Laser Hair Removal, Second Edition (Series in Cosmetic and Laser Therapy)

Laser Hair Removal - David J. Goldberg

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The world of cosmetic and aesthetic medicine and surgery has grown greatly in size and complexity over recent years, and the series in Cosmetic and Laser Therapy keeps readers up to date with the latest clinical therapies to improve and rejuvenate the appearance of skin, hair, and nails. Published in association with the Journal of Cosmetic and Laser Therapy , each volume in the series is prepared separately and typically focuses on a topical theme.

Volumes are published on an occasional basis, according to the emergence of new developments. Functional Anatomy and Injection Techniques. Textbook of Chemical Peels: Illustrated Manual of Injectable Fillers: Monheit June 08, Practitioners of aesthetic medicine and surgery already have a series of textbooks instructing on how to treat the standard patient. Unfortunately, they also have patients who do not conform to the average—those who are of a different age, or sex, ethnicity, or medical history, or who have special Anthony V Benedetto February 22, This bestselling guide to the complexities of botulinum toxins has now been extensively revised, updated, and expanded.

Now in two volumes, Volume 1 examines clinical adaptations in the toxins in use today, use with other injectables, use for other parts of the body and other indications, and legal Berlin May 31, Alterations in the amount of subcutaneous fat lead to significant changes in appearance, whether from excess as seen in bodily obesity or in loss of fat as seen in facial lipodystrophy associated with the aging process.

This book incorporates the current knowledge of the physiology of fat with Robert Baran, Howard I. Maibach May 22, This text documents the science that lies behind the expanding field of cosmetic dermatology so that clinicians can practice with confidence and researchers can be fully aware of the clinical implications of their work. New chapters have been added to this edition on photodamage, actinic keratoses, Philippe Deprez, Philippe Deprez May 24, Chemical peels have returned to the forefront of the practitioner's armamentarium and are popular because they offer nearly immediate results.

The Textbook of Chemical Peels is the definitive guide to all types of chemical peel treatments.

It covers the practical application and scientific Publications on aesthetic rejuvenation often start with the treatment—such as fillers or lasers—and then work back to the patient problem. A Regional Approach starts from the perspective of what the patient perceives as the problem region of the body. In color throughout, Illustrated Manual of Injectable Fillers clearly evaluates the uses, limitations, and compositions of the growing variety of available fillers involved in face and body rejuvenation.

It includes detailed techniques for the facial analysis and diagnosis of aging conditions. Kenneth Beer, Mary P. Narurkar January 18, Minimally invasive aesthetic procedures continue to be popular with patients, so many medical practitioners who have not previously specialized in the field or practiced very widely are either turning to this area or expanding the range of treatments they currently offer. Cosmeceuticals are skin-care products that fall between a cosmetic and a pharmaceutical; that is, they have active ingredients that counter skin ageing and promote skin rejuvenation.

As such, they are an invaluable adjunct to the cosmetic dermatologist or plastic surgeon performing minimally Avi Shai, Howard I. The evidence is controversial as to what pretreatment methods of hair removal will help achieve the most effective laser hair removal.

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In the guidelines set forth by the European Society for Laser Dermatology, Drosner and Adatto recommended avoiding any pretreatment plucking, waxing, or electrolysis because the light needs the melanin in the hair shaft as a chromophore in order to produce successful photoepilation. I routinely recommend that patients avoid plucking or waxing initially prior to laser hair removal treatment; I also recommend that patients cut or shave hair prior to treatment to minimize absorption of laser energy by melanin above the surface of the skin.

Some of the most frequent complications following laser use are persistent erythema and pigmentary change. There is a paucity of controlled studies examining pre- and postoperative sun exposure in regard to frequency of complications following laser treatment. For many years, cosmetic surgeons have advised their patients to avoid sun exposure prior to and following laser treatment, believing, based on empiric data, that it leads to postinflammatory hyperpigmentation. Hyperpigmentation of the skin is typically related to stimulation of the melanocytes while hypopigmentation results from melanocyte destruction, suppression of melanogenesis, or melanin redistribution in the keratinocytes.

Some authors have recommended sun avoidance for up to 3 months following laser treatment to minimize additional inflammation of the treated area, however there are no formal recommendations regarding sun exposure before and after laser treatment. Such recommendations are particularly difficult in warmer, sunny climates. Following her third treatment, the patient had sunlight exposure on the treated sites during the week following her laser treatment and then developed hyperpigmented patches on her inner thighs. The authors speculated that the pigmentary changes may be directly related to the heat injury from the laser or the cold injury from the cryogen.

