Lasers in 2026: what's worth it, what to skip.

Laser, as a category, has become a catch-all for any aesthetic-clinic procedure that emits light. This is a problem. The differences between an Nd:YAG, a picosecond alexandrite, and a fractional CO₂ are not small differences — they are different machines, for different patients, with different outcomes and different risks. Mis-match the wavelength to the target and you do not get a milder version of the right treatment. You get a burn, a paradoxical darkening, a scar, or, most commonly, nothing at all.

The proliferation of branded platforms has not helped. Clear + Brilliant, Halo, Moxi, BBL HEROic, PicoWay, PicoSure, Fraxel, Lutronic, Cutera — every name on a clinic menu is a wrapper around one or two underlying physical mechanisms, dressed in marketing. The job, for a patient, is to look past the wrapper. The job, for anyone writing about these devices honestly, is to put the underlying physics back on the table.

What "laser" actually means

A medical laser is a coherent, monochromatic beam of light tuned to a specific wavelength. That wavelength is chosen because it is preferentially absorbed by one of three substances in human tissue: water, pigment (melanin and tattoo ink), or hemoglobin. Those are the three chromophores that matter in aesthetic medicine. Everything else is engineering around them.

The principle is called selective photothermolysis, and it was articulated in a 1983 paper by R. Rox Anderson and John Parrish at Massachusetts General Hospital that is still the most-cited document in cutaneous laser surgery. The idea: choose a wavelength absorbed by your target, a pulse duration shorter than the target's thermal relaxation time, and a fluence high enough to destroy the target without cooking what surrounds it. Hit those three parameters and you get a clean clinical result. Miss any of them and you do not.

Three chromophores. Three families of devices. Everything else — fractional patterns, picosecond pulses, hybrid passes, cooling tips, RF assist — is refinement on top of that scaffolding.

Water (resurfacing)

Water is the most abundant chromophore in skin, which means lasers tuned to water-absorption peaks are the ones that vaporize or coagulate tissue itself. The two clinical workhorses:

• CO₂ at 10,600 nm — the deepest-penetrating ablative wavelength in routine use. Highly absorbed by water; substantial residual thermal effect, which is what tightens tissue around the wound.
• Er:YAG at 2,940 nm — sits much closer to the actual water-absorption peak, so it ablates more efficiently with less residual heat. Cleaner cut, faster healing, less collagen contraction.

The CO₂ vs Er:YAG choice is a tradeoff that has not changed in twenty years. CO₂ gives you tightening and remodeling at the cost of longer downtime and more risk of hypopigmentation. Er:YAG gives you a faster, cleaner peel with less collagen rebuild.

Pigment (Q-switched and picosecond)

Melanin and tattoo ink absorb across a broad range of visible and near-infrared light, which is why pigment lasers come in several flavors:

• Q-switched Nd:YAG at 1064 nm — deeper penetration, safer in darker skin, excellent for dermal pigment (nevus of Ota, blue-black tattoo ink, deep melasma fragments).
• Q-switched Nd:YAG frequency-doubled to 532 nm — strong melanin absorption, used for solar lentigines and red/orange tattoo ink.
• Q-switched alexandrite at 755 nm — workhorse for green tattoo ink and epidermal pigment in lighter skin.
• Q-switched ruby at 694 nm — excellent melanin specificity, near-extinct in US clinics because of platform support.
• Picosecond platforms (PicoWay, PicoSure, Discovery Pico, enLighten) — same wavelengths in many cases, but pulse durations a thousand times shorter.

The shift from nanosecond Q-switched lasers to picosecond pulses is the most consequential change in pigment treatment of the last fifteen years. A shorter pulse means more of the energy is delivered as a photoacoustic shockwave and less as bulk heat. That shockwave shatters pigment into smaller fragments without depositing as much collateral thermal energy in surrounding tissue. In practice: faster tattoo clearance, fewer treatments, and — critically — a tool that can be used more safely in patients prone to post-inflammatory hyperpigmentation.

Hemoglobin (vascular)

Hemoglobin has absorption peaks in the yellow-green and a smaller shoulder in the near-infrared. The three vascular workhorses:

• Pulsed dye laser (PDL) at 595 nm — the gold standard for port-wine stains, rosacea, telangiectasias, and reactive erythema. Decades of evidence and the device of record for vascular birthmarks in pediatric dermatology.
• KTP at 532 nm — excellent for superficial facial vessels and diffuse redness; less downtime than PDL because purpura is more avoidable.
• Nd:YAG at 1064 nm — deeper penetration, the only laser most clinicians will use on leg veins, reticular vessels, and — importantly — vascular work in Fitzpatrick IV–VI skin.

