Chapter 66: Laser- and Light-Based Approaches to Hair Removal

Beginner Pearls

• Light-based therapies shown to be effective for LHR include ruby lasers, alexandrite lasers, diode lasers, Nd:YAG lasers, and intense pulsed light (IPL).

• The long-pulsed Nd:YAG is the most appropriate laser in darker-skinned patients because the longer wavelength and greater depth of penetration reduces the risk of epidermal injury when combined with appropriate epidermal cooling measures. IPL can also be used for hair removal in lighter-skinned patients (skin types I–III) depending on the filter used.

• The desired clinical endpoint for LHR is perifollicular erythema and edema.

Expert Pearls

• The hair should be freshly shaved, so that it is <1 mm in length, and so that exposed hair shafts do not lead to inadvertent epidermal burns.

• A dark-colored pen has an absorption spectrum similar to melanin, and can cause inadvertent burns and scarring, so white pencil is best used if marking the treatment site.

Don’t Forget!

• Physicians treating a patient with a history of recurrent herpes simplex virus (HSV) infections in the area of treatment should consider providing a course of anti-HSV medication such as valacyclovir.

• With IPL, posttreatment effects (perifollicular erythema) are not always apparent.

Pitfalls and Cautions

• Signs of tissue necrosis include immediate or delayed blistering, and/or graying or blackening of the skin. If tissue necrosis occurs, adjustment of the treatment parameters to increase the pulse duration and decrease the fluence should be strongly considered.

• Additional warning endpoints include a positive Nikolsky sign indicating epidermal necrosis; second- or third-degree “stamping burns,” indicating inadequate cooling, possibly from skin or charred hair residue on the skin contact window; crescent-shaped burns suggesting misalignment of the laser or cryogen cooling spray; or charring caused by tissue carbonization and burning.

Patient Education Points

• Multiple treatments will be needed to attain significant clinical improvement. It is important to review this with patients prior to initiating therapy so that they understand that a single treatment will likely yield only minimal improvement.

• While some patients (and laser systems) do not regularly need topical local anesthesia prior to treatment, this is variable, and many patients may benefit from anesthetics, particularly in sensitive locations.

Billing Pearls

• Almost all insurers in the United States exclude laser treatments from coverage.

• Patients may benefit from committing to a series of treatments, as this may allow significant cost savings.

• Pretreatment with occluded topical anesthesia can be started at home, and prescription plans may cover the cost of this medication.