Laser Hair Removal


Article Author:
Tanvi Vaidya


Article Editor:
Dinesh Kumar D


Editors In Chief:
Ahmad Al Aboud
Jayakar Thomas
Pramod Nigam


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/2/2019 9:56:20 AM

Introduction

The demand for safe, long-lasting, and effective hair reduction for aesthetic as well as medical indications is on the rise. A variety of options for hair removal are available, such as epilation by plucking or waxing, depilation by shaving, chemical depilatories, electrolysis, eflornithine cream, and laser and intense pulsed light (IPL) systems. A variety of lasers and IPL systems are available and are the best option for long-term hair reduction.[1] The mechanism of action of these systems is by targeting melanin in the hair shaft, follicular epithelium, and hair matrix by emitting light with wavelengths ranging from 600 to 1200 nanometers (nm), which is selectively absorbed by melanin.[2]

Anatomy

Selective Photothermolysis

Lasers for skin treatment work on the theory of "selective photothermolysis." This term implies a site-specific, thermally mediated injury of microscopic tissue targets by the selective absorption of pulses of radiation by the targets and the chromophores. The natural or artificial chromophores absorb monochromatic or broadband electromagnetic radiation of specific wavelengths. The chromophore employed in laser hair reduction is melanin. Melanin absorbs light in the range of 690 to 1000 nm, and lasers in this range of wavelengths can be effectively used for hair reduction.6836297[3][4]

An Extended Theory of Selective Photothermolysis

Target absorption may not always be uniform. In these cases, the weakly absorbing parts may have to be destroyed by heat diffusion from the highly absorbing parts. This is the extended theory of selective photothermolysis. This principle is applied to laser photoablation. Melanin content is much higher in melanin-bearing structures like the hair shaft and matrix cells than in the hair follicle. Thus melanin captures energy from the laser and distributes it to the surrounding follicular structures. This results in the destruction of the hair matrix and hair bulge stem cells.[5]

Indications

  1. Hirsutism and hypertrichosis
  2. Aesthetic purposes
  3. Medical indications like Pseudofolliculitis barbae, pilonidal sinus, and acne keloidalis nuchae.[6]

Equipment

Lasers for hair reduction include the following:

  1. Ruby LaserWavelength: 694 nmRed light is delivered through synthetic Ruby crystalsMore effective for lighter skin types with dark hairSkin types I-III*[7]
  2. Alexandrite LaserWavelength: 755 nmGreater penetranceGood for lighter hairSkin types I-III[8]
  3. Diode LaserWavelength: 810 nmPenetrates deeper, delivers better fluence, less epidermal damage.Safer in darker skin Skin types I-V[9]
  4. Neodymium: Yttrium-Aluminium-Garnet (Nd: YAG) LaserWavelength: 1064 nmBetter penetration, less epidermal damage, relatively less melanin absorption.Skin types I-VI[10]
  5. Intense Pulse Light (IPL) SystemHigh-intensity pulses of polychromatic, non-coherent light are delivered by a flash-lamp. Various filters allow the narrowing of the emitted wavelength band. Wavelength: 500 to 1200 nmCan be used on darker skinLarger areas can be covered due to its larger spot sizeLess expensiveNot as effective as laser systems[11][12][13]

* Fitzpatrick Skin Types[10]

  • I- Pale white skin, blue/green eyes, blond/red hair; always burns, does not tan
  • II- Fair skin, blue eyes; burns easily, tans poorly
  • III- Darker white skin; tans after the initial burn
  • IV- Light brown skin; burns minimally, tans easily
  • V- Brown skin; rarely burns, tans darkly easily
  • VI- Dark brown or black skin; never burns, always tans darkly

Preparation

  1. Detailed clinical history to rule out infections, drug intake, etc.
  2. Hormonal evaluation to assess causes of hirsutism.
  3. Counsel the patient to keep unrealistic expectations at bay. It must be stressed that the procedure provides permanent hair reduction and not removal.
  4. Evaluate skin and hair types to choose the right laser and parameters.
  5. Avoid hair epilation by plucking or waxing for 6 weeks before the procedure.
  6. Sunscreens may be prescribed 4 to 6 weeks before the procedure, especially on exposed areas.
  7. Pre-procedure photographs, with due consent, to maintain a record for evaluation of treatment response.
  8. Shave the area before the procedure.
  9. Obtain an informed consent.
  10. If need be, a topical anesthetic cream may be applied one-half to one hour before the procedure.[14][15]

