Nd:YAG 1064 nm

Status: draft compiled 2026-04-20.

The long-pulsed Nd:YAG (neodymium-doped yttrium aluminum garnet) laser at 1064 nm is the longest-wavelength laser in routine hair-removal use and the gold standard for Fitzpatrick V-VI skin. At 1064 nm, melanin absorption is substantially lower than at 755 or 810 nm, which means the beam deposits proportionally less energy in epidermal melanin on its way to the follicle — the safety envelope for dark skin is wider, the burn risk is lower, and the post-inflammatory hyperpigmentation rate drops to 2-3% versus up to 19% with shorter-wavelength lasers. The trade for the safety gain is that follicular absorption is also lower, so more sessions and higher fluences are typically needed than with alexandrite on equivalent dark coarse hair in light skin. For the Fitz V-VI population, this tradeoff is unambiguously worthwhile; for the Fitz I-III population, Nd:YAG is deeper-penetrating than needed but not dangerous.

The device class

Long-pulsed Nd:YAG platforms used for hair removal include the Candela GentleYAG Pro, GentleMax Pro (dual 755+1064), and Cutera CoolGlide CV / Excel V. Cynosure's Elite MPX is a dual-wavelength alexandrite + Nd:YAG system with a similar profile. Spot sizes typically 3-18 mm; pulse durations 10-100 ms standard, up to 300 ms on some platforms; fluences 24-100+ J/cm² for hair removal. Cooling is essential: DCD cryogen spray (Candela), sapphire contact (Cutera), or forced cold air (Zimmer Cryo 6 as adjunct). Q-switched Nd:YAG (nanosecond pulse duration) is used for tattoo and pigment work, not for hair removal; they are the same wavelength but totally different pulse regimes. Sources: Candela GentleMax Pro literature; Cutera Excel V+ literature. Confidence: C2.

Fitzpatrick safety envelope

Nd:YAG 1064 is the standard of care for Fitzpatrick V-VI. Starting parameters for true Fitz VI: 20-40 ms pulse, 10-12 mm spot, 24-40 J/cm² fluence with aggressive contact cooling. Battle EF & Hobbs LM 2002/2004, PMID 14725660 established the modern Nd:YAG protocol for Fitz V-VI hair removal. Ibrahimi et al 2011, PMID 21519944 reviewed long-pulsed Nd:YAG on Fitz IV-VI. Abdelaziz et al 2025 Lasers Med Sci, PMID 40892306 is a recent prospective study in 55 Sudanese women Fitz IV-VI using Nd:YAG with fluences 25-40 J/cm², 10-12 mm spot, and pulse widths 20-40 ms, confirming efficacy and safety with this range.

Nd:YAG is also reasonable for Fitz I-IV — it just works more slowly than the wavelength-optimal alternative. A Fitz III patient treated with Nd:YAG will see good results, but the time-to-clearance and the number of sessions may be slightly longer than with alexandrite. Confidence: C1.

Efficacy

Pooled systematic-review long-term reduction for Nd:YAG: 30-73.6% (Husain 2022, PMID 35634805). In the Kao 2023 network meta-analysis, PMID 37493187, Nd:YAG was statistically indistinguishable from alexandrite and diode on head-to-head comparisons when matched to appropriate skin type. Alster TS 2003 and 2001 Nd:YAG series reported 80-90% density reduction in dark skin with minimal adverse events. Confidence: C1.

The clinical observation is that Nd:YAG on matched patients is slower-working than alexandrite or diode on matched patients — the same end-of-course reduction takes slightly more sessions. This is consistent with the lower follicular-melanin absorption at 1064 nm requiring more thermal rounds to achieve equivalent cumulative follicular damage.

PIH rate

The single most important clinical advantage of Nd:YAG on darker skin is the dramatically lower rate of post-inflammatory hyperpigmentation. Dorgham 2020 skin-of-colour meta-analysis, PMID 31587390 supports Nd:YAG over both alexandrite and diode for PIH avoidance in Fitz V-VI. Observed PIH rates with properly-calibrated Nd:YAG run 2-3% in Fitz V-VI; with short-wavelength lasers at the same Fitzpatrick level the rate can reach 19% or higher. One Black-skin cohort reported 28% PIH with alexandrite. The practical rule: if the patient is Fitz V or darker, Nd:YAG is the default choice even when the hair-skin contrast would favour alexandrite on paper. Confidence: C1.