They did not comment on any associated sun exposure prior to or following laser treatment in these patients. In general, laser hair removal remains a very safe and effective treatment; however, there are some areas where the risks of laser hair removal outweigh any benefits.

Series in Cosmetic and Laser Therapy

Interestingly, there have been several reports of hair growth that was induced by laser treatment. The patient returned 14 weeks later with dramatically increased hair growth in the area of the test spot. Subsequent laser treatments were performed to the hypertrichotic area. Following the third treatment, an annulus of hair appeared surrounding the treated area which was then treated by electrolysis. The author speculated that the complex mechanism of laser hair reduction may incite a reaction that actually stimulates localized hair growth.

The authors hypothesized that in these cases, the produced heat is less than the temperature necessary for thermolysis and that the heat shock may induce follicular stem cell differentiation and growth via increased heat shock proteins and other growth factors.

The authors speculated that sublethal doses of IPL may have induced activation of dormant follicles. A separate study by the Finally, Vlachos and Kontoes described the development of terminal hair in areas treated by intense pulsed light. This was reported in 2 patients: Both of the patients developed terminal hairs in areas that had previously had only vellus hairs. The authors speculated that the inflammatory reaction induced by the IPL treatment can potentially induce hair growth.

Brilakis and Holland reported diode-laser-induced cataracts and iris atrophy as a complication of eyelid hair removal. The authors advised avoidance of periocular laser treatment; if treatment is necessary, they advocated the use of ocular shields.

Besides the periorbital area, we have not found that there is a specific area not to treat. Although there have been a few reports of paradoxical hypertrichosis following laser hair removal treatment, this is not the usual scenario. Laser hair removal is still an evolving treatment. There remain a limited number of studies regarding recommendations before, during, and after treatment. Evidence-based review of hair removal using lasers and light sources. J Eur Acad Dermatol Venereol ; Management of unwanted hair in females. Clin Exp Dermatol ; Treatments for unwanted facial hair.

Skin Therapy Lett Dec— Jan; 10 Clin Obstet Gynecol ; Long-term epilation with long-pulsed neodinium: A clinical study of hair removal using the long-pulsed ruby laser. YAG, long pulsed alexandrite, and long-pulsed diode lasers. Dermatol Surg ; — Long-term epilation using the EpiLight broad band, intense pulsed light hair removal system. Human hair growth in vitro. J Cell Sci ; Modulation of dermal cell activity during hair growth in the rat. J Cutan Pathol ; 2: Growth and differentiation of hair follicles between periods of activity and quiescence.

J Exp Zool Label-retaining cells reside in the bulge area of pilosebaceous unit: Growth of the hair. Physiol Rev ; The long-term results of ruby laser depilation in a consecutive series of patients. Plast Reconstr Surg ; Location of stem cells of human hair follicles by clonal analysis. Dermatol Ther ; Damage to the hair follicles by normal-mode ruby laser pulses.

J Investig Dermatol Symp Proc ; Guidance for the management of hirsutism. Curr Med Res Opin ; Does low penetration of human skin by the normal mode ruby laser account for poor permanent depilatory success rates? New dimensions in hirsutism. Time constants in thermal laser medicine. Lasers Surg Med ; 9: A review of the adverse effects of laser hair removal. Permanent hair removal by normal- mode ruby laser. Influence of the anagen: YAG laser hair removal efficacy. Histologic features seen in changing nevi after therapy with an nm pulsed diode laser for hair removal in patients with dysplastic nevi.

Hair growth cycle affects hair follicle destruction by ruby laser pulses. J Invest Dermatol ; 1: Laser-assisted hair removal by selective photothermolysis. Stem cells in the hair follicle bulge contribute to wound repair but not to homeostasis of the epidermis. Nat Med ; The effects of laser-mediated hair removal on immunohistochemical staining properties of hair follicles. The hair cycle on the human thigh and upper arm. Seasonal changes in human hair growth. Disorders of hair growth: New York, ; — Lasers may induce terminal hair growth.

Hair removal using an nm diode laser: Hair removal with the long-pulsed Nd: Comparison of alexandrite laser and electrolysis for hair removal. The role of number of treatments in laser-assisted hair removal using a nm alexandrite laser. J Drugs Dermatol ; 4: A comparison of the efficacy and side effects of different sources in hair removal.

