Nonlaser Hair Removal Techniques
- Author: Alicia Barba, MD; Chief Editor: Dirk M Elston, MD more...
Many men and women choose to remove unwanted body hair for cosmetic, social, cultural, or medical reasons.[1, 2, 3] Medical indications for hair removal include hirsutism (see the first image below), which is excess terminal hair in the distribution of hair growth influenced by androgens (ie, face, chest, back, abdomen),[4, 5] or hypertrichosis, which is congenital or drug-induced increase in hair growth in areas that are not androgen dependent. Other medical indications include pseudofolliculitis (see the second image below), hair growth from a grafted donor site, preoperative hair removal, and sex-change operations performed in men. The third image below depicts the anatomy of the hair follicle.
Many methods are available for temporary or permanent hair removal, each with its own relative efficacy and adverse effects. Different methods for the removal of body hair include the following:
Temporary hair removal - Shaving, epilation, depilation, bleaching 
Temporary hair reduction - Eflornithine hydrochloride (VANIQA cream 13.9%)
Permanent hair reduction- Intense pulsed light or laser-assisted hair removal
Permanent hair removal - Electrolysis
Temporary Hair Removal
Shaving is the method used most frequently to temporarily remove unwanted hair. Shaving is fast, easy, painless, effective, and inexpensive. The results are temporary, lasting 1-3 days, and shaving requires a constant commitment to maintaining a hair-free appearance.
Shaving is performed with a razor on wet skin using shaving cream or other lubricants, with the razor oriented against the direction of hair growth. For sensitive areas, shaving with the direction of hair growth may reduce cuts. Contrary to a widespread misconception, shaving does not result in increased hair growth. The primary disadvantages and/or adverse effects of shaving include skin irritation, cuts in the skin, ingrown hair pseudofolliculitis, the need to shave daily, and stubble.
Epilation involves the removal of the entire hair shaft and is the most effective method for temporarily removing hair. Epilation includes waxing, plucking, threading, sugaring, and using abrasives or mechanical devices (eg, Epilady). For epilation to be effective, treated hairs should be long enough for the device to grasp them. The long-term effects of epilation on the hair follicle are not known. Epilation wounds the hair follicle; therefore, repetitive epilation over several years may result in permanent matrix damage, resulting in finer or thinner hairs and, perhaps, as anecdotal evidence suggests, long-term permanent reduction in hair growth. Long-term clinical trials demonstrating the effects of repetitive epilation are lacking.
Plucking is best performed using tweezers and is a beneficial and economic method for removing the occasional coarse hair or a small group of hairs, such as those found on the eyebrows, chin, or nipples. The results of plucking last longer than shaving because hair is pulled from the hair shaft, as in waxing. This method is time consuming, tedious, and painful. The reaction of the hair follicle to plucking can be unpredictable, possibly resulting in folliculitis, hyperpigmentation, scarring, ingrown hairs, and distorted follicles. Adverse effects from plucking include pain, hyperpigmentation, scarring, folliculitis, and ingrown hair pseudofolliculitis.
Waxing is similar to plucking and involves applying warm or cold wax onto hair-bearing skin and quickly stripping off the hardened wax and embedded hairs against the direction of hair growth. Waxing is the most expensive yet most effective method of epilation because hair is removed completely from the hair shaft in large quantities. Often, hair can take 2-3 weeks to regrow. The effects on the hair follicle of long-term waxing are unknown. However, theoretically, this modality may reduce regrowth because repeated waxing may destroy follicles. Although many kits are offered for use at home, faster and more successful results are obtained by an experienced salon-based operator who is able to apply large quantities of wax quickly to a large body surface area for faster removal. See the image below.
Although no formal studies have been conducted, the recommendation is that patients using systemic retinoids (ie, isotretinoin [Accutane], acitretin [Soriatane]) refrain from waxing until treatment has been discontinued for a minimum of 6 months to 1 year to avoid tearing of the skin and scarring. Patients using topical retinoids (ie, tretinoin [Retin-A, Avita], adapalene [Differin]) should also be careful when waxing to avoid injuring the skin. It is recommended that a sign be visibly placed in waxing salons adverting clients not to wax if using systemic or topical retinoids.
Waxing should not be performed on moles, warts, or skin that is irritated, sunburned, or broken. Pay special attention to the temperature of the wax to avoid burning the skin. Adverse effects from waxing include pain, hyperpigmentation, scarring, folliculitis, and ingrown hair pseudofolliculitis. A life-threatening Streptococcus pyogenes and herpes simplexvirus infection of the external genitalia occurred in a 20-year-old diabetic woman following a routine perineal "Brazilian" bikini wax.
Threading is an ancient manual technique, popular in many Arabic countries, that involves the use of a long twisted loop of thread rotated rapidly across the skin. By maneuvering the twisted string, hairs are trapped within the tight entwined coils and are pulled or broken off. Adverse effects from threading include pain, hyperpigmentation, scarring, folliculitis, and ingrown hair pseudofolliculitis. One report suggests threading may be beneficial in patients on isotretinoin therapy, which may cause increased skin fragility.
