Experts Outline Safety Guidelines for Fully Ablative Lasers

Medscape

23-07-2025

Despite the growing use of fully ablative laser resurfacing for photodamaged skin, standard protocols for managing adverse events remain limited. A newly published international consensus statement now aims to close that gap.
Published in the June 2025 issue of Lasers in Surgery and Medicine , the consensus statement brings together expert recommendations on how to prevent and manage complications related to fully ablative laser resurfacing of the face. The authors emphasize that, while individual practice styles vary, consistent themes emerged — highlighting the importance of patient selection, comprehensive counseling, and detailed pre- and postprocedural care to improve safety and outcomes.
Why This Matters
Fully ablative carbon dioxide and erbium-doped yttrium aluminum garnet lasers remain gold standards for treating photodamaged skin because of their ability to provide deep resurfacing and robust collagen remodeling. But these benefits come at a cost: More extensive skin injury and a higher risk for complications compared with fractional or nonablative lasers, according to the authors.
Arisa Ortiz, MD
Risks include prolonged erythema, infection, pigmentary alterations, and scarring — issues that can be distressing to patients and difficult to manage without a standardized care framework. The consensus authors emphasized that, until now, clinical protocols for the prevention and management of complications have been largely based on anecdotal and variable experience.
Asked to comment on the consensus statement, one of the consensus authors, Arisa Ortiz, MD, dermatologist and director of Laser and Cosmetic Dermatology at UC San Diego Health, San Diego, called the statement 'a landmark in laser dermatology.'
'This consensus is a landmark in laser dermatology, finally providing unified, expert-backed guidance for a procedure that has historically lacked standardization. It gives clinicians a clear, practical roadmap for safe and effective fully ablative resurfacing,' Ortiz said.
Pooja Sodha, MD
Pooja Sodha, MD, associate professor of dermatology at George Washington School of Medicine & Health Sciences and director of the Center for Laser and Cosmetic Dermatology, both in Washington, DC, agreed with this sentiment, emphasizing the document is especially useful in clinical practice. 'This consensus helps to organize the thought process of how to prepare, counsel, and treat patients, almost providing a step-by-step guide of items to consider. This is great for new and old practitioners,' Sodha told Medscape Medical News . She was not an author of the statement.
Key Recommendations
The consensus outlines detailed step-by-step strategies to help clinicians reduce the risk for complications following fully ablative laser resurfacing. These recommendations span the entire patient journey — from pretreatment counseling to postoperative monitoring and management of adverse effects:
Infection prevention. The authors recommend antiviral prophylaxis for all patients undergoing full-face resurfacing, even when treatment is limited to perioral or periocular areas. 'The preferred agent for antiviral prophylaxis is valacyclovir, unless otherwise indicated,' they wrote. The consensus group also noted that oral or topical antibacterial prophylaxis may be appropriate in higher-risk individuals, such as those with diabetes or a history of methicillin-resistant Staphylococcus aureus colonization.
The authors recommend antiviral prophylaxis for all patients undergoing full-face resurfacing, even when treatment is limited to perioral or periocular areas. 'The preferred agent for antiviral prophylaxis is valacyclovir, unless otherwise indicated,' they wrote. The consensus group also noted that oral or topical antibacterial prophylaxis may be appropriate in higher-risk individuals, such as those with diabetes or a history of methicillin-resistant colonization. Postprocedural wound care. The authors emphasized the importance of frequent cleansing with soaks and keeping the skin moist with emollients. 'It is beneficial to apply topical lanolin‐free ointment or other appropriate posttreatment topical product,' the group noted.
The authors emphasized the importance of frequent cleansing with soaks and keeping the skin moist with emollients. 'It is beneficial to apply topical lanolin‐free ointment or other appropriate posttreatment topical product,' the group noted. Early recognition of infection. Patients should be educated to report signs such as increasing pain, drainage, erythema, or fever. 'It is appropriate to promptly evaluate (in person or virtually) patients with signs or symptoms concerning for infection,' the authors wrote.
Patients should be educated to report signs such as increasing pain, drainage, erythema, or fever. 'It is appropriate to promptly evaluate (in person or virtually) patients with signs or symptoms concerning for infection,' the authors wrote. Addressing pigmentary changes. The authors note that pigmentary changes such as hyperpigmentation, a common postprocedural complication, often resolve over 6-12 months, but proactive management may improve outcomes. The panel supports the use of 'topical lightening or bleaching agents' as helpful for treating hyperpigmentation and considers laser-based interventions or oral tranexamic acid in select patients, provided clotting risks are ruled out.
The authors note that pigmentary changes such as hyperpigmentation, a common postprocedural complication, often resolve over 6-12 months, but proactive management may improve outcomes. The panel supports the use of 'topical lightening or bleaching agents' as helpful for treating hyperpigmentation and considers laser-based interventions or oral tranexamic acid in select patients, provided clotting risks are ruled out. Scarring management. The consensus group recommended addressing scarring at the earliest signs. Interventions include intralesional corticosteroids or 5-fluorouracil, vascular lasers, or 'laser-assisted drug delivery of corticosteroid and/or 5‐fluorouracil,' according to the authors.
Challenges and Controversies
While the consensus process produced strong agreement in many areas, some topics remained divisive. Only a subset of proposed adverse events and contraindications reached full consensus. For instance, pretreatment counseling about eruptive keratoacanthomas or milia as possible adverse events did not meet agreement thresholds, according to the authors.
Ortiz noted that disagreement over rare complications reflects the complexity of real-world care. 'While most statements achieved strong agreement, there were important areas — like counseling for rare complications or defining contraindications — where expert opinions diverged,' she explained. 'These gray zones underscore the need for continued discussion and individualized care.'
The risk for vitiligo induction after laser resurfacing is still under debate. While not a formal contraindication, the authors suggest that 'practitioners might consider incorporating family history assessments into pretreatment consultations.'
The panel also noted that while darker Fitzpatrick skin types are not a contraindication to fully ablative laser resurfacing of the face, these patients face higher risks for postinflammatory pigmentary changes. Providers should employ strategies to reduce risk, which include conservative settings, rigorous sun protection, and topical corticosteroids after treatment when appropriate, according to the consensus group.
Sodha emphasized this point as an important area for ongoing refinement: 'I believe this statement is important — 'Darker Fitzpatrick skin types were not considered a contraindication to treatment' — and it highlights that our settings in this population need to be adjusted and these patients need to be counseled on the pigmentary risks, but treatment is still possible,' she explained. 'Building continued comfort here and defining the right parameters is worthy of a little more consideration in future guideline development.'
Sodha also noted that although the recommendations may seem straightforward, successful integration takes practice. 'The steps themselves are not difficult. This is about common sense,' she said. 'These recommendations remind us how important repetition is in integrating these principles so they are second nature.'
Looking Ahead
This expert-driven consensus offers a foundation for safe and consistent care in laser resurfacing but also highlights areas for future research, according to the authors.
Ortiz told Medscape Medical News that future data will be essential to address gaps in evidence. 'There's a pressing need for high-quality studies focused on managing complications like hypopigmentation and scarring, particularly to better understand long-term pigmentary outcomes and optimize treatment safety across diverse populations.'
The study received no specific funding. Several authors disclosed financial relationships with industry, while Ortiz and Podha reported no relevant disclosures.