Comparative Evaluation of Long-Pulse Alexandrite and

Long-Pulse Nd:YAG Laser Systems Used Individually and in

Combination for Axillary Hair Removal
JANE G. KHOURY, MD, RAMINDER SALUJA, MD, AND MITCHEL P. GOLDMAN, MDy

BACKGROUND The 755-nm alexandrite and the 1,064-nm Nd:YAG lasers are both utilized for hair re-
moval. Advances in laser technology have led to the development of dual-wavelength treatment for
increased efficacy.
OBJECTIVE The objective was to evaluate the safety and efficacy of combining 755- and 1,064-nm
wavelengths for axillary hair removal.
METHODS Twenty patients received three treatments at 4- to 6-week intervals in four axillary quad-
rants. The left upper axilla was treated with the alexandrite laser, the left lower axilla with the Nd:YAG
laser, the right upper axilla with combination alexandrite and Nd:YAG laser, and the right lower quadrant
with the diode laser. At 1- and 2-month follow-up visits, subjects completed questionnaires and were
assessed for percentage of hair reduction.
RESULTS Eighteen subjects completed the study. The greatest reduction was seen with the alexandrite
laser at 70.3% and combination of alexandrite and Nd:YAG laser at 67.1%. The diode laser was less
efficacious at 59.7% and the Nd:YAG laser had the least improvement with 47.4% reduction. Subjects
found the alexandrite and diode lasers to be the most tolerable and the Nd:YAG and combination
treatment to be the most painful.
CONCLUSION Combination treatment of alexandrite and Nd:YAG lasers provides no added benefit over
the alexandrite laser alone.
The Apogee Laser used in this study was loaned by Cynosure.

L aser hair removal is a well-established treatment

modality for the reduction of unwanted hair.
Based on the theory of selective photothermolysis,
of combining wavelengths for increased efficacy of
laser hair removal.

several hair removal laser systems have been devel-
oped.1 Because of their wavelengths and extended
pulse durations, the 755-nm alexandrite, 810-nm
diode, and 1,064-nm Nd:YAG lasers have been
shown to be effective in photoepilation.2–4 While
many studies have been published that document the
safety and efficacy of these laser systems, only two
studies exist to date that directly compare these three
wavelengths for laser-assisted hair removal.5,6 Rao
and Goldman6 in their study explored the benefit of
rotating these three wavelengths on improvement of
hair reduction. However, to the best of our
knowledge no study to date has explored the benefit
Recently, the emerging trend of multiwavelength la-
sers has led several companies to offer a 755-nm
alexandrite and a 1,064-nm Nd:YAG laser in one
unit. The 1,064-nm Nd:YAG wavelength is better
suited for removing hair from dark skin, but may not
provide the most effective treatment for lighter hair.
The 755-nm alexandrite wavelength can treat darker
hair and is more effective than the 1,064-nm wave-
length in treating lighter hair but is not ideal for
darker skin. A new laser system capable of emitting
755/1,064-nm wavelengths simultaneously may in-
crease efficacy in treating a wider variety of skin and
hair types.

Dermatology/Cosmetic Laser Associates; yLa Jolla Spa MD, La Jolla, California

& 2008 by the American Society for Dermatologic Surgery, Inc.
Published by Blackwell Publishing

ISSN: 1076-0512
Dermatol Surg 2008;34:665–671
DOI: 10.1111/j.1524-4725.2007.34125.x

