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  • Lasers are frequently used to treat pigmented lesions and tattoos.

  • Recent advances in picosecond lasers may improve both the efficacy and safety profile of these treatments.

  • Depending on the depth of treatment, topical anesthesia or none at all is generally sufficient for most cases.

image Beginner Tips

  • Patients with a suntan or sunless tan should avoid laser treatments. The increased melanin on tanned skin acts as a competing chromophore and can increase the risk of adverse events.

  • Extremely diligent sun protection is crucial after treatment of pigmented lesions such as lentigines, PIH, or melasma.

  • Both UVA and UVB can trigger hyperpigmentation or hypopigmentation.

image Expert Tips

  • Tattoos often require multiple lasers to treat appropriately.

  • Topical steroids may be considered after treatment of melasma or PIH to help prevent an inflammatory response that may worsen the pigmentation.

  • Start with a lower fluence and increase with subsequent treatments.

image Don’t Forget!

  • Extreme caution should be used prior to treating postinflammatory hyperpigmentation or melasma with lasers, as there is a risk of exacerbating the hyperpigmentation.

  • Lasers should not be used routinely to treat nevi without a preceding biopsy, and generally should not be used to treat nevi in patients with a personal or family history of dysplastic nevi.

image Pitfalls and Cautions

  • Distinguishing a benign lentigo from lentigo maligna may be challenging. Any concerning features on examination or history should prompt a biopsy for a definitive diagnosis before laser therapy is performed.

  • Allergic reactions are possible after treating tattoos, particularly red tattoos, due to breakdown and dispersal of the putative antigen.

image Patient Education Points

  • Realistic expectations are critical, particularly for tattoo removal.

  • Some tattoos require as many as 20 rounds of treatment, and some tattoos will never clear completely.

  • Postinflammatory hyperpigmentation and melasma may worsen after laser treatment.

image Billing Pearls

  • Almost all insurers in the United States exclude laser treatments from coverage.

  • Patients may benefit from committing to a series of treatments, as this may allow significant cost savings.

  • Pretreatment with occluded topical anesthesia can be started at home, and prescription plans may cover the cost of this medication.


The principle of selective photothermolysis has revolutionized laser treatment for pigmented lesions and tattoos.1 This principle describes the mechanism by which specific wavelengths of light are preferentially absorbed by a chromophore, leading to targeted destruction. There are three main components of selective photothermolysis. The laser wavelength must be preferentially absorbed by the target chromophore; the fluence, or energy per unit area, must be sufficient to destroy the target; and the pulse duration should be equal to or less than the thermal relaxation time (TRT) of the target.


The three main chromophores in the skin are oxyhemoglobin, melanin, and water, and ...

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