Lasers in Medical Science

https://doi.org/10.1007/s10103-019-02891-5

ORIGINAL ARTICLE

Comparison of fractional neodymium-doped yttrium aluminum

garnet (Nd:YAG) 1064-nm picosecond laser and fractional 1550-nm
erbium fiber laser in facial acne scar treatment
Pamela Chayavichitsilp 1 & Preeyachat Limtong 1 & Korn Triyangkulsri 1 & Nathathai Pratumchart 1

Received: 19 June 2019 / Accepted: 24 September 2019

# Springer-Verlag London Ltd., part of Springer Nature 2019

Abstract
To compare the safety and efficacy of fractional neodymium-doped yttrium aluminum garnet (Nd:YAG) 1064-nm picosecond
laser and fractional 1550-nm erbium fiber laser in acne scar treatment and to assess the adverse effects and complications of the
two devices. Thirty patients with cosmetically similar acne scars on both sides of the faces were enrolled and treated four times at
4-week intervals. Each side of the face was treated with either fractional 1064-nm Nd:YAG picosecond laser or fractional 1550-
nm erbium fiber laser. Efficacy was evaluated using digital photography taken at baseline and 5 months by a blinded dermatol-
ogist using the ECCA grading scale (échelle d’évaluation clinique des cicatrices d’acné). Patient overall satisfaction and self-
rated improvement scores were recorded at baseline and 5 months. Adverse effects were recorded at every visit. Twenty-seven
patients completed the study. Both devices demonstrated significant median ECCA score improvement from baseline
(P < 0.001). However, there was no significant difference between the two in terms of median ECCA score improvement,
patients’ perception of scar improvement, and overall satisfaction. Considering the adverse effects, more pinpoint bleeding
was significantly observed with the picosecond laser (P = 0.002), whereas more pain was noted with the erbium laser
(P < 0.001). Both fractional 1064-nm Nd:YAG picosecond laser and fractional 1550-nm erbium fiber laser are safe and effective
in the treatment of acne scars. Costs should be taken into consideration when deciding on which device to use to maximize
treatment outcomes.

Keywords Acne scar . Acne scar treatment . Erbium fiber laser . Fractional laser . Picosecond laser

Introduction
Acne and its common complication, acne scarring, are known
to affect people both physically and emotionally worldwide
regardless of sex, age, and ethnicity [1]. Although the best
management of acne scarring is to prevent the occurrence
through proper control of acne, many cases of acne remain
untreated or treated sub-optimally. Consequently, these pa-
tients later develop atrophic scars that are disfiguring and
can cause emotional distress. In the adult population, acne
scars are found in approximately 11–14% and can be
* Pamela Chayavichitsilp
pamela.chaya@gmail.com
1
Division of Dermatology, Faculty of Medicine, Ramathibodi
Hospital, Mahidol University, 270 Rama VI Road Ratchathewi,
Bangkok 10400, Thailand
classified into three types: icepick scars, boxcar scars, and
rolling scars [2].
Treatment of acne scars includes multiple modalities such
as chemical peeling, dermabrasion, needling, subcision, and,
in severe cases, punch excisions. In addition, lasers and other
energy-based devices are commonly used to treat atrophic
scars. Recently, the use of fractional resurfacing has gained
an increasingly important role due to their efficacy in compar-
ison with the formerly developed non-ablative lasers as well
as considerably less side effects and lower downtime relative
to ablative lasers [3].
Picosecond lasers differ from the traditional nanosecond
lasers in that it delivers ultra-short pulse durations which al-
lows for more photoacoustic effect and less non-specific
photothermal damage [4, 5]. It was initially approved by the
Food and Drug Administration in the treatment of unwanted
tattoos and is now commonly used on pigmented lesions. In
recent years, new studies have shown that the fractional pico-
second laser can be highly effective in the treatment of acne