665

D I O D E , A L E X A N D R I T E , A N D N d : YA G L A S E R S F O R H A I R R E M O VA L
This study evaluates the safety, tolerability, and
efficacy of the long-pulsed 755- and 1,064-nm lasers
individually, sequentially, and in comparison with
the long-pulsed 810-nm diode laser for hair removal
of the axilla.
Materials and Methods
Patients
Twenty healthy, untanned women with Fitzpatrick
skin types I–III and dark brown axillary hair were
selected for the study. Exclusion criteria included
any previous laser treatment to the study area, elec-
trolysis within the treatment area, waxing or
depilatory use within 1 month, hormonal dysfunc-
tion, isotretinoin use within the past year, or history
of photosensitivity. All 20 patients completed
three treatments. However, only 19 patients
were available for final evaluation 2 months after
their last treatment.
Laser Systems
The variable-pulse alexandrite laser (Apogee Elite,
Cynosure Inc., Chelmsford, MA) system used in this
study uses a beryllium alluminate crystal to achieve a
wavelength of 755 nm with a variable pulse duration
of 0.5 to 300 ms, a maximum fluence of 125 J/cm2,
and spot sizes from 3 to 15 mm in diameter. For this
study, the pulse duration and spot size were kept
constant at 20 ms and 12 mm, respectively. The flue-
nce was started at 18 J/cm2 and increased to maximum
tolerated fluence for each patient. Epidermal cooling
was achieved by continuous cold air blown on the
treatment surface before, during, and after laser irra-
diation using a chiller (SmartCool, Cryo-5, Zimmer,
Elektromedizin, GmbHm Neu-Ulm, Germany).
The Apogee Elite variable-pulse Nd:YAG laser
(Cynosure Inc.) system has an output wavelength
of 1,064 nm through a neodymium:yttrium-
aluminum-garnet (Nd:YAG) source. The system has
a variable pulse duration from 0.4 to 300 ms and
adjustable fluences up to 300 J/cm2 depending on the
spot size. At the 12-mm spot size, fluence was started
666 D E R M AT O L O G I C S U R G E RY
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at 40 J/cm2 and increased to 50 J/cm2, the maximum
fluence, in those patients that tolerated it.
The long-pulse diode laser (LightSheer XC, Lumenis
Ltd., Yokneam, Israel) system used in this study uses
a semiconductor diode at a wavelength of 810 nm
with a variable pulse duration of 5 to 400 ms, ad-
justable fluences of 10 to 100 J/cm2, and a square
spot size of 12  12 mm. The epidermis was cooled
before, during, and after laser irradiation by placing
a sapphire window-based dynamic 51C cooling sys-
tem (ChillTip) onto the skin surface. For this study,
the fluences were started at 22 J/cm2 and increased to
28 J/cm2 as tolerated by each patient. The pulse
width was set in ‘‘auto’’ mode, half the minimum
value for a particular fluence (e.g., 11–14 ms de-
pending on treatment fluence).
Statistical analysis was performed with statistical
software (Minitab 15, Minitab Inc., State College,
PA). To determine statistical significance, a two-sam-
ple t test was utilized with a = 0.05 for all these tests.
Treatment Protocol
The axilla was divided into superior and inferior
halves yielding four distinct treatment sites: (1) left
upper axillaFlong-pulse alexandrite laser; (2) left
lower axillaFlong-pulse Nd:YAG laser; (3) right
upper axillaFcombination of long-pulse alexandrite
and Nd:YAG laser; and (4) right lower axillaFlong-
pulsed 810-nm diode laser. This is depicted in Figure
1. Three treatment sessions were performed at 4- to
6-week intervals. Sequential digital photographs us-
ing identical light, patient positioning, and camera
equipment of the axilla were obtained at baseline,
before each treatment session, and at 1- and 2-month
follow-ups. Hair counts were performed manually to
the entire treatment area on each of the four axillary
quadrants. Subjects were instructed to shave their
hair 48 hours prior to treatment; however, hairs
longer than 1 mm were shaved close to the skin prior
to the treatment.
A board-certified dermatologist performed all laser
treatments. Each quadrant was treated with the
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K H O U RY E T A L

Right Axilla Left Axilla tistically significant difference was seen between the
alexandrite alone and the combination treatment.
The diode laser treatments were statistically more
755 nm
and 755 nm effective than the Nd:YAG laser alone; however, no
1064 nm statistically significant difference was found between
the diode and the combination alexandrite and
Nd:YAG laser treatment (Table 2).
810 nm 1064 nm
Side Effects

No blistering, scarring, pigmentary alterations, or

Figure 1. Map illustrating the four axillary quadrants and
their corresponding laser treatments.
designated laser system. The right upper quadrant
was first irradiated entirely with the alexandrite and
then immediately followed by Nd:YAG laser treat-
ment. Following each laser treatment, subjects were
evaluated for immediate side effects. At 1 and 2
months after final treatment sessions, all subjects
were seen for repeat hair counts using the same
methodology as described previously. Subjects were
also given questionnaires assessing laser tolerability
and satisfaction in each treatment area.
Results
Hair Reduction
other chronic adverse effects were observed or re-
ported. Immediate side effects of the laser treatments
included perifollicular erythema, edema, singed
hairs, and pain. These side effects were transient and
resolved within 2 days of onset in all patients.
Subject Tolerability and Satisfaction
Based on subject questionnaires, the long-pulse
alexandrite laser was rated as the least painful of the
three systems followed closely by the diode laser
with mean pain scores of 3.9 and 4.3 of 10, respec-
tively. The Nd:YAG laser was found to be less tol-
erable with a mean pain score of 7.0 of 10. Because
the combination quadrant involved sequential treat-
ment of the alexandrite and the Nd:YAG to one area,
this was found to be of a comparable pain level as
the Nd:YAG alone (Table 3).

