Laser Hair Removal
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Laser Hair Removal
Excessive and unwanted body hair is a common frustration for many individuals, and despite the many etiologies, the desire for permanent removal remains universal. Before the development of lasers and light sources, treatments for the removal of unwanted hair were tedious, generally temporary in nature and often associated with significant side-effects. The ability to selectively target and destroy hair follicles with lasers and light sources has revolutionized the ability to eliminate unwanted hair temporarily and permanently in many individuals. As laser technology advances, the ability to treat individuals of all skin types and all hair colors broadens.
Proper patient selection and laser and light source selection are key to the success of laser treatment. An understanding of hair anatomy, growth and physiology, together with a thorough understanding of laser–tissue interactions, in particular within the context of designing optimal laser parameters for effective laser hair removal, must be acquired before using lasers for hair removal.
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Hair Anatomy
The first hair follicles are formed at the end of the second and beginning of the third month of gestation in the eyebrow, upper lip, and chin regions, with further hair growth in a cephalad to caudal direction during the fourth to fifth months of gestation. No further follicular neogenesis occurs after birth.
The hair follicle is divided into three anatomical units: infundibulum, isthmus, and inferior segment. The infundibulum includes the region from the hair follicle orifice to the sebaceous duct entrance. The isthmus includes the region between the entrance of the sebaceous duct and the arrector pili muscle. The inferior segment extends from the insertion of the arrector pili muscle to the base of the follicle, including the hair bulb.
The hair bulb is composed of matrix cells interspersed with melanocytes. The matrix cells differentiate along separate pathways and form, from the outside inward, the outer root sheath, the three layers of the inner root sheath
The first hair follicles are formed at the end of the second and beginning of the third month of gestation in the eyebrow, upper lip, and chin regions, with further hair growth in a cephalad to caudal direction during the fourth to fifth months of gestation. No further follicular neogenesis occurs after birth.
The hair follicle is divided into three anatomical units: infundibulum, isthmus, and inferior segment. The infundibulum includes the region from the hair follicle orifice to the sebaceous duct entrance. The isthmus includes the region between the entrance of the sebaceous duct and the arrector pili muscle. The inferior segment extends from the insertion of the arrector pili muscle to the base of the follicle, including the hair bulb.
The hair bulb is composed of matrix cells interspersed with melanocytes. The matrix cells differentiate along separate pathways and form, from the outside inward, the outer root sheath, the three layers of the inner root sheath
Mechanism of laser hair removal
The theory of selective photothermolysis enables precise targeting of pigmented hair follicles by using the melanin of the hair shaft as a chromophore. Melanin has an absorbance spectrum that matches wavelengths in the red and near-infrared (IR) portion of the electromagnetic spectrum. To achieve permanent hair removal, the biologic “target” is the follicular stem cells located in the bulge region and/or dermal papilla. Due to the slight spatial separation of the chromophore and desired target, an extended theory of selective photothermolysis was proposed that requires diffusion of heat from the chromophore to the desired target for destruction. This requires a laser pulse duration that is longer in duration than if the actual chromophore and desired target are identical. Temporary LHR can result when the follicular stem cells are not completely destroyed, primarily through induction of a catagen-like state in pigmented hair follicles. Temporary LHR is much easier to achieve than permanent removal when using lower fluences. Long-term hair removal depends on hair color, skin color, and tolerated fluence. Approximately 15% to 30% long-term
Laser hair removal was FDA cleared in l996 and has an excellent safety and efficacy profile. Complications are rare if treatments are done carefully and with the patient’s skin type in mind.
Laser hair removal is not a painless procedure. Most patients experience some discomfort during and immediately after treatment. A topical or local anesthetic can be used before treatment to reduce this effect. Perifollicular erythema and edema are expected in many patients treated with significant laser fluences. The intensity and duration depend on hair color and hair density.
Epidermal damage occurs if excessive fluences are used It is also more common in patients with a tan. Herpes simplex outbreaks are uncommon but may occur. There is a higher risk among patients with a previous history of herpes simplex and when the perioral, pubic, or bikini area are treated. The risk of bacterial infection is extremely low. However, it may occur following epidermal damage.
Folliculitis may occur in areas treated after excessive sweating or vigorous exercise. An additional risk is posed by swimming or using a hot-tub around treatment sessions.
The most common side effects are transient pigmentary changes such as hypopigmentation or hyperpigmentation . It can be prevented if the appropriate treatment fluences are chosen for a certain skin type. This problem is mostly seen in patients with darker skin types or when patients have had a recent tan. Permanent pigmentary changes are unlikely except in dark-skinned individuals.
Scarring is unlikely except in cases of over-aggressive treatment or postoperative infection.
Loss of freckles or lightening of tattoos or pigmented lesions is not uncommon. Patients should be aware of this possibility.
Temporary or permanent leukotrichia has been said to develop following laser or IPL hair removal. This finding may be explained by the difference in the thermal relaxation times of melanocytes and germinative cells. The light absorbed and the heat produced by melanin may be sufficient enough to destroy or impair the function of melanocytes but insufficient to damage the hair follicle cells.
A case of lichen planus triggered by long-pulsed ruby-laser treatment for hair removal has been reported. Logic would suggest that all patients with a history of skin diseases known to show a Koebner phenomenon, such as psoriasis vulgaris, vitiligo, lichen planus, and Darier disease, should be informed about this possible adverse effect of treatment; clinically this is rarely seen.
Livedo reticularis, intense pruritus and urticaria have been reported, including a case of intense swelling and erythema. The pathophysiology of these phenomena is not known. Management included topical corticosteroids, antihistamines, and discontinuing treatment. Several cases of induction of hair growth following laser hair removal in young female patients with darker skin types have been reported. Two different phenomena have been observed: Either conversion of fine vellus hair to dark, coarse terminal hair at the site of treatment or induction of growth of long fine hairs in the immediate vicinity of the treatment area. Repetitive, low-fluence treatments with hair removal devices have also been reported to induce hair growth. Further study is ongoing to assess the mechanisms for this response. Treatment of this side effect has included continued treatment in some cases.
Light-based hair removal devices are designed for strong absorption by melanin and deep tissue penetration. These systems are therefore capable of causing retinal injury and proper eye protection must be worn by the patient and operating personnel. Treatment near or on the surface of an eye is not recommended. All other body sites can be treated safely.
The ‘plume’ generated by the vaporized hair shafts has a typical sulfuric smell and in large quantities, can be irritating to the respiratory tract. A smoke evacuator is recommended.
Summary
■ Lasers and light sources can provide temporary hair reduction for all individuals.
■ At present permanent hair reduction is possible only in individuals with pigmented terminal hairs.
■ Proper patient selection is vital to ensure effective treatment with minimal side-effects.
■ A thorough knowledge of laser–tissue interactions is mandatory to minimize side-effects.
■ Treatment outcome is optimized by understanding the attributes of specific laser and light systems.
■ Close follow-up care is necessary to provide optimum patient outcome.
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