Established and Emerging Laser Treatments for Acne Vulgaris in Diverse Skin Types

J Clin Aesthet Dermatol. 2025;18(6):41–48.

by Kimberly Huerth, MD, M.Ed; Chiamaka Ohanenye, MD; Andrea Quartey, MD; Brooke Jackson, MD; and Valerie Callender, MD

Dr. Huerth is with the Gateway Aesthetic Institute and Laser Center in Salt Lake City, Utah. Mses. Ohanenye and Quartey are with the Lewis Katz School of Medicine at Temple University in Philadelphia, Pennsylvania. Dr. Jackson is with Skin Wellness Dermatology Associates in Durham, North Carolina. Dr. Callender is with the Howard University College of Medicine in Washington, District of Columbia, and the Callender Dermatology and Cosmetic Center in Glenn Dale, Maryland.

FUNDING: No funding was provided for this article.

DISCLOSURES: The authors declare no conflicts of interest relevant to the content of this article.

Abstract: Objective: This review examined studies published during the past two decades in which lasers were used to treat acne vulgaris. Its aim was to assess the mechanism, efficacy, and safety of lasers as a treatment modality for this vexingly common and potentially disfiguring condition. Methods: PubMed searches were performed to identify articles published through December 2023 that discuss the use of lasers for the treatment of acne vulgaris. Results: Various lasers, including visible light, infrared, fractional ablative CO₂ lasers with isotretinoin, and two 1726-nm lasers approved by the United States Food and Drug Administration, show efficacy in treating acne vulgaris. Studies vary widely in their design, characteristics, and methodological rigor. Limitations: The available literature on using lasers to treat acne is limited by variability in study design, short-term follow up, and small sample sizes. Conclusion: Lasers have demonstrated efficacy as primary or adjunctive treatment modalities for acne vulgaris in certain clinical scenarios. Larger randomized, controlled, double-blinded studies with sufficiently long follow-up periods and standardized objective measurements are needed to substantiate the efficacy of lasers in treating acne vulgaris. Keywords: Acne, acne vulgaris, acne treatment, acne treatment alternatives, Cutibacterium acnes, fractional ablative laser, fractional photothermolysis, isotretinoin, laser, laser acne treatment, pulsed-dye laser, sebaceous glands, selective photothermolysis, skin of color

Introduction

Acne vulgaris (AV) is one of the most common diseases encountered by dermatologists. It has been estimated to affect up to 50 million people annually in the United States (US),¹ including around 85 percent of adolescents.² The pathogenesis of AV is multifactorial and involves hyperkeratinization and Cutibacterium acnes (C. acnes) colonization of pilosebaceous units, excess sebum production, and perifollicular inflammation. Topical and systemic therapies, including antibiotics, retinoids, hormonal modulators, and keratolytics are the guideline recommendations to treat AV.^3,4 These approaches, however, are potentially limited by drug interactions, intolerable adverse effects, contraindications, and poor response durability that may impair compliance or require cessation of therapy. During the past few decades, lasers have been studied as possible alternative or adjunctive treatments that are capable of circumventing many of the challenges associated with the medical management of AV.

Due to this topic’s breadth, highlights and insights from the literature will comprise the body of this review. It is not possible to make direct comparisons between studies due to differences in study design, patient demographics, devices, treatment parameters, and follow-up periods. These characteristics and statistically significant outcomes of trials in which laser was employed to treat AV as a monotherapy or as an adjunct to isotretinoin are outlined in Table 1.

Methods

A literature search to identify clinical trials, case reports, and case series was conducted in PubMed with the search terms “acne,” “fractional photothermolysis acne,” “laser acne vulgaris,” and “laser isotretinoin” between June and December 2023. Additional publications were identified by examining the references of those papers identified in this manner. The search was limited to studies written in English. Abstracts were not included. This qualitative and narrative review will summarize laser therapies used for the treatment of active inflammatory (characterized by papules, pustules, nodules, cysts) and noninflammatory (comedonal) AV.

Results

Treating acne vulgaris with conventional laser therapy. Visible light: 532-nm potassium titanyl phosphate (KTP) and 585/595-nm pulsed-dye laser (PDL). KTP (green) and PDL (yellow) are visible light lasers that are thought to affect AV through similar mechanisms. C. acnes produces protoporphyrin, uroporphyrin, and coproporphyrin III as part of its normal metabolic processes. Porphyrins absorb visible light (400–700nm) light to form singlet oxygen radicals that destroy lipids in the cell wall of C. acnes and cause nonspecific collateral thermal injury to sebaceous glands,^5,6 though this has not been shown to impact sebum production.⁵ The effects of visible light lasers on C. acnes are often short-lived, as the bacterium can reproduce in hyperactive sebaceous glands.⁷ Oxyhemoglobin is a chromophore that allows both lasers to target the microvasculature of inflammatory acne to a depth of 1 to 1.5mm. Immunohistochemical studies of the skin of patients with AV treated with PDL have demonstrated reduced proinflammatory interleukin-8 (IL-8) and elevated transforming growth factor-β (TGF-β)—the latter of which inhibits inflammation—and induces keratinocyte growth arrest to interfere with microcomedone formation, while promoting wound healing and neocollagenesis.^5,8,9 The majority of studies examining the use of visible light lasers for AV were conducted in the mid-2000s through the mid-2010s.^8,10–26