Evaluation of the ruby Chromos for hair removal in various skin sites. Laser hair removal, guidelines for management. Am J Clin Dermatol ; 3: Effect of wax epilation before hair removal with a long-pulsed alexandrite laser: Dermatol Surg ; 29 2: Modulation of murine hair follicle function by alterations in ornithine decarboxylase activity. J Invest Dermatol ; 5: Am J Clin Dermatol ; 2 3: Eflornithine cream combined with laser therapy in the management of unwanted facial hair growth in women: Solar-induced postinflammatory hyperpigmentation after laser hair removal.

Free radicals in human skin before and after exposure to light. Arch Biochem Biophys ; Pigmentary changes after alexandrite laser hair removal. Hair growth induced by diode laser treatment. Development of terminal hair following skin lesion treatments with an intense pulsed light source.

Aest Plast Surg ; Paradoxical effect after IPL photoepilation. Side-effects after IPL photoepilation. Diode-laser-induced cataract and iris atrophy as a complication of eyelid hair removal. Am J Ophthalmol ; —3. Global photos are important as they capture the overall appearance of the patient and the distribution and apparent density of hair across the region of interest.

Global photos are most likely to be used for a quick assessment of progress at each patient visit and to prove efficacy to patients. Good global photos will save the practice time as efficacy of therapy and patient progress can often be assessed with but a cursory glance. Global photographic methods range from point and shoot camera snap shots through serial photos where distance, focal length zoom , lighting, and photographic technique are all standardized. The variables we must master are as follows: Focal length can be simply standardized with digital SLRs by selecting a fixed focal length non-zoom lens.

Lighting reproducibility is achieved by simply using a flash for all your global photos. Post treatment erythema can be difficult to quantify when the wrong white balance or inconsistent white balance is selected. Photographic technique encompasses aperture, shutter speed, ISO, and white balance. Space precludes a detailed discussion of the meaning and effect of each of these terms.

Suffice it to say, that the camera you choose for your clinical photos should feature the ability to set these parameters yourself to ensure consistency and reproducibility. Positioning can be standardized by creating an internal photo-standard illustrated with views to be acquired, and featuring photos to be referred to as canonic standards. To standardize the angle of patient rotation in the Z-axis, a patient-posing mat can be created or purchased as illustrated Figure 9. For headshots, use the ears as landmarks to minimize rotation; if one ear is showing much more than the other, chances are the patient is rotated.

Rotation of the head in the X-axis tilt is best managed by using an anatomic standard Frankfurt Line Figure 9.

The Frankfurt Line runs from the external auditory meatus to the inferior orbital rim. Pay attention too to the angle at which you take your images. In most cases you will want the lens perpendicular to the anatomy you are Have the patient sit or get up on a photo stage rather than anglingthe camera and distorting anatomy. Views can be kept to a minimum. Position the subject and camera so that the regionof interest is as close as possible to parallel to the capture plane.

For specific regionsas requested by the patient, always check the pre-procedure photo so as toduplicate the view post treatment. For many common hair removal sites, views can Often, a simple photo with the patient facing you or turned degrees will suffice Figures 9. For facial photos, always capture a tight headshot and a close-up of the area of interest Figures 9. For the axilla, have the patient place the palm of the hand on the back of the neck while rotating the patient 30 degrees anteriorly Figure 9.

For the bikini area, have the patient face you, one foot pointed forward, the other rotated 90 degrees externally. This view must be captured with each leg rotated in turn. For the neck and submental region, the patient stands, and tilts the head back 30 degrees off the Frankfurt Line Figure 9. If choosing a point and shoot camera, choose a camera that allows for a mode that lets you set the aperture white balance and ISO. Use an external flash to provide more homogeneous lighting. Macro twin flashes Figure 9. Choose someone with a trackrecord in clinical photography for best results.

Its raked lighting system also helps visualize very fine and pale hairs. Despite this, macro photography is a different animal and good macro photos are rarer than good global photos. SLRs have superior optics, easier manual focusing, TTL metering and external macroflash options, which make them a better choice for good macro photography than point and shoot cameras.

With point and shoot cameras, metering for macro images is difficult — they tend to overexpose if you get in too close to the subject matter. Turn on your macro function the little flower , step back and zoom in. If you need to see more detail, good image management software will allow you to zoom in afterwards for review.

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Cameras rely on contrast to auto-focus. When the camera is in very close to the anatomy and you are blocking the light the camera needs to focus, the lens may move back and forth in a fruitless effort to focus. With an SLR, switching to manual focus and turning the lens to some preset number on the lens distance, reproduction ratio will allow you to move the camera slightly forward and aft, shooting when the anatomy is in focus.