Technique

  1. Clean the area to remove oils from the skin
  2. Position the patient comfortably.
  3. Use eye protection for both the operator as well as the patient.
  4. Avoid reflecting surfaces or metallic objects near the laser.
  5. Individualize the parameters to each patient's skin and hair type and the type of laser being used. 
  6. Place the handpiece perpendicular to the skin. Ensure that it is pressed down gently and firmly to bring the follicles close to the surface and temporarily decrease the blood supply to the local area.
  7. Perifollicular edema and erythema is an expected side effect, and this must be explained to the patient.[14][15]

Post-Procedure Care

  1. Although most machines have inbuilt cooling systems, ice packs or cooling agents may be used post-procedure to minimize pain and swelling.
  2. In case of inadvertent epidermal injury, topical antibiotics may be used.
  3. Strict sun protection and the use of sunscreens is a must.
  4. Topical steroid creams may be prescribed to minimize erythema and swelling.[14][11]

The hair matrix being sensitive to laser treatment in the anagen phase necessitates multiple treatments to treat all hairs during this most sensitive phase. In the initial phase, 4 to 6 treatments spaced 4 to 6 weeks apart are a minimum to achieve adequate results. Subsequently, patients may be maintained with repeat treatments once every 6 to 12 months as small vellus hair may grow back.[16]

Various factors may affect the outcome, such as:

  1. Hair location (axillary and pubic hair respond better than hair on the extremities and chest)
  2. Skin and hair color (light skin of Fitzpatrick skin types I-IV with dark hair being most sensitive)
  3. Hair growth stage (anagen hair being most sensitive)
  4. Laser type
  5. Hormonal status
  6. Treatment plan[2]

Complications

Adjacent epidermal structures other than melanin within the hair bulb can compete for absorption, and may cause laser energy to be absorbed by pigment in the epidermis. This hampers the effectiveness of the treatment and causes adverse effects due to adjacent epithelial damage. [17]

Common adverse effects of laser or IPL-based hair removal include post-treatment erythema, pain, and burning.[18]

More severe adverse effects include blistering, crusting, dyspigmentation, purpura, and sometimes, scarring.[19][20] Ocular complications due to accidental injury may be seen. Paradoxical hypertrichosis may rarely occur, more commonly in skin types III and with the use of IPL systems.[21][22][23]

Clinical Significance

Selecting the correct lasers with the appropriate parameters, individualized to each patient, is very important, particularly in patients with intrinsically dark skin. Most of the complications are preventable when adequate precautions are taken with adjustment of the fluence, spot size, wavelength, and the use of cooling methods. Thus, it is all the more important that trained personnel with a thorough knowledge of the mechanisms, techniques, and complications, carry out these procedures.

Enhancing Healthcare Team Outcomes

Laser hair removal is done by many healthcare workers including nurses, dermatologist, plastic surgeons, primary care providers and cosmetic surgeons. Unfortunately, because of lack of oversight complications are common during this procedure. To make matters worse, patients are often given unrealistic expectations. The key is to use the correct laser, especially in dark skinned individuals. Common adverse effects of laser or IPL-based hair removal include post-treatment erythema, pain, and burning.[18] More severe adverse effects include blistering, crusting, dyspigmentation, purpura, and sometimes, scarring.[19][20] Ocular complications due to accidental injury may be seen. Paradoxical hypertrichosis may rarely occur, more commonly in skin types III and with the use of IPL systems.[21][22][23]

Overall, lasers can remove hair but rarely does the procedure provide a permanent cure for hair growth. Touch ups are required in future in most patients.


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Laser Hair Removal - Questions

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Which of the following is the most appropriate laser to remove hair for a fair-skinned, white female?



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Prior to laser hair removal, what advice is given to patients?



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Which is true about laser hair removal?



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A patient with type V skin presents to your office for consultation regarding laser hair reduction. Which laser is considered safest for laser hair reduction in dark-skinned individuals?



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Which of the following is allowed in the intervening period between the sessions of laser hair reduction?



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Which of the following lasers is not used in for laser hair reduction?



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What is the target chromophore which absorbs photons of the laser in hair reduction?



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Which of the following is true?



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Which of the following is not allowed to be done on an area, prior to the procedure of laser hair reduction?



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Which condition is not treated with laser hair reduction?