Abrasives such as pumice stones and devices or gloves made of fine sandpaper work by physically rubbing the hair away from the skin surface. This method can be irritating to the skin and is not commonly used today for hair removal.
Sugaring is similar to waxing. The sugar mixture is prepared by heating sugar, lemon juice, and water to form a syrup. The syrup is formed into a ball, flattened onto the skin, then quickly stripped away. Similar to waxing, the hair is removed entirely from the hair shaft, and sugaring is an alternative to waxing for people sensitive to wax. Adverse effects from sugaring include pain, hyperpigmentation, scarring, folliculitis, and ingrown hair pseudofolliculitis.
Chemical depilatories remove part of the hair shaft and are easy and painless to use. The standard chemical depilatory agents, available in gels, creams, lotions, aerosols, or roll-on forms, are the salts of thioglycolic acid (sodium or calcium thioglycolate) that were patented in the 1930s for removing the hair from cattle hides. Thioglycolate depilatories work by hydrolyzing and disrupting disulfide bonds of hair keratin, causing the hair to break in half and allowing the hair to separate from the skin. Depilatories are good for use on the legs, bikini line, face, and underarms, and they perform best when hair is at a reasonable length. Before using a depilatory, carefully read the manufacturer's instructions. Test a small site before use to assess for irritation or allergic reactions. Do not use these agents on eyebrows, near mucous membranes, or on broken skin.
Adverse effects include skin irritation, burns, folliculitis, ingrown hairs, and allergic contact dermatitis to either thioglycolate or fragrances.
Bleaching is not a method of hair removal, but many women use bleaching as an inexpensive method of disguising the presence of unwanted hair by removing the hair's natural pigment. Common sites for bleaching include the upper lip, beard area, and arms. The active ingredients in over-the-counter bleaching agents are hydrogen peroxide and sulfates as activating agents, a combination that bleaches, softens, and oxidizes hair. A variety of commercial bleaches are available, and the manufacturer's instructions are easy to follow. As with chemical depilatories, perform a small patch test to assess for allergic reaction.
The disadvantages of bleaching include skin irritation, temporary skin discoloration, pruritus, and the prominence of bleached hair against tanned or naturally dark skin. Reports exist of generalized urticaria, asthma, syncope, and shock in reaction to the persulfate activator added to boost the effect of hydrogen peroxide bleach.
Temporary Hair Reduction
Eflornithine, a novel method for temporary hair reduction in women, is a topical cream available by prescription only and has been approved by the US Food and Drug Administration for the reduction of unwanted facial hair in women. Eflornithine is not a hair remover or depilatory, but is a topical cream that decreases the rate of hair growth. It works by inhibiting the enzyme ornithine decarboxylase, an enzyme in human skin that stimulates hair growth. When this enzyme is blocked by the medication, metabolic activity in the hair follicle decreases and hairs grow in more slowly. It has been studied only on the face and the adjacently involved areas under the chin; therefore, it should be used only in those areas. Because eflornithine does not remove hair, it must be used in combination with the patients' normal hair removal methods (eg, shaving, waxing, plucking). It is rubbed onto the affected areas on the face twice daily.
Approximately 32% of 393 female subjects showed marked improvement (reduction of unwanted facial hair) compared with only 8% of 201 control subjects who used placebo. Results are based on prerelease clinical trials in which eflornithine was used twice daily for 24 wk (6 mo). Improvement often occurred in as few as 4-8 wk. After discontinuing treatment, facial hair growth was similar to pretreatment levels within 8 wk.
Eflornithine (Vaniqa) is not a hair remover or depilatory, but is a topical cream that decreases the rate of hair growth. In animals, it irreversibly inhibits the enzyme ornithine decarboxylase, thus inhibiting cell division and synthetic functions, retarding the rate of hair growth. Clinical studies show it retards hair growth in humans as well.
In adults, a thin layer is applied twice daily to affected areas of the face and is thoroughly rubbed in. Do not wash the area for at least 4 hours. Pediatric recommendations have not been established. No interactions have been reported, and contraindications include documented hypersensitivity. Eflornithine may cause temporary redness, stinging, burning or tingling, rash, and folliculitis. It is pregnancy class C, meaning that a fetal risk has been revealed in studies in animals but not established or studied in humans; thus, it may be used in pregnant patients if the benefits outweigh the risk to the fetus.
Permanent Hair Reduction
Laser-assisted hair removal
Laser-assisted hair removal is a method available to achieve permanent reduction of unwanted hairs. The various lasers now most commonly available for hair removal are the alexandrite laser (755 nm), diode laser (810 nm), and Nd:YAG laser (1064 nm). These lasers target melanin and subsequently produce selective photothermolysis of the hair follicles. The longer wavelengths, such as with the 1064-nm Nd:Yag laser, are safer for darker skin types IV-VI. The risk for adverse events such as dyspigmentation, blistering, crusting, edema, and scarring is greater with darker skin types. See Laser-Assisted Hair Removal for more information.