The percentage of hair reduction for each laser

At the final visit, subjects were asked to rank im-
removal system is listed in Table 1. The mean
provement for each axillary quadrant on a scale
hair reductions were 70.3 7 14.4, 47.4 7 16.7,
from 0 to 5. The alexandrite, diode, and combina-
59.7 7 13.6, and 67.1 7 15.1 for the alexandrite,
tion lasers were all found to be fairly comparable
Nd:YAG, diode, and combination alexandrite and
with mean scores of 3.9, 3.8, and 4.0, respectively.
Nd:YAG lasers, respectively. The combination alex-
The Nd:YAG laser alone was reported to be the least
andrite and Nd:YAG treatment arm was statistically
effective, with a mean score of 3.3 of 5 (Table 4).
more effective than the Nd:YAG alone but no sta-

TABLE 1. Treatment Parameters Discussion

Laser Duration Fluence Mean Fluence Effective laser hair removal depends on the princi-
Pulse (nm) (ms) Range (J/cm2) (J/cm2) ples of selective photothermolysis. To accomplish
755 20 18–24 755 21.6 7 1.3 this, a system must possess the appropriate wave-
1,064 20 40–50 1064 48.3 7 3.4 length, spot size, pulse duration, and fluence to
755/1,064 20/20 18–24/40–50 – – achieve adequate laser energy to the depth of the
810 11–14 22–28 810 24.9 7 2.0
follicle with sufficient cooling to protect the epider-

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D I O D E , A L E X A N D R I T E , A N D N d : YA G L A S E R S F O R H A I R R E M O VA L

TABLE 2. Hair Reduction (Data Analysis)

t Test

Combination
Alex/Nd:YAG Combination Combination
Treatment Hair versus Alex/Nd:YAG Alex/Nd:YAG Alexandrite
Session reduction (%) Alexandrite versus diode versus Nd:YAG versus Diode

1 month s/p 3 treatments NS (p = .752) NS (p = .799) Significant NS (p = .514)

(p = .005)
Alexandrite 81.9
Diode 79.2
Nd:YAG 61.8
Combination Alex/Nd:YAG 80.3
2 months s/p 3 treatments NS (p = .501) NS (p = .125) Significant Significant
(p = .001) (p = .025)
Alexandrite 71.3
Diode 60.1
Nd:YAG 48.2
Combination Alex/Nd:YAG 68.1

NS, not significant; s/p, status post.

mis from thermal injury. Many studies have been
published that document the safety and efficacy of
several laser systems.2–7 However, most studies in-
volve a wide variety of laser parameters, skin types,
treatment areas, and number of treatments. Because
all these factors can influence the results of laser hair
removal, it can be challenging to interpret the find-
ings. This study was designed to control many of
these variables while evaluating the three most
popular wavelengths for laser hair removal, the long-
pulsed 755-nm alexandrite, 810-nm diode, and
1,064-nm Nd:YAG lasers. In addition, this is the first
study that evaluates the long-pulsed 755- and 1,064-
nm lasers in combination for axillary hair removal.
In this study, spot size was set at 12 mm for all three
laser systems. Standardizing this is important as in-
TABLE 3. Tolerability of Laser Hair Removal Sys-
tems Based on Subject Questionnaires
Laser System
Long-pulse 755 nm alexandrite laser
Long-pulse 810 nm diode laser
Long-pulse 1,064 nm Nd:YAG laser
On pain scale from 0 to 10.
creasing spot size increases optical transmittance
across the skin surface and results in more effective
laser hair removal.7,8 Pulse duration was set at 20 ms
for the 755- and 1,064-nm systems. The long-pulsed
810-nm diode laser lacks a 20-ms pulse width and
was set on ‘‘auto’’ with pulse width equal to half the
treatment fluence, 11 to 14 ms for the treatments.
Research has shown that ideal pulse width for hair
follicles varies from 10 to 100 ms depending on the
anatomic location, size of hair follicle, and patient
skin type.9–11 We chose patients with Fitzpatrick
skin types that would safely allow for pulse dura-
tions in this range.
Standardizing effective fluences for different laser
systems is challenging. For this study, the patients
were started at a set fluence based on hair size and
density and then increased to maximum tolerated
fluence. By treating with maximum tolerated fluence
for each of the three systems, a more reliable com-
parison can be made. Unfortunately, two limitations
Mean Pain exist when establishing maximum fluence for the
Score
1,064-nm Nd:YAG laser. First, at the 12-mm spot
3.9 size, the Apogee Elite has a maximum fluence of
4.3 50 J/cm2, which several patients comfortably toler-
7.0
ated but could not be increased. Another limitation
for many patients was discomfort. Subjects were not