Because melanin is a chromophore at 532-nm, studies of KTP laser are limited to subjects with skin phototypes (SPT) I–III; 532-nm is not safe in more melanin-rich skin. Although two small studies did show statistically significant, modest improvements in total acne severity scores after four treatments, they both had short, four-week follow-up periods.^10,12

PDL is one of the most extensively studied lasers for treating AV.^8,13–30 A recent systematic review and meta-analysis found that when four or more treatments were administered, or when longer pulse durations were utilized, PDL could significantly decrease acne severity scores, and particularly improve noninflammatory lesion counts.³¹ Another systematic review deemed PDL to be effective against AV based on Grade B level of evidence.^32,33 There have been no direct comparisons between the efficacy of 585- versus 595-nm PDL, though the effect of varying fluences failed to yield significant differences in two studies.^24,25 Treatments were reported to be well tolerated among subjects, many of whom were SPT III–IV, with only transient erythema and edema.^{8,13–15,20,24,25,28} Although these studies enrolled few patients with SPT V–VI, all were reported to experience purpura or postinflammatory hyperpigmentation (PIH).^22,24,25

Near-infrared: 1064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG). 1064-nm Nd:YAG laser may alter the course of AV through various mechanisms related to chromophore specificity, pulse duration, and immunomodulation. When targeting water as a chromophore, long-pulse (LP; millisecond), quasi-LP (QLP; microsecond), and quality-switched (QS; nanosecond) 1064-nm is capable of thermally-injuring vasculature, pilosebaceous units, and C. acnes.^8,9,34 This effect has been enhanced by the use of exogenously applied chromophores such as topical carbon and gold-coated silica microparticles that absorb 1064-nm and amplify thermal injury to the cutaneous structures containing them.^9,35 QS-pulse widths can generate high-incident irradiance manifesting as superficial ablation that decreases stratum corneum and follicular epithelium thickness, facilitating sebaceous outflow from once-occluded pores.⁹ Finally, immunohistochemical studies have revealed 1064-nm laser to induce TGF-β, and reduce proinflammatory cytokines such as IL-8, matrix metalloproteinase-9 (MMP-9), toll-like receptor-2 (TLR-2), nuclear factor-kappa beta (NF-κB), IL-1, and tumor necrosis factor alpha (TNF-α).^5,8,9

The efficacy of 1064-nm in treating AV with LP-,^{8,23,27,36–39} QLP-,^40,41 QS-,⁴² and various combined pulse durations^9,43 has been examined. This laser has also demonstrated an ability to improve AV when used alone or in combination with PDL.^8,23,27 When used in combination, PDL facilitates conversion of oxy- to methemoglobin, which increases 1064-nm absorption into targeted vasculature by 3- to 5-fold, allowing for lower fluences and reducing the risk of cutaneous thermal damage.⁴⁴

Some studies have found that 1064-nm may demonstrate superior efficacy against inflammatory lesions,^23,27 and delay the rebound of noninflammatory lesions.⁸ It is of importance to note that the majority of studies had relatively short follow-up, ranging from 1 to 3 months following treatment cessation,^{8,9,23,27,38–42} though one study followed patients for a mean of 22.7 months.⁴³

Studies of 1064-nm are notable for their representation of diverse skin types.^{9,27,39,41–43} In fact, there are several studies that exclusively enrolled patients with SPT III–VI.^9,27,39,42 Treatments were consistently rated as tolerable, causing only minimal pain, transient erythema, and less discomfort than PDL.²⁷ There were no reports of 1064-nm Nd:YAG causing thermal injury, pigmentary abnormalities, or scarring. While the majority of studies explicitly excluded pregnant patients,^{8,9,23,29,40,42,43} there is one report of a pregnant woman with SPT IV whose severe inflammatory facial acne markedly improved after 10 weekly sessions of LP-Nd:YAG.³⁶ She experienced no adverse cutaneous effects or pregnancy complications during treatment and expressed high satisfaction with her outcome.

