Laser Hair Removal Treatment & Management

Alternative treatments for hair removal or concealment are available and include waxing or sugaring, electrolysis, bleaching, depilation, shaving, tweezing, and application of eflornithine hydrochloride cream (Vaniqa).

Vaniqa is a recently introduced topical cream that works for some women. The active ingredient is eflornithine hydrochloride, which inhibits an enzyme (ornithine decarboxylase) that affects hair growth. Unpublished efficacy data submitted to the FDA showed that about 58% of women using the cream on facial hair had an improvement. This observation suggests the cream may be particularly effective in postmenopausal women. Vaniqa is currently approved for use on only the face and chin in female adolescents and women older than 12 years. In theory, the agent can be used as an adjuvant to laser hair removal.

Patients are ready for treatment after their skin type is categorized and after they have had a patch test. The treatment can be performed with or without topical anesthesia, depending on the patient's comfort level; however, see Cautions about topical anesthetics below. The pain response varies with the individual, with the area being treated (see the image below), and with the energy level of the treatment. Accordingly, anesthesia must be tailored to each patient.

Pain-sensitivity diagram.

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In the opinion of the present authors, the most effective and simplest anesthesia currently available is eutectic mixture of local anesthetics (EMLA) or ELA-Max topical anesthetic cream. Table 1 lists the most common anesthetics, their active ingredients, and their advantages and disadvantages.

Table 1. Advantages and Disadvantages of Anesthetics (Open Table in a new window)

Patients are instructed not to pluck hairs for several weeks prior to treatment and not to sunbathe for several weeks or even months before the procedure. Some lasers (eg, the CoolGlide laser) are reported to work even when patients sunbathe, but the procedure is less effective in people who sunbathe than in those who do not.

The area to be treated is shaved before anesthetic cream is applied. The cream is later removed, and the area is marked (an eye-makeup marker works best) and photographed. If a cooling gel is used, it is applied at this stage. If the handpiece offers dynamic cooling, it is firmly applied to the skin.

Cautions about topical anesthetics

At least 3 deaths have been linked to use of topical anesthetics in preparation for laser hair removal. Practitioners must educate patients about interactions between topical anesthetics and other pain medications, and both the practitioner and the patient must be aware of early symptoms of adverse reactions.

The laser is applied to the target area at the fluence level predetermined by patch testing.

After treatment, most patients have a mild sunburn-type sensation that fades in 2-3 hours. Moisturizers and/or cool compresses can help during this time. Small blister areas can be treated with Bacitracin applied 3 times daily until they resolve.

Sunblock should be used for as long as 6 weeks after treatment if sun exposure is anticipated. No waxing, shaving, or dying should be performed for 2 weeks after treatment. Pretreatment restrictions also apply to the posttreatment period.

Ejection of hair shafts (ie, clearing out) occurs in the first 10-14 days. Some erythema and minor edema can persist for 2-3 days after facial treatment and longer in other areas (eg, 1 wk on the trunk). Treated sites should be washed with gentle soap (eg, Dove) and water twice a day.

A study by van Vlimmeren et al indicated that during photoepilation, light pulses prompt a dose-dependent response (both macroscopic and microscopic) in hair follicles. The investigators found that once exposed to fluences below 13.2 J/cm², follicles in the anagen stage of the hair growth cycle underwent catagen-stage changes, while higher fluences prompted coagulation in the hair follicle compartments. ^[16]

Three treatments (range, 2-6 sessions) are usually needed to achieve the desired effects. The timing of treatments is important because hair should be treated during the anagen phase. This phase is short (6-12 wk) for hair on the head, and treatments are spaced a month apart. On the trunk, the telogen phase lasts 12-24 wk, and 2-month spacing is best.

Table 2. Distribution of Hairs in the Telogen and Anagen Phases and Growth Times (Open Table in a new window)

Hyperpigmentation is the most common effect and usually resolves within 6 months without treatment. The following complications are possible: itching during treatment; pain, tingling, or a feeling of numbness (with a cold spray); crusting or scab formation on ingrown hairs; bruising (rare); purpura on tanned areas; redness; swelling; infection (uncommon); and temporary hypopigmentation or hyperpigmentation; and scarring (which does not occur at proper fluences and with appropriate skin cooling). ^[18]

Table 3. Reported Incidence of Adverse Events in Different Laser, Light, and Light/Heat Energy Systems on Skin Types IV-VI (Open Table in a new window)

A study by Atta-Motte and Załęska indicated that the side effects of hair removal with the 805 nm diode laser can vary according to patient ethnicity. Patients in the report underwent treatment of the pubic area, with the investigators finding that sensitivity, hyperpigmentation, and burns occurred more frequently in black and mixed-race patients than in those of White or Asian ethnicity. However, ethnicity did not significantly affect the incidence of erythema. In addition, the study reported that the development of side effects was also associated with the number of laser treatments. While multiple side effects arose in 9.79% of patients who underwent six treatments, one third of individuals who had more than six treatments experienced multiple effects. ^[20]

Based on over 1200 medical device reports (MDRs) concerning medical technology used in dermatology, as contained in the US Food and Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database, Tremaine and Avram identified radiofrequency devices, diode lasers, and intense pulsed light devices to be the devices most frequently reported in association with injuries. ^[21]

Outcomes vary, and any assurances of 100% effectiveness or 0% regrowth (often stated in marketing campaigns) should not be believed. Certain patients have a minimal response, whereas others have exceptional response. In addition, the treatment applied is often variable in the outcome.

Treatment at painless, low-energy levels produces a response that the present authors call laser waxing. This technique essentially induces the follicles to enter the telogen phase so that they grow back over time; however, they grow back exactly as they had been.

For permanent hair reduction, the laser must be applied to its limit for the particular patient and for the area being treated (as determined with careful patch testing). This requirement usually means a painful treatment and a need for local anesthesia. Only this method truly provides an opportunity for permanent follicular death. Any claims to the contrary should be viewed with suspicion.

Treatment as described provides gratifying and permanent results, and patients are often extremely pleased.

A study by Ormiga et al involving 21 female patients indicated that a diode laser and intense pulsed light (IPL) can both be used to achieve safe, effective long-term axillary hair removal. The diode laser was nonetheless found to be more effective than IPL, although it was also found to be more painful. ^[22]

Laser manufacturers will further refine their products, and other modalities (eg, oral or topical medical therapy) may eventually supplant laser hair removal. Until then, current laser treatment probably has reached its maturity, and the field lacks only long-term studies to prove the permanent efficacy of laser hair removal when it is properly applied.

In 2007, Sand et al published a paper that studied the use of sprayed-on liposomal melanin (Lipoxome; Dalton Medicare B.V., Zevenbergschen Hoek, The Netherlands) to allow removal of blond/white and gray hair with a diode laser. ^[23] Their study found a very mild increase in the removal of such hairs after 6 months, but "the clinically observed hair reduction was so weak that additional effort as well as higher costs argues against the application of the tested formulation."

A study by Chuang et al suggested that the burning-hair plume often released during laser hair removal is a biohazard and that smoke evacuators, good ventilation, and respiratory protection should therefore be employed for health-care workers involved in this procedure, especially those who undergo prolonged plume exposure. Using gas chromatography-mass spectrometry, the investigators found known or suspected carcinogens and known environmental toxins in the plume. ^[24]