Lasers and Light for Acne and Rosacea

As lasers and light-based devices continue to gain traction in dermatology, their role in managing acne and rosacea is evolving beyond adjunctive use. In this Q&A, Emmy Graber, MD, MBA, FAAD, discusses how emerging technologies (particularly the 1726-nm laser) are reshaping treatment algorithms, patient selection, and combination strategies in clinical practice.

Where do lasers and light fit in with treatment algorithms for acne and rosacea today?

It really depends on the patient. In years past, especially for acne, I thought of lasers and light as a last resort. Now, however, I bring up that option to nearly all my acne and rosacea patients, because a surprising number of them prefer that type of treatment to a pharmaceutical, whether it be a cream or a pill. Some want a device treatment in addition to their pharmaceutical treatment. 

For rosacea, lasers and lights have always been an important part of treating the erythema and the telangiectasias of rosacea, and that continues to be a mainstay of treatment for those patients. It certainly does not address the papules and pustules, but conversely, most of our topical options and oral options for rosacea only address the papules and the pustules. They do not address the background erythema or the static telangiectasias. So, when I lecture now about lasers for rosacea, I try to emphasize that while topical metronidazole, azelaic acid, oral doxycycline, and oral minocycline are great for the papules and pustules, they will not touch the erythema, so practitioners should be counseling on lasers for rosacea.

None of that is new with rosacea, but with acne, my practice has really changed since the introduction of the 1726-nm laser 4 years ago. Other wavelengths have been studied for acne, but the 1726-nm laser directly targets the sebaceous gland, whereas many other lasers, such as infrared, suppress the sebaceous gland as a bystander but do not directly target it. We are nearing 500 treatments with the 1726-nm laser in my practice, and it works very well. I am now bringing it up to patients during initial consultations, not to say that I think lasers are the best treatment for acne or that they are right for every patient, but because some patients just do not want an oral or topical treatment. It is good to know that up front so that we can jump to the laser and make them happy or encourage them to choose it in combination with other treatments.

In addition to your clinical experience, what studies convinced you to change the way you practiced?

A clinical trial published by Alexiades et al in the Journal of the American Academy of Dermatology followed 104 patients treated with one of the two 1726-nm devices that are cleared for treating acne, the AviClear (Cutera).¹ That is a very large cohort for a laser study, so it was pivotal in the use of lasers for acne. For the initial article, they followed the patients for 6 months, but they have released data since then from up to a year after treatment. Of the 104 patients, 99% had moderate or severe (grade 3 or 4) acne, and they were not on any other treatments. Each patient underwent three treatments, approximately 1 month apart. Interestingly, the primary endpoint was what they called the responder rate, which they defined as patients who had at least 50% improvement in inflammatory lesions. These responder rates were remarkable, and they continued to improve with time. At 12 weeks after the third treatment, 79.8% of the patients had at least a 50% reduction in inflammatory lesions. That number rose to 87.3% of patients after 26 weeks and 91.5% of patients after 52 weeks. So, even when doing nothing after their three laser treatments, they continued to improve with time. I was also impressed that there were still 71 patients in the study 1 year after the final treatment, so the dropout rate was certainly no greater than most of our other acne studies.

Responder rate is not a typical primary endpoint for acne studies. Most acne studies dealing with pharmaceutical therapeutics look at IGA (Investigator Global Assessment) success—and they did look at that as a secondary endpoint in this study. All but one patient in this study started with moderate or severe acne, and they had to get to clear or almost clear to be an IGA success. At 4 weeks out, 9.6% achieved IGA success, but at 12 weeks out, it was 30.8%; at 26 weeks out, it was 32.7%; and at 1 year out, 49% had achieved IGA success. Again, they were not doing anything else for their acne. In a real-life scenario, these patients are likely to be utilizing topical medications and/or oral medications, and when we think about IGA success in other acne studies, this was really in line with what we typically see. For topical agents such as tazarotene, 0.45%, two identical studies had 26% and 30% IGA success at week 12.² Studies with oral sarecycline had 22% and 23% achieving IGA success.³ So, although we do not have head-to-head trials comparing the 1726-nm laser to these other pharmaceuticals, the results seem to be comparable to what we see in other acne studies.

The Alexiades et al clinical trial did find that the 1726-nm laser was much better at treating inflammatory lesions than non-inflammatory lesions. That is why I said at the beginning that, for most acne patients, this is a good treatment option. If I have a patient who only has comedonal lesions, which we classically refer to as non-inflammatory lesions, even though there is some inflammation in them, I do not think that this laser technology will be as good for that type of patient as it would be for a patient who has more inflammatory lesions. 

The Alexiades et al study also looked at the absolute median inflammatory lesion count reduction and the percent change from baseline; at 4 weeks after the third treatment, it was a 37.8%, at 12 weeks it was 55.9%, at 26 weeks it was 72%, and at 52 weeks the results were still getting better with a 78.6% median inflammatory lesion count reduction. 

How do those results impact how you practice?

This device works well, but it takes time. I tell patients that it will not be an overnight success. They need to give it time, and I try to encourage them to do other things as well—maybe it’s just topicals, maybe it’s topicals and an oral agent. At least until they start to see some results from the laser in the few months following the third laser treatment. 

What clinical endpoints do you target during a laser or light procedure?

With the pulsed dye laser for rosacea, the sweet spot in terms of a good clinical endpoint is getting to some very transient purpura, such that when you pulse the laser on the skin, you see this quick flash of purple that then fades to pink within seconds. That indicates you are on the verge of inducing true purpura that would last a week, so we want to avoid lasting purpura as a clinical endpoint. I am also careful to tell patients that there are occasions when a patient gets edematous after pulsed dye laser treatment. Nonetheless, the treatment endpoint should be that flash of very transient purpura lasting just a few seconds and then fading to erythema.

