To Peel or To Laser: The Resurfacing Question

Peels vs. Lasers: What Are We Actually Doing to the Skin?

When we talk about skin rejuvenation, chemical peels and laser resurfacing are often discussed together because they can address many of the same concerns—fine lines, texture, pigmentation, and photodamage. But biologically, they are doing very different things. A resurfacing laser uses energy to remove and thermally damage tissue. A chemical peel uses chemistry to alter tissue.

Understanding that difference is important when deciding how you want to approach skin rejuvenation.

• What Does a Resurfacing Laser Actually Do?

An ablative resurfacing laser delivers concentrated energy into the skin. Because water is the primary target, that energy is rapidly absorbed and converted into heat. When enough energy is delivered, the water within the targeted tissue is heated to the point that the tissue is vaporized.

But vaporization isn’t the only effect.

The intense heat also creates a surrounding zone of thermally damaged tissue. With fractional ablative resurfacing, this occurs in microscopic columns, leaving untreated skin between the treated areas.

The skin then responds to both the tissue that was removed and the tissue that was thermally damaged. Inflammatory signaling is initiated, damaged material is cleared, epidermal cells regenerate, and fibroblasts and the extracellular matrix become involved in the repair and remodeling process.

The basic sequence is:

Energy → rapid heating → vaporized tissue + thermal damage → inflammatory response → repair and remodeling

• How Is a Chemical Peel Different?

A chemical peel doesn’t use laser or thermal energy to remove tissue. Instead, a chemical agent is applied to the skin and produces a chemical reaction within the tissue. The exact mechanism depends on the peeling agent and formulation.

Some acids primarily disrupt the bonds between cells in the epidermis, allowing those cells to separate and shed. Other peeling agents cause protein denaturation and coagulation within the treated tissue.

The affected tissue is then shed, the epidermis regenerates, and—depending on the depth and type of peel—the healing response can also contribute to dermal remodeling.

How deeply and extensively that occurs depends on factors including the specific acid, concentration, pH, formulation, application technique, number of passes, and contact time.

The basic sequence is:

Chemical agent → chemical alteration of tissue → shedding/regeneration → inflammatory response → repair and remodeling

• Personalized Treatment vs. Standardized Protocols

Many laser systems come with manufacturer-developed treatment protocols and recommended parameters based on the device and treatment area. Those parameters can include energy, pulse duration, density, and other settings that directly influence the depth and extent of tissue injury. (PubMed⁠)

In practice, these protocols can become quite standardized, with the provider working within a relatively narrow range of predetermined settings. That also makes it important to understand who is actually performing the procedure. In many cases the supervising physician is NOT the one performing the procedure, but rather, it is delegared to a trained technician following these standardized protocols.  The level of medical supervision required can vary significantly depending on state regulations and the procedure being performed.

So who is assessing your skin, who is deciding how aggressively to treat it, who is performing the procedure, and what level of medical oversight is actually involved can often be vague and ambiguous.

• Why More Injury Isn’t Always Better

This is where the condition of the skin matters.

Repeated or aggressive resurfacing can affect the dermal structures that give skin its strength, elasticity, and support—including fibroblasts and elastin.

In a human ultrastructural study of CO₂ laser resurfacing, elastin abnormalities and fibroblast necrosis were observed after treatment, with the extent and depth of fibroblast necrosis increasing with additional laser passes. (PubMed⁠)

That matters when the skin is already thin or losing structural support with age.

And there is another consideration: inflammation and hormones are connected.

Inflammation is a necessary part of healing, but the body doesn’t treat inflammation as an isolated event occurring only in the skin. The skin communicates with the nervous, immune, and endocrine systems, including pathways involved in the body’s stress and hormone response. Current research describes the skin as a neuro-immuno-endocrine organ with bidirectional communication between the skin, nervous system, immune system, and endocrine pathways. (PubMed⁠)

That is particularly relevant when working with skin that is already changing because of hormonal shifts, including menopause or hormone replacement therapy. The point is that when we deliberately create a significant inflammatory response, we should consider the overall biological environment we’re asking the skin and body to manage.

• A Progressive Approach to Peels

This is one of the reasons I favor a progressive approach with chemical peels.

The process begins before the peel itself. The skin is prepared at home based on its needs. For someone prone to pigmentation, that may include a regimen containing tyrosinase-inhibiting ingredients to help regulate melanin production before intentionally creating an inflammatory stimulus.

The peel is then selected according to the skin’s current condition and the goal of treatment.

I prefer to begin at a level the skin can appropriately tolerate, observe how it responds, and use that information to determine what comes next. If the response is appropriate, treatment can progress through a series toward stronger or deeper treatments when indicated. If the skin needs more time, the approach can be modified. The skin’s response helps determine the next step.

The goal isn’t to create the biggest injury or the biggest inflammatory response possible. The goal is to create the right biological stimulus for the skin we’re working with.

The skin doesn’t have to be pushed to its limit to make progress.