Mid-infrared lasers (MIRL): 1320-, 1450-, 1540-, 1550-, and 1927-nm. The absorption coefficient of water, the most abundant chromophore in the dermis and epidermis, becomes significant in the infrared range (excepting sebum absorption peaks).⁴⁵ These wavelengths are minimally absorbed by melanin, which make them relatively safe in diverse skin types, with appropriate technique and parameters. The energy delivered by MIRL cause nonselective heating of cutaneous structures, including sebaceous glands, which have demonstrated post-treatment diminution in biopsied skin.^46,47 However, consequent reduction in C. acnes has not been supported by ultraviolet (UV) follicular fluorescence examination.⁴⁸

In the early 2000s, initial clinical trials of MIRL examined their photorejuvenating capacity;^49–51 by the mid-to-late 2000s, studies were assessing their ability to treat AV.^{46,48,52–65} While the majority reported statistically significant improvements in lesion counts and/or grading severity indices,^{47,48,52–58,60,61,63,66–68} around half as many studies either did not find that MIRL improved AV compared to control,⁵⁹ did not find that improvement was significant,⁶² or simply did not analyze data for statistical significance.^{46,64,65,69,70} Assessments of the durability of these improvements were limited in many studies by short follow-up periods of 1 to 3 months.^{52–54,56–58,60,63,66,68} Some studies allowed their subjects to continue a wide variety of topical and systemic acne medications of unspecified dosing schedule and prior duration during the trial period and did not separate them in the data analysis from patients being treated with MIRL as a monotherapy.^{57,58,60,61,63} Finally, the present-day clinical applicability of these studies must be considered, given that MIRL most frequently studied—1320-nm Nd:YAG (CoolTouch II™, New Star Lasers; Concord, North Carolina),⁵³ 1450-nm diode (SmoothBeam™, Candela Medical; Marlborough, Massachusetts),^{48,54,56–63} 1540-nm erbium-glass (Aramis™, Quantel Medical; Cournon-d’Auvergne, France)^46,64—have largely been supplanted by newer fractional technologies^47,52,68,69 and are no longer being manufactured.

Treatments were generally accompanied by transient mild to moderate pain, erythema, and edema, as only one study reported moderate to extreme pain experienced by 100 percent of patients.⁵³ There were no instances of permanent pigmentary complications or scarring among SPT V–VI^{47,48,53,59,61,66,70} though cryogen or thermally-induced PIH was occasionally observed among East Asian patients in three studies.^48,66,68

New and emerging laser-based approaches to treating acne vulgaris

A novel 1726-nm laser that targets sebaceous glands. In 2022, the United States Food and Drug Administration granted 501(k) clearance to two novel 1726-nm lasers for the treatment of mild to severe inflammatory AV in individuals aged 16 and older. In March, a contact-cooled 100W-diode laser (AviClear™, Cutera; Brisbane, California)⁷¹ was approved, followed by an air-cooled 70W-diode laser in November (Accure™, Quanta, Milan, Italy).⁷²

A decade before the advent of these devices, Sakamoto et al⁷³ utilized a superconducting free-electron laser to reveal that sebum has absorption peaks near 1210-, 1728-, 1760-, 2306-, and 2346-nm. Sakamoto et al⁴⁵ further demonstrated that optical pulses with wavelengths between 1700- to 1720-nm could destroy sebaceous glands in ex vivo human facial skin, with minimal damage to surrounding tissues.⁴⁵ Selective sebaceous gland photothermolysis occurs as a consequence of sebum’s higher absorption coefficient (1.8:1) than water at 1726-nm.⁷⁴ Histologic studies of skin five days post-treatment with 1726-nm have demonstrated miniaturization of sebaceous glands and pilosebaceous follicles, with irreversible necrosis of up to 84.3 percent of sebocytes, surrounded by intact dermis and epidermis.⁷⁵

A prospective, open-label, single arm study of 104 subjects, ages 16 to 60 (67% Caucasian, 20% Asian, and 13% SPT IV–V) with moderate to severe AV who underwent three treatments with a 1726-nm laser (AviClear™) was recently published.⁷⁶ Of the 89 patients who completed three treatments, 32.6 percent were “responders” (≥50% reduction in active inflammatory lesions) at four weeks, 79.8 percent at 12 weeks, and 87.3 percent at 26 weeks. A smaller study of 14 subjects (SPT II–IV) who completed 1 to 3 treatments showed significant improvements in Investigator Global Assessment scores at four and 12 weeks following treatment.⁷⁷ Transient edema and mild erythema were common, treatment-related discomfort was tolerable, and device-related acneiform eruptions that resolved without blistering, scarring, or hyperpigmentation were also observed.^76,77

Fractional ablative CO₂ (FACL). A number of different mechanisms have been proposed to account for the ability of FACL to improve AV. Ablative channels in the epidermis and dermis may reduce occlusion of pilosebaceous units, and facilitate transepidermal elimination of sebaceous debris.⁷⁸ Associated coagulation zones may reduce inflammation, hypervascularity, and damage pilosebaceous units, decreasing sebum production and C. acnes colonization.^45,79 Immunohistochemical studies of skin treated with FACL have demonstrated anti-acnegenic changes in Forkhead box protein O1 (FOXO1) and peroxisome proliferator activated receptor gamma (PPAR-γ) nuclear-to-cytoplasmic ratios.⁸⁰ Finally, expression of anti-inflammatory heat shock proteins and TGF-β increase following FACL.^78,81