668 D E R M AT O L O G I C S U R G E RY

TABLE 4. Subject Ranking of Hair Reduction after
Three Laser Hair Removal Sessions
Average Subjective
Laser System Improvement
Long-pulse alexandrite laser 3.9
Long-pulse diode laser 3.8
Long-pulse Nd:YAG laser 3.3
Combination alexandrite/ 4.0
Nd:YAG laser
Based on a scale from 0 to 5.
pretreated with any topical anesthetics and some had
to decrease fluence midtreatment due to pain intol-
erance. All 20 patients rated the Nd:YAG as the most
painful of the laser systems, which is consistent with
the literature on laser hair removal.5,6,12,13
These standardizing efforts were undertaken so that
differences in the results could be correlated as much
as possible to the various wavelengths.4 Bouzari and
colleagues5 in their study comparing the long-pulsed
Nd:YAG, long-pulsed alexandrite, and long-pulsed
diode lasers found that the small subset of their pa-
tients who underwent laser therapy with different
laser systems were found to have the best treatment
outcome. They hypothesized that using two different
laser systems increased the chance of destroying both
deep and superficial targets. Rao and Goldman6
explored this further in their study by evaluating
rotational treatment consisting of a single session by
each of these laser wavelengths on axillary hair re-
moval. They found no increased efficacy over the
alexandrite or the diode laser alone, although rota-
tional treatment was found to be more effective than
the Nd:YAG system alone.
With the advent of many dual-wavelength systems,
combination treatment is an emerging trend in the
field of laser surgery. We hypothesized that by com-
bining two different pigment-absorbing wavelengths,
a long-pulsed 755-nm alexandrite laser and a long-
pulsed 1,064-nm Nd:YAG laser, there would be in-
creased efficacy over either one alone. The 1,064-nm
laser is better suited for targeting deeper hair follicles
15244725, 2008, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1524-4725.2007.34125.x by CAPES, Wiley Online Library on [08/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
K H O U RY E T A L
and removing hair in patients with darker skin while
the 755-nm laser is very effective in treating lighter
hair and more superficial hair structures.
The long-pulsed alexandrite laser was found to be
slightly more effective than the combination of
alexandrite and Nd:YAG, although not significantly
so. The increased efficacy of the alexandrite over the
Nd:YAG laser is not surprising and correlates with
past reports.5,6 However, it is of note that there was
a statistically significant difference between the mean
hair reduction at 2 months between the alexandrite
and the diode lasers that was not seen at 1 month
follow-up. Most studies comparing the long-pulsed
alexandrite and the long-pulsed diode lasers show
almost equal efficacy and tolerability.5,6,14,15 Given
the sample size and 2-month follow-up, it is difficult
to draw any conclusions about the disparity in
lasting effects.
Most laser hair removal studies evaluate patients at a
minimum of 3 months’ follow-up because this is the
duration of telogen for axillary hair.16 However, the
purpose of our study was to establish if there was any
increased benefit to combination therapy of alexand-
rite and Nd:YAG. No improvement over alexandrite
alone was seen after each of the three treatments and
this trend remained consistent through to the last
follow-up, 4 months after the first treatment.
The two quadrants that had the best results were
both located in the superior aspect of the axilla while
the diode and the Nd:YAG lasers alone were both
designated to the inferior axilla. A randomization of
each treatment quadrant could have obviated this
potential study bias.
Based on our findings, combination treatment of
alexandrite and Nd:YAG provides no added benefit
over the alexandrite alone. However, in this study
the combination treatment was not delivered simul-
taneously. The quadrant was irradiated with the
alexandrite laser and followed within 1 minute by
the Nd:YAG laser. This does not preclude the the-
oretical benefit of delivering two wavelengths within
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D I O D E , A L E X A N D R I T E , A N D N d : YA G L A S E R S F O R H A I R R E M O VA L

50 ms, which would allow each to act within the 8. Baumler W, Scherer K, Abels C. The effect of different spot sizes
on the efficacy of hair removal using a long-pulsed diode laser.
thermal relaxation time of the hair follicle. Dermatol Surg 2002;28:118–21.