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Laser Hair Removal - References

References

Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation., Anderson RR,Parrish JA,, Science (New York, N.Y.), 1983 Apr 29     [PubMed]
Extended theory of selective photothermolysis., Altshuler GB,Anderson RR,Manstein D,Zenzie HH,Smirnov MZ,, Lasers in surgery and medicine, 2001     [PubMed]
Hair removal with a non-coherent filtered flashlamp intense pulsed light source., Weiss RA,Weiss MA,Marwaha S,Harrington AC,, Lasers in surgery and medicine, 1999     [PubMed]
Evidence-based review of hair removal using lasers and light sources., Haedersdal M,Wulf HC,, Journal of the European Academy of Dermatology and Venereology : JEADV, 2006 Jan     [PubMed]
Laser hair removal., Goldberg DJ,, Dermatologic clinics, 2002 Jul     [PubMed]
Hair removal using a pulsed-intense light source., Tse Y,, Dermatologic clinics, 1999 Apr     [PubMed]
Laser therapy on darker ethnic skin., Battle EF Jr,Hobbs LM,, Dermatologic clinics, 2003 Oct     [PubMed]
Lasers in dermatology: four decades of progress., Tanzi EL,Lupton JR,Alster TS,, Journal of the American Academy of Dermatology, 2003 Jul     [PubMed]
Laser-assisted hair removal in Asian skin: efficacy, complications, and the effect of single versus multiple treatments., Hussain M,Polnikorn N,Goldberg DJ,, Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 2003 Mar     [PubMed]
Side effects and complications of laser therapy., McBurney EI,, Dermatologic clinics, 2002 Jan     [PubMed]
Reticulate erythema following diode laser-assisted hair removal: a new side effect of a common procedure., Lapidoth M,Shafirstein G,Ben Amitai D,Hodak E,Waner M,David M,, Journal of the American Academy of Dermatology, 2004 Nov     [PubMed]
Paradoxical hypertrichosis after laser epilation., Alajlan A,Shapiro J,Rivers JK,MacDonald N,Wiggin J,Lui H,, Journal of the American Academy of Dermatology, 2005 Jul     [PubMed]
Laser-assisted hair removal by selective photothermolysis. Preliminary results., Lask G,Elman M,Slatkine M,Waldman A,Rozenberg Z,, Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 1997 Sep     [PubMed]
A practical review of laser-assisted hair removal using the Q-switched Nd:YAG, long-pulsed ruby, and long-pulsed alexandrite lasers., Nanni CA,Alster TS,, Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 1998 Dec     [PubMed]
Hair removal by lasers and intense pulsed light sources., Dierickx CC,, Dermatologic clinics, 2002 Jan     [PubMed]
Damage to hair follicles by normal-mode ruby laser pulses., Grossman MC,Dierickx C,Farinelli W,Flotte T,Anderson RR,, Journal of the American Academy of Dermatology, 1996 Dec     [PubMed]
Permanent hair removal by normal-mode ruby laser., Dierickx CC,Grossman MC,Farinelli WA,Anderson RR,, Archives of dermatology, 1998 Jul     [PubMed]
Laser hair removal: a review and report on the use of the long-pulsed alexandrite laser for hair reduction of the upper lip, leg, back, and bikini region., McDaniel DH,Lord J,Ash K,Newman J,Zukowski M,, Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 1999 Jun     [PubMed]
Laser-assisted hair removal: side effects of Q-switched Nd:YAG, long-pulsed ruby, and alexandrite lasers., Nanni CA,Alster TS,, Journal of the American Academy of Dermatology, 1999 Aug     [PubMed]
Alexandrite laser hair removal is safe for Fitzpatrick skin types IV-VI., Garcia C,Alamoudi H,Nakib M,Zimmo S,, Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 2000 Feb     [PubMed]
Nd:YAG laser hair removal in Fitzpatrick skin types IV to VI., Chan CS,Dover JS,, Journal of drugs in dermatology : JDD, 2013 Mar     [PubMed]
Long-term photoepilation using a broad-spectrum intense pulsed light source., Sadick NS,Weiss RA,Shea CR,Nagel H,Nicholson J,Prieto VG,, Archives of dermatology, 2000 Nov     [PubMed]
Prospective study of hair reduction by diode laser (800 nm) with long-term follow-up., Lou WW,Quintana AT,Geronemus RG,Grossman MC,, Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 2000 May     [PubMed]

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