Do any specific demographics benefit more than others from 1726-nm laser treatment for acne?

Alexiades et al included skin types 2 through 6 in their study, and there were no cases of hyperpigmentation, crusting, blistering, or scarring with the laser. That is important because people hear “laser” and often think it is only for fair skin tones or that it could be dangerous for darker skin tones, and that is not the case with this laser.

Beyond that, and this has not been demonstrated in any studies, but I find the greatest success for this device lies with the adult female patient who is also on oral spironolactone. Maybe they have had some good results with it, but their acne is not completely clear, and they just do not want to do anything else. There might not be room to increase the spironolactone dose, so adding a 1726-nm laser for these patients works really well. The Alexiades study demonstrated that patients also perceive an improvement in their pore size, which is the subject of a common patient complaint, so that is a nice side benefit to mention when I am counseling patients. I don’t think I have had any patients do it just to treat their pores, but they do appreciate that benefit of the laser as well.

Are any subtypes of rosacea more responsive or less responsive to lasers?

Patients who have static erythema and telangiectasias do the best with laser therapy. Some studies suggest that IPL (intense pulsed light) may be more effective than pulsed dye laser for rosacea, but in my hands, for almost 20 years, pulsed dye laser has worked much better than intense pulse light devices for treating rosacea. The 532-nm wavelength is also a strong option. Still, either option requires multiple treatments. I am careful to tell patients we still cannot cure rosacea. They will need repeat treatments.

Patients who have neurogenic rosacea or those with only intermittent flushing are harder to treat. They need to be red at the time of treatment. All these lasers and light devices function by targeting the blood vessels—the erythema. If the patient only has intermittent, intense flushing episodes, if they are looking fine at the time, laser treatment is not effective as that red chromophore is not present. Also, some of the neurogenic response that drives the flushing, that neurovascular response, comes from deeper within and cannot be suppressed with a laser.  

How does that impact combination therapy strategies?

The evidence indicates that using oxymetazoline or brimonidine with a pulsed dye laser concomitantly is safe,⁴ and I do have patients using both to try to treat their erythema, but they need to stop the oxymetazoline or brimonidine a few days prior because it is the same concept: if they apply one of those gels that morning and the gel suppresses the redness, the laser will not work as well.

Does that extend to doxycycline and minocycline?

No, but that is a common misconception. I have had patients tell me their general dermatologist or primary care physician told them they needed to stop taking doxycycline before a laser treatment because it is a photosensitizing medication. However, the photosensitizing effect only applies to the ultraviolet wavelength of light. We are talking about lasers that are within the visible light spectrum, and so there is no need for patients to stop their photosensitizing medications such as doxycycline or minocycline prior to pulsed dye laser treatment.

Do you have any strategies for preparing patients for laser treatment when they are not red?

We keep a hair dryer in the room and the hot air for a lot of patients will make them flush. They can get a little more swollen afterward with that, but I do think it helps a little bit.

What combination treatments work well for acne?

Past studies looking at the use of pulsed dye laser in combination with isotretinoin for active acne have been somewhat mixed; some large studies showed that it may improve active acne, but some others indicated that it made no difference. A fairly recent study, however compared patients on only low-dose isotretinoin to patients who were on the same low dose of isotretinoin plus three monthly treatments of a pulsed dye laser, and those patients on the combination treatment did much better.⁵ Their acne improved faster, their overall erythema lessened, and they seemed less likely to have that initial flare-up or purge that patients report with isotretinoin. That is another thing that has changed in my practice: if I am starting a patient on isotretinoin, sometimes I offer to treat them with the pulsed dye laser at the time of initiation of isotretinoin because they may see faster improvement in their acne and they may be less likely to have an initial flare. I have done that for multiple patients, and I do feel that it is very beneficial. 

Overall, the two big changes with lasers and lights for acne in the past few years in my practice have been counseling patients about the benefits of the 1726-nm laser and trying to incorporate the use of the pulsed dye laser with isotretinoin. 

Disclosure: Dr. Graber is a consultant/advisor for Cutera.

1. Alexiades M, Kothare A, Goldberg D, Dover JS. Novel 1726 nm laser demonstrates durable therapeutic outcomes and tolerability for moderate-to-severe acne across skin types. J Am Acad Dermatol. 2023;89(4):703-710. https://doi.org/10.1016/j.jaad.2023.05.085

2. Cook-Bolden FE, Gold MH, Guenin E. Tazarotene 0.045% lotion for the once-daily treatment of moderate-to-severe acne vulgaris in adult males. J Drugs Dermatol. 2020;19(1):78-85. https://doi.org/10.36849/JDD.2020.3979

3. Moore A, et al. Once-daily oral sarecycline 1.5 mg/kg/day is effective for moderate to severe acne vulgaris: results from two identically designed, phase 3, randomized, double-blind clinical trials. J Drugs Dermatol. 2018;17(9):987-996. 

4. Shao K, et al. Pulsed dye laser is more cost-effective than topical brimonidine and topical oxymetazoline for the treatment of erythematotelangiectatic rosacea: a systematic review of the literature and meta-analysis. J Am Acad Dermatol. 2020;83(6):AB68. 

5. Haus A, et al. Combining 675 nm laser with isotretinoin for enhanced acne vulgaris treatment outcomes. Healthcare. 2025;13(23):3068. https://doi.org/10.3390/healthcare13233068

Emmy Graber, MD, MBA, FAAD

• Founder, The Dermatology Institute of Boston
• Affiliate Clinical Instructor, Northeastern University
  Boston, MA