9. Nanni CA, Alster TS. Long-pulsed alexandrite laser-assisted hair

Future studies with a multiplex unit that allows for removal at 5, 10 and 20 millisecond pulse durations. Laser Surg
sequential irradiation of these two lasers would ex- Med 1999;24:332–7.

plore this hypothesis. In addition, by utilizing a laser
system that will allow for higher Nd:YAG fluences
and incorporating some topical anesthesia, the effi-
cacy of the combination treatment may be increased.
10. Rogachefsky AS, Becker K, Weiss G, Goldberg DJ. Evaluation of a
long-pulsed Nd:YAG at different parameters: an analysis of both
fluence and pulse duration. Dermatol Surg 2002;28:932–5.
11. Fiskerstrand EJ, Svaasand LO, Nelson JS. Hair removal
with long pulsed diode lasers: a comparison between two
systems with different pulse structures. Lasers Surg Med 2003;
32:399–404.

References
1. Anderson RR, Parish RR. Selective photothermolysis: precise
microsurgery by elective absorption of pulsed radiation. Science
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2. Campos VB, Dierickx CC, Farinelli WA. Hair removal with an
800-nm pulsed diode laser. J Am Acad Dermatol 2000;43:442–7.
12. Chan HH, Ying SY, Ho WS, et al. An in vivo study comparing the
efficacy and complications of diode laser and long-pulsed
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13. Guardiano RA, Norwood CW. Direct comparison of EMLA ver-
sus lidocaine for pain control in Nd:YAG 1,064 nm laser hair
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3. Eremia S, Li CY, Umar SH, Newman N. Laser hair removal: long- 14. Eremia S, Li C, Newman N. Laser hair removal with alexandrite
term results with a 755 nm alexandrite laser. Dermatol Surg versus diode laser using four treatment sessions: 1-year results.
2001;27:920–4. Dermatol Surg 2001;27:925–30.

4. Tanzi EL, Alster TS. Long-pulsed 1064-nm Nd:YAG laser-assisted
hair removal in all skin types. Dermatol Surg 2004;30:13–7.
5. Bouzari N, Tabatabai H, Abbasi A, et al. Laser hair removal:
comparison of long-pulsed Nd:YAG, long-pulsed alexandrite, and
long-pulsed diode lasers. Dermatol Surg 2004;30:498–502.
6. Rao J, Goldman MP. Prospective, comparative evaluation of three
laser systems used individually and in combination for axillary
hair removal. Dermatol Surg 2005;31:1671–7.
15. Handrick C, Alster TS. Comparison of long-pulsed diode
and long-pulsed alexandrite lasers for hair removal: a
long-term clinical and histologic study. Dermatol Surg 2001;
27:622–6.
16. Dierickx C. Laser-assisted hair removal: state-of-the art. Dermatol
Ther 2000;13:80–9.

7. Nouri K, Chen H, Saghari S, Ricotti CA. Comparing 18- versus Address correspondence and reprint requests to: Mitchel P.
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alexandrite laser. Dermatol Surg 2004;30:494–7. Jolla, CA 92037, or e-mail: MGoldman@Spa-MD.com

COMMENTARY

During the last decade laser treatment has become an effective and safe, well tolerated and widely
accepted routine procedure for pigmented hair reduction.
Various systems have been studied according to GCP guidelines.

Based on the maximum absorption of pigmented target structures ruby laser light (694 nm) is best ab-
sorbed with the least absorption in water and haemoglobin compared to other laser systems. Hence, the
ruby laser should be the best for pigmented hair removal, theoretically. 1 But, q-switched ruby laser pulses
Fin the nanosecond rangeFare too short to harm pigmented hair follicles effectively enough to achieve
sufficient hair reduction. Logically, the laser system with the next higher available wavelength in the
visible red part of the spectrumFthe alexandrite laser (755 nm) featuring the ability of emitting longer
pulses (‘‘long-pulse’’ = milliseconds)Fturns out to be the most efficacious tool for pigmented hair re-
duction, followed closely by diode laser systems (800 nm, 810 nm). Nd-YAG laser systems (1.064 nm) are
able to emit q-switched pulses as well as ms-pulses but this wavelength is not only absorbed by pigmented

670 D E R M AT O L O G I C S U R G E RY
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K H O U RY E T A L

structures but also by water. Therefore it heats up the skin more than the other systems causing much
more pain for the patients and therefore it is not as well tolerated.
To date long-pulse systems emitting in the visible red part of the light spectrum can be rated first choice for
the reduction of unwanted pigmented hair as shown by Khoury et al.
DAISY KOPERA, MD
Austria

Reference
1. Goldberg DJ. Laser- and light-based hair removal: an update. Ex-
pert Ref Med Devices 2007;4:253–60.

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