Resurfacing: fractional, non-ablative, hybrid

The dominant resurfacing modality of the last decade has been fractional ablative laser — a CO₂ or erbium platform that creates microcolumns of thermal injury surrounded by untouched tissue. The untouched tissue does the heavy lifting of healing. That is why fractional treatments produce most of the benefits of fully ablative resurfacing with a fraction of the downtime, and why Anderson and Manstein's 2004 paper introducing fractional photothermolysis is the second-most-cited document in this field after the 1983 chromophore paper.

Inside fractional, there are three sub-categories that get muddled in clinic marketing:

Fractional ablative. The skin is vaporized in patterned micro-columns. Real downtime — seven to ten days of oozing, crusting, and pink. Real results: deep rhytides, acne scars, actinic damage, photoaged skin all respond. The Lumenis UltraPulse and the Sciton ProFractional are the platforms most clinicians cite. This is the heaviest single treatment available short of fully ablative resurfacing.

Non-ablative fractional. The skin's surface is preserved; thermal columns are placed in the dermis only. Less downtime, less impressive on a per-session basis, more sessions needed. Fraxel Dual (1550/1927 nm) is the canonical example. Moxi (1927 nm thulium) is its successor and the device that has, more than any other, displaced "lunchtime peels" in the higher end of the market.

Hybrid resurfacing. A single pass combining ablative and non-ablative wavelengths. The Sciton Halo (2940 nm + 1470 nm) is the platform. The clinical case for hybrid is real for the right skin: combined energies produce more uniform improvement in texture, tone, and pigment in a session than either component alone. The clinical case against it is that in inexperienced hands, combined energies combine risks.

A note on the branded wrapper. Halo is a hybrid laser; Moxi is a fractional non-ablative thulium; Clear + Brilliant is the entry-tier fractional non-ablative from Solta; Fraxel is its mid-tier sibling; BBL HEROic is a broadband light system, not a laser at all. When a clinic markets "Halo and Moxi together" they mean exactly what it sounds like — two devices, two passes, two recovery profiles. None of these are magic. They are well-engineered platforms, each tuned to a specific clinical job, that work when the operator matches them to the right patient.

Pigment: pico versus Q-switched, and why it matters

For two decades, Q-switched nanosecond lasers were the standard for tattoo removal and recalcitrant pigment. They worked. They worked slowly, they worked with a meaningful rate of post-inflammatory hyperpigmentation in darker skin, and they worked best on dark blue and black ink — leaving greens, light blues, and yellows as a multi-year problem.

Picosecond lasers, introduced commercially in 2012 (PicoSure) and widened by Candela's PicoWay and Cutera's enLighten in the years after, did three things at once. They cleared multicolor tattoos in fewer sessions. They expanded what we could safely treat in Fitzpatrick III–V skin by reducing collateral thermal damage. And they opened the door to fractional pigment treatments — using a diffractive lens to convert a picosecond beam into a pattern of high-fluence microspots — that work on melasma, acne scars, and pore size with less downtime than fractional resurfacing.

The FDA has cleared picosecond platforms for tattoo removal, benign pigmented lesions, acne scars, and wrinkles; specific clearances by wavelength and indication are searchable in the agency's 510(k) database. The clinical evidence is strongest for tattoos and lentigines and noticeably weaker for melasma, where even picosecond treatment is still adjunctive to topical and oral therapy in most expert hands.

Vascular: PDL, KTP, Nd:YAG

For redness — rosacea, telangiectasias, post-laser erythema, port-wine birthmarks — the pulsed dye laser at 595 nm remains the gold standard. Decades of literature, including the multi-center pediatric PWS work that shaped the modality, support it. The trade-off is purpura, the bruising that classical PDL produces for a week. Newer pulse-stacking protocols and longer pulse durations can avoid the purpura; some patients prefer that, some clinicians believe the purpuric setting produces better long-term clearance, and the debate is unresolved.

KTP at 532 nm targets superficial facial vessels and matted telangiectasia with less risk of purpura. It does not penetrate deeply enough for leg veins or reticular vessels.

Nd:YAG at 1064 nm is the indispensable vascular laser for two populations: patients with leg vessels (because of penetration depth), and patients with Fitzpatrick IV–VI skin (because the long wavelength is poorly absorbed by epidermal melanin, which means the laser can reach the target vessel without burning the skin above it). For darker skin tones, the 1064 nm Nd:YAG is the only vascular wavelength most board-certified dermatologists will use without serious caution.