In 2009, Cho et al⁸² reported improvement following FACL in seven Korean patients with recalcitrant AV who had failed treatment with systemic and topical retinoids and antibiotics. Since this initial report, there have been additional case series and trials that have documented the efficacy and safety of FACL in treating AV.^80,83–86 FACL has been shown to significantly decrease both inflammatory and noninflammatory lesion counts,^80,83,85,86 in addition to improving the appearance of acne scarring.^83,85 Pain during treatment as well as transient post-treatment erythema, edema, and crusting were among the most commonly noted side effects, with no treatment-related scarring reported.^80,82–86 Notably, despite the majority of subjects having SPT III–IV and hailing from East Asia and the Middle East, prolonged hyperpigmentation was not reported.^{80,82,83,85,86}

Lasers with systemic isotretinoin. In the mid-1980s, three case series described keloid formation and delayed healing in a total of 11 patients treated with isotretinoin, following either mechanical dermabrasion or argon laser treatment.^87–89 These reports engendered the recommendation to delay cutaneous laser treatments during isotretinoin therapy, and for 6 to 12 months following cessation.³ There has consequently been a long-standing hesitancy among many physicians to combine the use of lasers with systemic isotretinoin to treat AV. However, studies examining their concurrent use have reported rapid lesion clearance, and enhanced clinical outcomes, without abnormal scarring or healing complications.^{29,30,90–95} Recent reviews and expert consensus statements align with the findings of these studies, asserting that there is insufficient evidence to delay most laser procedures for patients currently or recently taking isotretinoin.^96–98

Many studies published within the last three years have examined the concomitant use of isotretinoin and lasers, including 585/595-nm,^29,30 1064-nm,^30,91 1550-nm,^94,95 1565-nm,⁹⁰ and fractional CO₂,^92,93 to treat moderate to severe inflammatory AV. In addition to efficacy and rapidity of lesion clearance with combined therapy, studies have reported improvement in pre-existing acne scars.^90–93 Lower daily isotretinoin doses (0.2–0.3mg/kg/day or 10–20mg daily)^{29,91,94,95,99} as well as lower cumulative doses^29,99 were facilitated by the addition of laser. It follows that a lower incidence of adverse effects, namely severe xerosis and AV flaring, were observed in patients treated with low-dose isotretinoin and laser.^29,99 Frequency and duration of laser treatments varied widely among studies, making direct comparisons or generalizations among protocols difficult. Overall, studies on the use of lasers with isotretinoin reported that treatments were well tolerated, with transient erythema and edema, and no serious adverse effects.^{29,91,92,94,95,99} There was one report of keloid scar formation in a retrospective study of 187 patients treated with combined 585/1064-nm laser who received an average daily dose of 40mg of isotretinoin.³⁰

Discussion

Prior reviews of lasers as therapeutics for AV have decried various difficulties in drawing meaningful conclusions from studies that are widely heterogeneous in methodology, characteristics, outcome measures, and data reporting.^100–104 A common critique is that these studies tend to lack a control group, and yet patients must serve as their own controls when a laser treatment is being trialed in the context of a split-face study, which many are. This creates the additional problem of blinding participants to their intervention to protect the integrity of self-assessments, which is only possible with a convincing sham laser treatment, a contradictory expectation in terms of both language and reality. Regarding assessments, there are currently more than two dozen different methods in the literature that are used to assess acne severity with very little consensus on which should be consistently utilized.¹⁰⁵ While repeated calls for higher quality studies should not be ceased in the face of these obstacles, an acknowledgement of why it might be difficult to answer them is not unreasonable.

Beyond designing methodologically rigorous studies to vet potential treatments with, we have additional responsibilities to our specialty, and to our patients, to act in ways that minimize harm and maximize benefit. Barbieri et al¹⁰⁶ and multiple acne guidelines, have urged physicians to limit the use of antibiotics, which remain the most frequently prescribed systemic therapy for acne,^3,4 often for longer durations than recommended.^107,108 Poor antibiotic stewardship can contribute to microbiome disruption, and to bacterial resistance, which we are currently observing among isolates of C. acnes to tetracyclines.¹⁰⁹ On a more urgent and personal level, early, effective treatment to induce rapid and complete AV remission is needed to avoid the physical, psychosocial, and emotional sequelae caused by scarring, which does not always correlate with the severity and chronicity of lesions. Incorporating lasers into acne treatment regimens can help address both of these concerns.

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