This body focusing1 helps to standardize your field of view too. With a point and shoot camera, it may help to add some artificial contrast to the image, a mm sticker for instance. You can also slip a cotton swab into the field of view, depress the shutter, let the camera focus, withdraw the cotton swab and depress the shutter the rest of the way to take the photo. Also ensure a manual focusing option is available.

Close-up scales Figure 9. The same lens can be used for your global photos. Close-up scales can be purchased to standardize distance and introduce a frame of reference. Macro twin flashes are a good option for macro work as the built-in flash may be partially blocked by the lens.

For the macro image, pick a landmark or skin feature that you can see on the global view. In clinical trials, a This is not the case in private practice imaging. For precise imaging in the absence of tattooing, a sheet of acetate with a cut-out in the center can be employed. Two landmarks outside the field of view are marked mole, scar, vein, etc.

ELM employs a light source close to the skin and a glass contact plate Figure 9. Fluid isopropyl alcohol, hand gel, etc. The glass contact plate is then placed against the skin and the photo taken. The fluid optically couples the glass plate to the skin, minimizing reflection and refraction, so that hair and follicle can be more clearly visualized Figures 9.

For computer-aided density counts, the field of view needs to be standardized or a distance scale included on all photos. Capture of the same anatomic area is essential for recording meaningful data. The proper software package will also include tools for quickly calculating density counts. The medical software application you choose should include the following: Both global and macro photos are required for managing this patient population. Good photos are an important resource for marketing your practice, illustrating your technical acumen, and ensuring patient satisfaction.

Good clinical photos will help you retain patients as clients for other aesthetic procedures as the field of aesthetic medicine grows ever more crowded. Cutis, ; 54 3: Most individuals demonstrate greater melanin density in their hair as compared to their epidermis such that the absorption coefficient of the hair shaft and bulb is roughly 2—6 times that of the epidermis. Unfortunately, such a situation does not exist. The advantage of choosing melanin as a hair absorbing target is that it is already present in both the hair follicle and shaft.

However, in terms of complications, melanin is found not only in the hair follicle, but in the epidermis as well. Light must initially pass through the epidermis in order to get to the deeper hair follicle and is therefore potentially absorbed first in the epidermis. This may have several consequences.

Absorption of light in the epidermis results in possible adverse effects such as vesiculation, crusting, burns, and dyspigmentation. The incidence of cutaneous adverse effects, after laser hair removal, is both patient and wavelength dependent. It should be noted that such complications are not limited to patients with genetically determined dark skin.

They may also be seen in patients with darker skin due to other reasons, such as sun-tanning and lentiginous photoaging. A constitutionally higher reactivity to a variety of trauma in these darker skin types may be the reason for this observed effect. Factors that could theoretically impact on the incidence of adverse effects include utilized wave length, fluence, pulse duration, utilized hand piece spot size, and the use of appropriate cooling. A laser with a longer wave length and longer pulse duration is less likely to be absorbed by epidermal melanin.

While it is true that wavelengths with lower absorption coefficients will decrease the amount of light absorbed by epidermal melanin, these longer wavelengths also decrease the amount of light absorbed in hair and hair shaft containing melanin. With this occurring, the amount of heat producing delivered light must be increased to obtain the desired effect. Similarly, increasing the pulse duration will decrease the rate of heat generation in both the epidermis and in the hair follicle, again requiring an increased amount of light to be delivered to obtain the desired result.

Variations in these parameters can either be beneficial or detrimental. Thus, in the end, the laser parameters need to be chosen to limit thermal diffusion to the size of the hair follicles, and limit its diffusion into surrounding tissue. Effective laser hair removal requires an appropriately delivered spot size of energy.

The smaller the spot size, the more rapid is the scattering of photons away from the treated follicle. Using a larger spot size leads to more efficient light penetration, greater depth of penetration, and a lower required threshold fluence. By requiring a lower fluence, less collateral heat is delivered lessening undesired thermal damage. Greater utilized fluences lead to greater heat deposition in the hair and hair shaft — a desired effect. However the same heat induction can lead to epidermal blistering and a diffuse thermal effect — an undesired effect that is lessened with current cooling devices.

Unfortunately these studies have not been carried out under standardized conditions. Different laser parameters have been used; the follow up period has varied from 90 days to 2 years; the preoperative skin characteristics were not standardized hair color, skin pigmentation, anatomical region ; and the majority of studies estimated the incidences of side effects by subjective clinical evaluations.