Skin of color: a separate conversation

Aesthetic-laser literature has historically been written for Fitzpatrick I–III skin. That is changing — slowly. The clinically relevant facts for Fitzpatrick IV–VI patients:

• Nd:YAG 1064 nm is the safest workhorse. Long wavelength, poor melanin absorption, deep penetration. Used for hair removal, vascular work, pigment, and skin tightening in darker skin.
• Alexandrite 755 nm is risky. Strong melanin absorption means the surrounding skin competes with the target chromophore. Hair removal on darker skin with alexandrite is a well-documented cause of burns and post-inflammatory dyspigmentation.
• IPL is risky and frequently misused. Broadband light, no real wavelength control, and a tendency in inexperienced hands to produce hypo- and hyperpigmentation in darker skin.
• Fractional CO₂ requires real caution. Possible in Fitzpatrick IV–V with conservative settings, prophylactic topical regimens, and an experienced operator. In VI, most experts will reach for non-ablative fractional or RF microneedling instead.

The American Academy of Dermatology and the American Society for Dermatologic Surgery have both published guidance frameworks for cosmetic procedures in skin of color; they are worth reading before any device is chosen.

Devices that disappoint

A working field guide has to be honest about what does not work, or works less than its marketing suggests.

IPL is not a laser. It is broadband intense pulsed light, a flashlamp filtered to a range of wavelengths rather than a single coherent wavelength. IPL does useful work — diffuse facial redness, solar lentigines, the early stages of photoaging — in the right skin. It is also the most over-promised modality in the cosmetic clinic and the one most often sold as "laser" to patients who do not know the difference. The branding "BBL" (Sciton) and "Lumecca" (InMode) is IPL with refinements; useful, not laser.

At-home "laser" devices are almost all LED arrays or low-power diode systems that do not approach the fluences required for clinical photothermolysis. Some have modest evidence for very specific indications — low-level light therapy for androgenetic alopecia, for instance, has supportive RCTs. Most are cosmetic skincare in the shape of a gadget.

"Laser facials" sold as walk-in services at medspas — particularly when the device is unbranded or rotates weekly — are usually a low-fluence IPL or a hand-held diode used at a setting that produces no meaningful thermal injury and therefore no meaningful remodeling. They are safe. They are also, in most cases, an expensive placebo.

Hair-removal claims on grey or red hair are physically impossible with conventional lasers because the target chromophore (melanin) is absent. No device has cleared the FDA for blonde, red, or grey hair removal. Clinics that promise it are selling something else.

The no-treat list

A provider who books anyone, on any day, for any device, is the wrong provider. The following categories belong on the no-treat or defer-treatment list for most ablative and many non-ablative procedures:

Isotretinoin patients. The traditional teaching held that patients had to be off isotretinoin for six months before laser resurfacing or even superficial chemical peels, for fear of scarring. That rule originated from a small number of case reports in the late 1980s and has been substantially revised. A 2017 consensus statement from a panel including members of the American Society for Dermatologic Surgery concluded that there is insufficient evidence to delay non-ablative fractional resurfacing, superficial chemical peels, and laser hair removal in patients on or recently off isotretinoin. The panel maintained caution for fully ablative resurfacing. The American Academy of Dermatology has integrated this revised guidance into its discussion of isotretinoin care. A responsible clinic will know the difference between the 1980s teaching and the current consensus.

Active herpes simplex. Any resurfacing procedure can trigger a herpetic outbreak that, if untreated, can scar. Prophylactic antiviral therapy is standard before fractional ablative work.

Melasma. This is the unfair condition. Melasma frequently worsens with aggressive lasers — the same energy that breaks up pigment can also drive a rebound flare a few weeks later. The condition is best managed with topical regimens (hydroquinone, tranexamic acid, retinoids), strict photoprotection, and only the most cautious laser involvement (low-fluence Nd:YAG, picosecond toning, occasional non-ablative fractional in the right hands). Patients who walk into a clinic asking for "the laser that will fix this" are often best served by a provider who declines.

Recent sun exposure. Tanned skin is competing pigment. Treating it raises the risk of dyspigmentation and burns. Most reputable clinics defer four to six weeks.

Unrealistic expectations. This is a clinical category. The patient who expects a single session to reverse twenty years of photoaging, or who wants a laser to do the work of a facelift, is a patient who will be unhappy regardless of outcome. Good providers screen for this. Bad providers book the treatment anyway.