scars with minimal side effects [6, 7]. However, these
studies were prospective in nature. To the best of our
knowledge, randomized controlled studies comparing
fractional picosecond lasers to fractional nanosecond la-
sers in the treatment of acne scars are still lacking in
the literature.
Our study aims to compare the safety and efficacy of frac-
tional neodymium-doped yttrium aluminum garnet (Nd:YAG)
1064-nm picosecond laser and fractional 1550-nm erbium fi-
ber laser in the treatment of acne scarring in Fitzpatrick’s skin
types III and IV and to assess the adverse effects and compli-
cations of the two devices.
Methods and materials
Study design and setting
Our study was a randomized, single-blinded, intrapatient, left-
to-right comparative study conducted at the outpatient derma-
tology clinic at Ramathibodi Hospital Medical School in
Bangkok, Thailand, during the period of February to
October 2018.
Participants
Thirty subjects (16 males and 14 females) were recruited for
this study. Inclusion criteria are as follows: (1) age ≥ 18 years,
(2) presence of cosmetically similar atrophic acne scars on
both sides of the face, (3) no severe underlying diseases, and
(4) willingness to follow up and comply with the study
protocol. Exclusion criteria include a history or suspi-
cion of active infection at the sites of treatment, uncon-
trolled acne vulgaris, presence of hypertrophic scarring,
immunocompromised status, history of skin cancer, re-
current herpes viral infection, oral intake of vitamin A
derivatives in the past 3 months, photosensitizing drug
use such as diuretics and antibiotics including doxycy-
cline or tetracycline, history of chemical peeling 1 month
prior to the study, facial laser treatment in the past
3 months, photosensitivity, pregnancy or breastfeeding
status, and patients who withdrew from the study.
Eligible patients were included and randomized to treat-
ment based on algorithms shown in Fig. 1.
Randomization
Informed consent was obtained from all participants. Each
participant was then randomized to receive a split-face treat-
ment with fractional Nd:YAG 1064-nm picosecond laser on
one side and fractional 1550-nm erbium fiber laser on the
other side. The decision of the specific laser treatment was
determined by block randomization.
Lasers Med Sci
Treatment protocol
A topical anesthetic cream containing lidocaine 2.5% and
prilocaine 2.5% was applied on both sides of the face under
occlusion for 30 minutes prior to the laser treatment. Each side
of the face was treated with standardized parameters in all
participants as follows: the fractional Nd:YAG 1064-nm pico-
second laser with fractional lens array (DiscoveryPICO®;
QuantaSystem, S.p.A., Samarate (VA), Italy) with spot size
of 8 mm, fluence of 0.3–0.4 J, and frequency of 10 Hz was
applied for one pass, while the fractional 1550-nm erbium
fiber laser (Finescan®; TNC Medditron Co., Ltd., Bangkok,
Thailand) with a density of 100–400 spots/cm2 and energy
density of 25–30 J/cm2 was applied for two passes. The opti-
mal clinical endpoint was moderate erythema and/or accept-
able pinpoint bleeding. During the laser treatment, a cooling
device was used. Patients were scheduled to be treated four
times at 4-week intervals and followed up at 4 and 8 weeks
post-procedure.
After the treatment, patients were advised to frequently
apply petrolatum ointment on the treated areas, avoid sun
exposure or outdoor activities, and routinely use a broad-
spectrum sunscreen on the entire face.
Data collection and outcome measurements
Data regarding age, sex, underlying diseases, current medica-
tions, Fitzpatrick’s skin types, duration of acne scarring, and
history of previous treatment were recorded in the case record
form.
Efficacy was assessed by a blinded dermatologist using
digital photography (Visia CR®; Canfield Imaging Systems,
Fairfield, NJ, USA) taken at baseline and 5 months. The
ECCA grading scale (échelle d’évaluation clinique des cica-
trices d’acné) as shown in Fig. 2 was used for the assessment
[8]. Patients’ overall satisfaction and self-rated improvement
scores were recorded at baseline and 5 months. In addition,
pore counts were obtained at baseline and 5 months using the
same digital photography software (Visia CR®; Canfield
Imaging Systems, Fairfield, NJ, USA).
Regarding safety outcomes, immediately after each treat-
ment session, pain scores were evaluated using a visual analog
scale (0–10), and adverse effects including erythema,
hypopigmentation, hyperpigmentation, and pinpoint bleeding
were recorded.
Statistical analysis
All data analyses were performed using Stata Version 14.0
(StataCorp, TX, USA), and a p value of less than 0.05 was
considered to be statistically significant. Categorical variables
were expressed as a percentage, while continuous variables
were expressed in mean ± SD for data with normal distribution
Lasers Med Sci

