and photodynamic light therapies can help reduce inflammation and acne scarring, but they are less effective on whiteheads and blackheads, or on cysts or nodules. To give you the best results, your dermatologist may recommend using another acne treatment, such as medicine that you apply to your skin. Results vary from person to person. “Right now, there’s no way to know who will see clearer skin and how much the skin will clear when treated with a laser or other light treatment,” Devgan says. According to the AAD, multiple treatments deliver significantly better results than a single treatment.
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8. Keep Your Expectations in Check
Lasers are powerful and can produce amazing results, but they aren’t miracle machines. Depending on your specific skin condition and the kind of treatments you get, results can take time, and repeat sessions may be necessary, even with the most aggressive laser. Skin cells are always growing, shedding, and turning over, and so while your results may last several years, per the American Society of Plastic Surgeons, they’re not permanent.
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9. Understand That Maintaining Your Results Is in Your Hands
“If somebody is going to be investing time and money into a laser routine at the doctor’s office, it’s really vital that they do a good topical maintenance routine at home to optimize the results of the treatment,” says Westley. “Home regimes should include regular use of retinoids, vitamin C serum, and sunscreen, of course.”
Devgan agrees that at-home maintenance is key, as is avoiding behavior patterns that are going to re-create problems for you. “If you go out into the sun, or you skip using your retinoid, or you touch your face and continue to break out, no laser will save you,” she says. “You have to have the behavior modification also. Then also, just be very wary of anything that sounds too good to be true because, as they say, it probably is.”