Laser Hair Removal Treatment & Management

Updated: Aug 28, 2019
  • Author: Mounir Bashour, MD, PhD, CM, FRCSC, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
  • Print
Treatment

Medical Therapy

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 Unpublished efficacy data submitted to the FDA showed that about 58% of women using the cream on facial hair had an improvement.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.

Next:

Surgical Therapy

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. Pain-sensitivity diagram.

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)

Anesthetic

Active Ingredient

Advantages

Disadvantages

Ametop gel

Tetracaine 4%

  • Performed well in clinical trials

  • Requires no plastic covering

  • Has rapid onset

  • Must be applied generously

  • Not available in the United States

  • May become runny or sticky after application

Betacaine cream

Lidocaine, prilocaine

  • Requires no plastic covering

  • Has a rapid onset

  • Requires no prescription

  • Must be applied generously

  • May become runny or sticky after application

  • Can cause redness that lasts a few hours

  • Available only from manufacturer

ELA-Max or ELA-Max 5 cream

Lidocaine 4% or 5%, respectively

  • Performed well in clinical trials

  • Requires no plastic covering

  • Has a rapid onset

  • Requires no prescription

  • Widely available

  • Must be applied generously

  • May become runny or sticky after application

  • Can cause redness that lasts a few hours

EMLA cream

Lidocaine 2.5%,

prilocaine 2.5%

  • Performed well in clinical trials

  • Might be covered by insurance

  • Widely available

  • Must be applied generously

  • Must be covered with plastic

  • Has slow onset

  • Requires a prescription

  • May lose effectiveness once uncovered

  • Can cause skin whitening for a few hours

Mento-kaine liquid

Benzocaine 20%, phenol, camphor, menthol

  • Good before waxing

  • Inexpensive

  • Has a rapid onset

  • Does not penetrate as deeply or as well as creams or gels

  • Irritates sensitive skin

Stud spray

Lidocaine 9.6%

  • Good before waxing

  • Inexpensive

  • Has a rapid onset

  • Does not penetrate as deeply or as well as creams or gels

  • Small bottle

Previous
Next:

Preoperative Details

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.

Previous
Next:

Intraoperative Details

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

Previous
Next:

Postoperative Details

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. [15]

Previous
Next:

Follow-up

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)

Location

Resting Hairs,

%

Growth Time

Telogen

Anagen

Telogen

Anagen

Head

Scalp

13

85

3-4 mo

2-6 y

Eyebrows

90

10

3 mo

4-8 wk

Ear

85

15

3 mo

4-8 wk

Cheeks

30-50

50-70

NA

NA

Beard or chin

30

70

10wk

1 y

Mustache or upper lip

35

65

6 wk

16 wk

Body

Axillae

70

30

3 mo

4 mo

Trunk

NA

NA

NA

NA

Pubic area

70

30

3 mo

4 mo

Arms

80

20

18 wk

13 wk

Thighs

80

20

24 wk

16 wk

Breasts

70

30

NA

NA

NA = not applicable.

*Adapted from Cutis. Mar 1990;45(3):199-202 [16]

 

Previous
Next:

Complications

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). [17]

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)

Adverse event

Long-Pulsed

694 nm Ruby

Long-Pulsed

755 nm Alexandrite

Long-Pulsed

800 nm Diode

Long-Pulsed

810 nm Diode

Long-Pulsed

1064 Nd:YAG

IPL

IPL/

Heat Energy

Erythema

...

90%

69%

52%

23%

92%

54%

Burning

...

61%

30%

44%

14%

...

4%

Blistering/crusting

8%

...

...

5%

...

4%-12%

...

Hypopigmentation

4%

8%

5%

11%-25%

...

12%

8%

Hyperpigmentation

16%

40%

31%

9%-38%

2%

12%

8%

Other scarring

...

15%

6%

...

2%

...

...

* Adapted from J Drugs Dermatol. Jan 2007;6(1):40-6 [18]

Laser hair removal has not been available long enough to permit a full assessment of its long-term health effects. At this time, short-term data indicate that laser hair removal is generally safe. Because studies have shown that laser hair removal can alter skin structures such as sweat and oil glands, they may cause lasting changes to the skin as adverse effects in some patients.

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. [19]

Previous
Next:

Outcome and Prognosis

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. [20]

Previous
Next:

Future and Controversies

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. [21] 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. [22]

Previous