Fig. 1 Flow diagram showing 30 participants (60 treatment sites)

patients participating in the study

Intra-individual randomization

2-dimensional imaging assessment

30 treatment sites 30 treatment sites

Fractional Nd:YAG 1,064-nm Fractional 1,550-nm
picosecond laser erbium fiber laser
(on visit 1 - 4) (on visit 1 - 4)

Evaluation
- Side effects (visit 1 - 4)
- 2-dimensional imaging assessment (visit 1 - 6)
- results and satisfaction by participant (visit 6)
- results by a blinded dermatologist (visit 6)

2 participants lost to follow-up

1 participant excluded due to PIH

27 participants (54 sites)

Statistical analysis

Nd:YAG: Neodymium-doped Yttrium Aluminium Garnet; PIH: post-inflammatory hyperpigmentation

and median (range) for data with non-normal distribution. Paired t test and Wilcoxon sign-rank test were used for the
McNemar’s test was utilized for the evaluation of differences evaluation of differences in paired continuous data with normal
between categorical variables of the two dependent groups. and non-normal distributions, respectively.

Fig. 2 The ECCA grading scale

(échelle d’évaluation clinique des
cicatrices d’acné)

Results
Out of 30 participants, 27 participants completed the study
with 2 participants lost to follow-up and 1 dropped out after
3 sessions of treatment due to post-inflammatory hyperpig-
mentation. The mean age of participants was 30.4 ± 6.8 years.
Sixteen participants were male and 14 were female. Ninety
percent of participants had Fitzpatrick’s skin type III, the other
10% had skin type IV. The median duration of acne scarring
was 10 years (range of 3–37 years). Ninety-six percent of
participants had a mixture of icepick and boxcar scars.
One participant had icepick scars only. Nineteen percent
of all participants had a combination of all three types
of scars.
In terms of efficacy assessed by the physician, both devices
significantly reduced the median ECCA scores at 5 months
compared to baseline (P < 0.001). The median ECCA score
improvement on the picosecond laser side and the erbium
fiber laser side was 38.89% and 33.33%, respectively.
However, there was no statistically significant difference in
the percentage of median ECCA score improvement between
the two lasers (P = 0.317). Similarly, the efficacy assessed by
the patients showed no statistically significant difference be-
tween the two devices in terms of patient’s self-rated improve-
ment of scars (P = 0.417) and overall satisfaction (P = 0.232)
as shown in Fig. 3. Interestingly, our study also revealed that
both devices showed a notable decrement of pore counts from
baseline (7.5% improvement in the picosecond laser and
15.4% in the erbium fiber laser, P < 0.05) with a significantly
higher pore count improvement on the erbium fiber laser side
(P = 0.0163) (Fig. 4).
Fig. 3 Clinical efficacies of both
lasers shown as a median ECCA
scores and median ECCA score
improvement and b patient’s self-
rated improvement and overall
satisfaction percentage (ECCA,
échelle d’évaluation clinique des
cicatrices d’acné)
Lasers Med Sci
Considering the side effects, there were no differences
concerning erythema and hyperpigmentation between the two
lasers with P values of 0.5096 and 1.0000, respectively. No
hypopigmentation was observed. Nevertheless, significantly
more pinpoint bleeding was found on the picosecond laser side
(P = 0.0020) while pain scores were noted to be higher on the
erbium fiber laser side (P < 0.001) as shown in Table 1.
Discussion
To the best of our knowledge, our study is the first random-
ized, intrapatient study comparing between fractional 1064-
nm picosecond Nd-YAG laser and fractional 1550-nm erbium
fiber laser in the treatment of facial atrophic acne scars in the
Asian population. Both lasers showed statistically significant
improvement of acne scars using both dermatologist assess-
ment with the ECCA scoring system as well as patient’s self-
rated improvement and satisfaction scores. The differences in
the degree of improvement, however, were not statistically
significant between the two arms. Side effects were acceptable
in both arms which included pinpoint bleeding, pain, and post-
inflammatory hyperpigmentation which was in part due to
non-compliance with sun protection post-procedure.
Upon review of the literature, two prior studies were per-