PFB and AKN

Long-pulsed Nd:YAG 1064 is the first-line laser for pseudofolliculitis barbae and acne keloidalis nuchae, specifically because the population with clinically significant PFB is predominantly Fitz IV-VI. Key trials: Ross EV et al 2002, JAAD 47:263-270, PMID 12140465 — 2-session Nd:YAG significantly reduced papule counts in Fitz IV-VI beards; Smith EP et al 2009, J Drugs Dermatol n=26 reduced PFB papules 11.6 vs 30.1 untreated; [Battle 2021] in US service members ~74% Black: 88% satisfied, 70% achieving ≥75% lesion reduction. See ../populations/pfb-akn.md. Eflornithine + Nd:YAG is additive (Aboelsaad 2021, PMID 33629488). Confidence: C2.

Hidradenitis suppurativa

Long-pulsed Nd:YAG 1064 reduces disease severity in Hurley stage I-II hidradenitis suppurativa through a combination of hair follicle reduction and anti-inflammatory dermal heating. Mahmoud BH et al 2010, JAAD, PMID 19438670 is the primary RCT. Xu LY et al 2011 histopathologic series, JAMA Dermatol confirmed mechanism. 2024 alexandrite RCT in JAAD Int and 2025 systematic review in J Clin Med 14(21):7683 update the evidence base. See ../populations/hs.md. Confidence: C2.

Pulse duration and fluence

For Fitz V-VI: 20-40 ms pulse, 10-12 mm spot, 24-40 J/cm² starting fluence; increase to 45-60 J/cm² in subsequent sessions as tolerated. For Fitz III-IV: 15-25 ms pulse, 10-15 mm spot, 30-60 J/cm². For Fitz I-II: pulse and fluence can be more liberal; Nd:YAG on light skin is typically at 20-60 ms and 40-100 J/cm², though alexandrite is usually the simpler choice. Aggressive cooling (DCD or sapphire contact) is essential at all fluences above about 30 J/cm². Sources: Battle 2002/2004; Ibrahimi 2011; Abdelaziz 2025. Confidence: C2.

Pain

Nd:YAG is the most painful of the three primary wavelengths per pulse at matched efficacy. The mechanism is deeper beam penetration producing nociceptor activation at dermal depths where superficial cooling provides less protection. Topical anaesthetic use is more common for Nd:YAG sessions than for alexandrite or diode sessions. Standard pain scores for Nd:YAG hair removal on bikini or Brazilian areas run 5-7/10; aggressive cooling (DCD or sapphire) and longer pulse durations reduce the peak. Confidence: C3.

Tattoo contraindication

Nd:YAG 1064 is among the most efficient tattoo-ink-absorbing wavelengths, which is why Q-switched Nd:YAG is a dominant tattoo-removal laser. For hair removal, this means tattoos in the beam field are a strong contraindication — beam absorption by ink at hair-removal fluences produces ink fragmentation, superficial burns, and permanent change to the tattoo. Mask or avoid tattoos. Electrolysis is the correct method for hair in or adjacent to tattoos. Confidence: C1.

Chrysotherapy history

A historical-only caution: patients with prior gold therapy (chrysotherapy, used for rheumatoid arthritis decades ago) should avoid Nd:YAG because of risk of chrysiasis (permanent blue-grey skin discoloration) from photodeposition of gold salts retained in the dermis. This is a rare concern in 2026 because chrysotherapy has largely been replaced by methotrexate and biologics, but it appears in the differential for any unusual post-Nd:YAG pigmentation in a patient with old rheumatology history. Confidence: C3.

Best-use summary

Long-pulsed Nd:YAG 1064 is the first-line choice for Fitzpatrick V-VI hair removal on any body region; the first-line laser for pseudofolliculitis barbae and acne keloidalis nuchae regardless of Fitzpatrick level; the standard for hidradenitis suppurativa Hurley I-II adjunct therapy; and the safer choice for tanned or sun-exposed skin of any baseline Fitzpatrick level. It is slower than alexandrite on matched light-skin dark-hair combinations but rarely a bad choice in those cases. It is ineffective on blonde/red/grey/white hair for the same reason any melanin-dependent laser is — no chromophore — and those patients should be routed to electrolysis. It is contraindicated in beam fields that contain tattoos or in rare patients with chrysotherapy history. Confidence: C1.