Intense pulsed light sources for hair removal
Intense pulsed light sources use the same principle of selective photothermolysis used with lasers to target melanin in hair follicles; however, a noncoherent filtered flashlamp that emits wavelengths ranging from 500-1200 nm is used in this process, rather than one wavelength. Different cutoff filters are used to select the appropriate wavelength for each patient; however, intense pulsed light subjects the skin to a wider range of light energies of varying absorption coefficients for the chromophores, which may expose the patient to some unnecessary wavelengths. A disadvantage of intense pulsed light is that some machines have capitated maximum energies, which can hinder those patients needing higher energies in order to achieve better results.
Studies have shown that the hair removal efficiency rate (ie, percent of the number of hairs present compared with baseline counts) is best after 1-3 treatments. Adverse effects are minimal, and the hair removal efficiency rate achieved was 76% after a mean of 3.7 treatments and greater than 50% when evaluated more than 12 months following the last treatment.
Laser and intense pulsed light devices are also capable of treating a variety of conditions in addition to hair removal, including treatment of vascular and pigmented lesions, warts, wrinkles, and even acne.
Home-use devices have been developed, and some claims to efficacy have been made.
Permanent Hair Removal
Electrolysis, also termed electrology, is an effective method for permanently removing hair, especially in small areas. Electrolysis involves the insertion of a small, fine needle into the hair follicle, followed by the firing of a pulse of electric current that damages and eventually destroys the hair follicle. Multiple treatment sessions are required to achieve a clinically significant result. The 2 types of electrolysis are galvanic electrolysis (direct current electrolysis) and thermolysis (alternating current electrolysis).
Galvanic electrolysis: In galvanic electrolysis, a direct electric current is passed down a needle inserted into the hair follicle, where it acts on tissue saline to produce sodium hydroxide (lye), a caustic agent that destroys the hair bulb and dermal papilla (chemical reaction 2 NaCl + 2 H 2 0 = 2 NaOH + H 2 + C l2). During the procedure, the patient holds a metal rod covered with conductive cream or gel or a metal plate attached to a moistened pad. The current (milliamperes) is set by the technician based on the patient's pain threshold, and the duration of the pulse is controlled by how long the technician presses down on the hand or foot pedal. Galvanic electrolysis is slow and may require a minute or more for each hair, including repeated insertions into the follicle.
Thermolysis: Thermolysis uses a high-frequency alternating current that is passed down the needle into the follicle. The high-frequency alternating current produces heat in the hair follicle via molecular vibration, resulting in destruction of the hair bulb by thermal, not chemical, means.
Most modern electrolysis machines use thermolysis or the blend method, a combination of galvanic electrolysis and thermolysis. Unfortunately, no controlled clinical trials have compared the 2 methods, and claims of superiority of one method over the other are based on anecdotal evidence.
Significant evidence indicates that the region of the erector pili muscle insertion is the site of the stem cells responsible for hair regeneration. More research is needed to determine the effects of electrolysis on this region.
Proper electrolysis requires accurate needle insertion technique and appropriate intensities and duration of current. In addition, only anagen-phase hairs should be treated because telogen-phase hairs are believed to be more resistant to damage. Anagen-phase hairs can be distinguished easily from telogen-phase hairs by shaving the area to be treated and, in a few days, treating only those hairs visible on the skin surface (anagen-phase hairs).
Electronic tweezer devices have been developed for home use; however, because hair is not an electric conductor, current cannot be transmitted via hair to the hair bulb. In addition, no published data prove that damage occurs in the hair follicle or that these devices produce permanent hair removal. Likely, they represent a means for temporary hair shaft removal similar to waxing or plucking, but do not work well as a means of permanent hair removal.
Important and potentially permanent adverse effects of electrolysis include scarring (ie, keloid formation) and postinflammatory hyperpigmentation or hypopigmentation, adverse effects that are dependent on technician experience and the duration and intensity of the current. Pain, a primary adverse effect of electrolysis, can be diminished with the use of new topical anesthetic creams (eutectic mixture of local anesthetics [ELA-Max]) 1 hour prior to the procedure. This should be performed in a monitored setting and only to limited areas of skin. Maintaining some sensation is desirable because pain is related to the amount of damage to the hair follicle. Other adverse effects include local bacterial and viral infections. The spread of hepatitis or HIV has not been reported with electrolysis. Electrolysis is not safe for patients with pacemakers and should not be used on these patients.
Temporary and permanent methods of hair removal or reduction are important components in the treatment of patients with unwanted hair. No single method is perfect for all patients. Factors such as the underlying medical conditions causing excessive hair growth, size and location of treatment area, desire for temporary versus permanent hair removal, and expertise of the technician providing treatment should be considered when choosing a method for nonlaser hair removal.
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