Objective To compare the efffcacy and safety of Q-switched Nd:YAG laser and trepanation in the treatment of cutaneous pigmented nevus. Methods A total of 300 patients with cutaneous pigmented nevus treated in the Dermatology Outpatient Department of our hospital from January 2024 to June 2025 were selected, and they were divided into the control group and the observation group according to different treatment methods, with 150 patients in each group. The control group was treated with Q-switched Nd:YAG laser, and the observation group received trepanation. The clinical efffcacy, complication rate, recurrence and satisfaction were compared between the two groups. Results The total effective rate of the observation group (98.00%) was higher than that of the control group (88.00%) (P<0.05). There was no signiffcant difference in the incidence of complications between the two groups (P>0.05). The recurrence rate of the observation group was lower than that of the control group, and the satisfaction was higher than that of the control group (P<0.05). Conclusion Trepanation is superior to Q-switched Nd:YAG laser in terms of clinical efffcacy and recurrence control in the treatment of cutaneous pigmented nevus, with higher patient satisfaction, which will not increase the probability of complications.