formed on picosecond lasers in the treatment of acne scars,
both of which were prospective trials with picosecond lasers
as the only treatment modality. Brauer et al. performed 6 treat-
ments in 20 subjects using a 755-nm alexandrite picosecond
laser with diffractive lens array and demonstrated that the scar
volume decreased by 24.3% compared to baseline. This effect
Lasers Med Sci
Fig. 4 Before and after photographs of acne scars treated with a picosecond laser and b erbium fiber laser
was maintained at 1 and 3-month follow-ups. Histologic ex-
amination of biopsy specimens from 2 of the subjects from the
study showed elongation and an increase in density of elastic
fibers, collagen type III, and mucin deposition [6]. Another
study, by Tantrapornpong was performed in 10 patients with
similar skin types as in our study (Fitzpatrick’s skin types III–
V). They demonstrated that 1 session of treatment with frac-
tional 1064-nm picosecond laser resulted in 26–50% improve-
ment of acne scars in 30% of patients and a significant im-
provement in skin texture [7]. Although direct comparison
cannot be performed due to the use of different grading scales,
the results from both studies were similar to ours in that frac-
tional picosecond laser proved to be an effective modality in
the treatment of acne scars. Furthermore, our study showed
that the picosecond laser is not significantly inferior in com-
parison with the fractional erbium fiber laser that is a com-
monly used device in the treatment of acne scars in Thailand.
One notable difference was that in our study, the energy set-
tings required to achieve the desirable endpoints and efficacy
were lower in comparison with previous studies (0.3–0.4 J in
our study versus 0.7–0.8 J in previous studies).
Another interesting finding from our study was that pore
counts were reduced with both lasers; however, the reduction
was significantly higher on the erbium fiber laser side. To explain
this, we must discuss the various factors that contribute to the
enlarged pores which consist of decreased elasticity around the
pores, excessive sebum, and increased hair follicle volume [9]. It
Table 1 Side effects comparison
between 1064-nm Nd:YAG pico- Categories
second laser and 1550-nm erbium
fiber laser
Erythema (mean ± SD)
Hypopigmentation
Hyperpigmentation
Pinpoint bleeding
Pain score (mean ± SD)
Nd:YAG neodymium-doped yttrium aluminum garnet, SD standard deviation
has been shown in many studies that fractional lasers can im-
prove pore enlargement by increasing elasticity around the pores
through collagen remodeling, which is the same mechanism as
in acne scar treatment given their structural similarities [10, 11].
Another proposed mechanism is through bulk heating and ther-
mal damage of the sebaceous glands. Paithankar et al. demon-
strated that a 1450-nm diode laser was able to reduce sebum
production in rabbit ear and ex vivo human skin [12]. This
mechanism of thermal damage could have been what the pico-
second laser arm was lacking given our lower energy settings.
Therefore, pore count reduction in the picosecond laser arm was
significantly lower in comparison with the erbium fiber arm.
Our study was limited by a relatively small sample size and
the utilization of two-dimensional imaging assessment of
scars. Ideally, evaluators may be able to make a more accurate
assessment from a three-dimensional imaging or real-life as-
sessment although the latter can bring another set of evaluator
bias. In addition, the energy settings of the picosecond laser
arm could have been higher to achieve the added benefit of
pore count reduction through the mechanism of thermal dam-
age. However, this would have to be done in selected cases as
the settings we used already achieved a desirable endpoint of
pinpoint bleeding as well as comparable efficacy to the erbium
fiber laser arm. If side effects such as post-inflammatory hy-
perpigmentation were avoidable with higher energy settings,
we may observe significantly increased efficacy in the treat-
ment of acne scars from the fractional picosecond laser arm.
Fractional Nd:YAG 1064-nm Fractional 1550-nm P value
picosecond laser erbium fiber laser
4.54 ± 1.61 days 4.43 ± 1.48 days 0.5096
0 0 –
2/30 (6.67%) 3/30 (10%) 1.0000
10/30 (33.33%) 0/30 (0%) 0.0020
4.31 ± 1.68 5.65 ± 1.56 < 0.001

