Background: The low-fluence Q-switched 1064-nm neodymium-doped yttrium aluminum laser (QSNYL) can effectively treat melasma and photoaging. Fractional photothermolysis has gained popularity because patients can be treated safely with less downtime than with conventional laser treatments. Objectives: To compare the safety and efficacy of fractional QSNYL and conventional QSNYL for the treatment of melasma and photoaging through a randomized, split-face, patient- and evaluator-blind study. Methods: Thirteen Asian women were treated once a week for 6 weeks with fractional QSNYL on one side of the face and conventional QSNYL on the other side. We evaluated the pigmentation area and severity index (PSI), melanin index, erythema index, and patient’s self-assessment of satisfaction. Results: At 2 post-treatment months, the PSI score improved compared with baseline, by 14.48% on the conventional QSNYL side and 21.81% on the fractional QSNYL side. Both groups showed improvements in the melanin index but not the erythema index. The treatment was tolerable to all patients with minimal adverse effects,none irreversible. Conclusion: Fractional QSNYL shows efficacy and safety in the treatment of melasma and photoaging. Although not statistically significant, fractional QSNYL shows better treatment outcomes than conventional QSNYL with minimal side effects.