These changes generally depended on the degree of pre-treatment pigmentation. The postoperative reflectance- determined skin pigmentation differed from the preoperative skin pigmentation in 47 out of 51 treated areas; yet clinically visible pigmentary changes were only seen in 6 of the treated areas. No linear dose—response relationship was observed. Anecdotally, many clinicians have noted that light-pigmented skin types experience more postoperative sub-clinical hyperpigmentation. Darker pigmented skin types experience more postoperative sub-clinical hypopigmentation.

This finding might occur because laser light in dark-pigmented skin types is strongly absorbed by epidermal melanin. This absorption might lead to damage of melanocytes. Hypopigmentation Hypopigmentation, though generally transient, can be unpleasant for the cosmetic laser hair removal patient. This loss of pigment may last for many months.

This hypopigmentation may be related to destruction of melanocytes, suppression of melanogenesis, or the redistribution of melanin in the keratinocytes. Recent research has shown8 that the number of melanocytes with tyrosinase activity the first enzyme in the synthesis pathway of melanin decreases dramatically immediately after laser treatment.

Yet, the absolute number of S positive melanocytes remains constant. In addition, there appears to be no definite alteration in the distribution of melanosomes in keratinocytes after treatment. It is therefore likely that the hypopigmentation seen after laser treatment is related to the suppression of melanin synthesis, rather than a change in the number of melanocytes in the basal layer of the epidermis.

The mechanism of tyrosinase block is unknown. It could be due to the effect of heat, as tyrosinase enzymatic activity is normally suppressed by high temperature. It could also be due to the mechanical disruption of melanosomes following laser irradiation. This is all consistent with the general clinical finding of reversibility of skin hypopigmentation after laser assisted hair removal. However, in those circumstances where melanocytes in the periglandular and perifollicular areas are destroyed or significantly disabled, the Permanentloss of pigment is very rare Figures Patients presenting with this complication seem to show a similar patternof initial hyperpigmented rings that subsequently develop into a thin wafer-likecrust followed by hypopigmentation with a gradual return to normal skin color.

In trying to analyze the possible etiologies for this occurrence, some authors havesuggested several possibilities. Additionally, investigators have suggested, that if suchhypopigmentation was machine malfunction related, one would expect a consecutivenumber of patients to be affected. This has not been the case in our series. Instead,affected patients seem to be treated on different dates with numerous patients beingtreated between these occurrences. In analyzing the complication of hypopigmentation, it is important to note thatcurrent hair removal lasers tend to operate with 2 diametrically opposed forces.

There is heat that is generated as a result of selective photothermolysis, which ismeant to heat, and thereby damage, the hair follicle. There is also cooling that isdesigned to protect the epidermis as the laser beam penetrates the skin surface enroute to deeper structures. Both the delivered heat and cold can generate pigmentarydyschromia. Some have suggested that the pattern of pigmentary change wouldsuggest cold as the underlying cause.

The rings of hypopigmentation generallycorrespond to the size and shape of the end of cryogen cooling associated distancegauges that contact the skin. However, to be effective and safe, the cooling medium must completely cover theskin surface before laser irradiation. These authors note that cryogen cooling associated epidermal protection iscomplete only when the handpiece is held perpendicular to the skin surface.

If thehandpiece is angled from perpendicular, incomplete cryogen coverage of the laserspot occurs and a crescent-shaped burn can be observed. If thermal injury is noted when the handpiece is held perpendicularly and adequate cryogen spurt duration has been chosen, the spray nozzle may be misaligned and require adjustment.

This may require special attention, particularly during treatment of curved anatomic surfaces. Hyperpigmentation The exact pathogenesis of posttreatment hyperpigmentation is also obscure. Hyperpigmentation of the skin after most cutaneous skin injuries is related to melanocytic stimulation. In addition, arachadonic acid metabolites and histamine, which are found in increased amounts in inflamed skin, are thought to play a key role in post-injury pigmentary changes.

This darkening is usually transient, lasting only 3—4 weeks and resolving spontaneously without sequelae. Although immediate pigment darkening always resolves, this second type of hyperpigmentation has the potential for permanent dyschromia, both in very dark-skinned individuals and darkly tanned individuals Figures These changes, as described above, are typical for those seen after a YAG laser hair removal YAG laser hair removalFigure Laser Hair Removal - David J.

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