In conclusion, this is the first randomized, single-blinded,
intrapatient, left-to-right study comparing the efficacy of frac-
tional 1064-nm Nd:YAG picosecond laser to fractional 1550-
nm erbium fiber laser in the treatment of acne scars. Both
devices are safe and effective with minimal side effects.
Further randomized controlled trials with higher energy set-
tings of the picosecond lasers are suggested and may show
different results in comparison with other fractional ablative
lasers. Lastly, costs should be taken into consideration when
deciding on which modality to use in order to maximize the
benefits of treatment.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional and/or national research committee (Committee on Human Rights
Related to Research Involving Human Subjects, Faculty of Medicine,
Ramathibodi Hospital, Mahidol University, ID 10-60-37) and with the
1964 Helsinki Declaration and its later amendments or comparable ethical
standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
References
1. Fried RG, Wechsler A (2006) Psychological problems in the acne
patient. Dermatol Ther 19:237–240. https://doi.org/10.1111/j.1529-
8019.2006.00079.x
2. Goulden V, Stables GI, Cunliffe WJ (1999) Prevalence of facial
acne in adults. J Am Acad Dermatol 41:577–580
Lasers Med Sci
3. Sobanko JF, Alster TS (2012) Management of acne scarring,
part I: a comparative review of laser surgical approaches.
Am J Clin Dermatol 13:319–330. https://doi.org/10.2165/
11598910-000000000-00000
4. Sakamoto FHAM, Anderson RR (2012) Lasers and other energy
technologies principles and skin interactions. In: Bolognia JL,
Jorizzo JL, Schaffer JV (eds) Dermatology, 3rd edn. Mosby
Elsevier, Spain, pp 2251–2253
5. Ross V, Naseef G, Lin G, Kelly M, Michaud N, Flotte TJ, Raythen
J, Anderson RR (1998) Comparison of responses of tattoos to pi-
cosecond and nanosecond Q-switched neodymium: YAG lasers.
Arch Dermatol 134:197–171
6. Brauer JA, Kazlouskaya V, Alabdulrazzaq H, Bae YS, Bernstein
LJ, Anolik R, Heller PA, Geronemus RG (2015) Use of a pico-
second pulse duration laser with specialized optic for treat-
ment of facial acne scarring. JAMA Dermatol 151:278–284.
https://doi.org/10.1001/jamadermatol.2014.3045
7. Tantrapornpong PSP (2018) Efficacy and safety of using a
fractional picosecond 1064-nm laser for treatment of atrophic
acne scars in Asian skin types. TJPS 42(supplement issue):
180–184
8. Dreno B, Khammari A, Orain N, Noray C, Merial-Kieny C,
Mery S, Nocera T (2007) ECCA grading scale: an original
validated acne scar grading scale for clinical practice in der-
matology. Dermatology (Basel, Switzerland) 214:46–51.
https://doi.org/10.1159/000096912
9. Lee SJ, Seok J, Jeong SY, Park KY, Li K, Seo SJ (2016) Facial
pores: definition, causes, and treatment options. Dermatol Surg 42:
277–285. https://doi.org/10.1097/DSS.0000000000000657
10. Suh DH, Chang KY, Lee SJ, Song KY et al (2015) Treatment of
dilated pores with 1410-nm fractional erbium-doped fiber laser.
Lasers Med Sci 30:1135–1139
11. Saedi N, Petrell K, Arndt K, Dover J (2013) Evaluating facial pores
and skin texture after low-energy nonablative fractional 1440-nm
laser treatments. J Am Acad Dermatol 68:113–118
12. Paithankar DY, Ross EV, Saleh BA, Blair MA, Graham BS (2002)
Acne treatment with a 1,450 nm wavelength laser and cryogen
spray cooling. Lasers Surg Med 31:106–114
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