Cheat sheet: energy-based devices, by what they actually do

Costs vary widely by market, by clinic, by package pricing, and by what is bundled with a single visit. The point of the table is not to set a number; it is to put downtime and indication next to each other so that a patient walks in informed about which questions to ask.

The provider question

The single greatest predictor of a laser outcome is not the device. It is the person at the foot pedal.

This is a sentence dermatologists say at conferences and patients almost never hear. It is the only sentence in this article that genuinely matters. A board-certified dermatologist or plastic surgeon with five years of fractional CO₂ experience will produce, on average, a better result on a mid-tier platform than a nurse-injector on the newest device in the country. The opposite is rarely true. The injuries that bring patients into corrective clinics — hypopigmentation, scarring, paradoxical darkening, persistent erythema — overwhelmingly come from operator error, not device failure.

What to look for, when you are choosing the person rather than the platform:

• Board certification. In the United States, that means certification by the American Board of Dermatology, the American Board of Plastic Surgery, or, for some scopes, the American Board of Facial Plastic and Reconstructive Surgery. Verify directly with the certifying board, not just with the clinic's website.
• Procedure-specific volume. Ask how many fractional CO₂ cases the provider personally performs per month. Not the clinic. The provider.
• Photographs. Ask to see before-and-after photographs of the specific device on a patient with your Fitzpatrick type and your concern. Generic gallery shots of someone else's skin tell you nothing.
• Who is at the foot pedal. In some clinics, a board-certified physician owns the practice but a non-physician operates the laser. That is a different transaction. It can still be a good one — many experienced laser nurses are excellent — but you are entitled to know who is doing the work before the device fires.
• Willingness to decline. A provider who tells you that a device is not the right answer for your concern is a provider worth keeping. The clinics that say yes to everything are the clinics whose patients show up in someone else's office a year later.

The right device, in the right hands, for the right patient, is one of the most powerful tools in modern dermatology. The wrong device — or the right device in the wrong hands — is a permanent injury waiting to happen. Both sentences are true. The job of the next decade in this field, more than any new wavelength or any new platform, is to make the first sentence the default and the second one rare.

Sources

• Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science. 1983. https://pubmed.ncbi.nlm.nih.gov/6836297/
• Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers in Surgery and Medicine. 2004. https://pubmed.ncbi.nlm.nih.gov/15334610/
• U.S. Food and Drug Administration. 510(k) Premarket Notification database — search by product code GEX (laser, surgical) and OHS (laser, dermatologic). https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm
• U.S. Food and Drug Administration. Laser Products and Instruments — performance standards and consumer guidance. https://www.fda.gov/radiation-emitting-products/home-business-and-entertainment-products/laser-products-and-instruments
• American Academy of Dermatology. Lasers, lights, and energy-based devices — patient and clinician resources. https://www.aad.org/public/cosmetic/lasers-lights
• American Academy of Dermatology. Isotretinoin: clinician and patient information. https://www.aad.org/public/diseases/acne/derm-treat/isotretinoin
• Waldman A, Bolotin D, Arndt KA, et al. ASDS Guidelines Task Force: consensus recommendations regarding the safety of lasers, dermabrasion, chemical peels, energy devices, and skin surgery during and after isotretinoin use. Dermatologic Surgery. 2017. https://pubmed.ncbi.nlm.nih.gov/28858159/
• American Society for Dermatologic Surgery. Laser skin resurfacing — patient information and provider directory. https://www.asds.net/skin-experts/skin-treatments/lasers-lights-and-energy-based-treatments
• American Society of Plastic Surgeons. Laser skin resurfacing — procedure overview. https://www.plasticsurgery.org/cosmetic-procedures/laser-skin-resurfacing
• Alexis AF, Coley MK, Nijhawan RI, et al. Nonablative fractional laser resurfacing in skin of color: a review. Journal of Drugs in Dermatology. 2021. https://pubmed.ncbi.nlm.nih.gov/33538561/
• Wat H, Wu DC, Chan HHL. Picosecond lasers for the treatment of dermatologic disorders. Lasers in Surgery and Medicine. 2020. https://pubmed.ncbi.nlm.nih.gov/31441080/
• Tanzi EL, Lupton JR, Alster TS. Lasers in dermatology: four decades of progress. Journal of the American Academy of Dermatology. 2003 (foundational review, still cited). https://pubmed.ncbi.nlm.nih.gov/12894066/