1

Dr. T.A. RANAMBBS, M.D. (Skin & VD)

Dermatologist & Cosmetic Laser Surgeon

•Consultant at Shri Ram Hospital & Heart Institute,

Delhi

•Vinayak Hospital, Sec-27, Noida (U.P.)

•Panchsheel Hospital, Yamuna Vihar, Delhi

PERMANENT LASER HAIR

REDUCTION

3

Permanent Hair Reduction

Hair growth has three phases

Anagen (active)

Catagen (regression)

Telogen (resting)

Growth cycle

depends on the body part,

lasts anywhere from 4 to 12 months.

Hair reduction is considered permanent when a

significant amount of hair does not return for longer than

the complete growth cycle

4

Specific Targets

Lasers generate heat in

the hair shaft, which

diffuses to the stem cell

and matrix targets to

cause desired damage

5

Damage to the Hair Shaft

A normal follicle Immediately after treatment

6

Depth of Penetration

Longer wavelengths allow laser light to penetrate more deeply for more effective heating of the hair shaft (typical depths are 2-6 mm)

7

How Does It Work?

Based on the theory of Selective

Photothermolysis:

The target chromophore is melanin

Present in the hair shaft

Also present in the upper third of the follicular

epithelium

Heat generated in the hair shaft diffuses to the

follicular epithelium to cause the damage that is

desired

8

Ideal Laser System

Provides Permanent Hair Reduction

Safe and effective on all skin types

Effective on a broad range of hair colors

Effective on a broad range of hair diameters

9

Ideal Laser System

Must combine the following parameters:Appropriate wavelength absorption by melanin

Strong enough to allow treatment of finer and lighter hairs

Moderate enough to protect epidermis even on dark skin types

Penetration to target

Appropriate pulse widthsShort pulses for treatment of finer hairs

Long pulses for safety in darker skin types

Effective spot size and fluences

Aggressive Cooling

Compression

10

Appropriate Wavelength

Ideal wavelength in range 750-1200 nm

Ruby (694 nm) too well absorbed by melanin to treat

darker skin patients

Nd:YAG (1064 nm) requires 3-4 times the fluence for

similar effect

11

Pulse Width Considerations

If parallel cooling is used, the longer the

pulse, the lower the epidermal temperature

rise at a particular fluence setting

There is not a pulse width that is “too long” as

far as the epidermis is concerned

Thus longer pulse widths are great for dark

skin

12

Pulse Width Considerations

If the pulsewidth is much longer than the

Thermal Relaxation Time (TRT) of the hair

follicle, the hair follicle will not get hot

enough to be destroyed

The TRT depends on how thick the hair is

Finer hair requires shorter pulse

Coarse hair can be treated with longer pulse

13

Fluence (J/cm2)

Studies have shown a fluence dependent

response with hair removal results

The higher the fluence the better the response

Risk of side-effects increases with increased

fluence

Select maximum tolerated fluence for best

efficacy

14

Cooling

Must protect the epidermal melanin while

treating at clinically effective fluences

Treatments with an effective cooling design

can allow 3-4 times greater fluence without

epidermal damage

15

Compression

Reduces competing chromophore, oxyhemoglobin

Blanches vessels and eliminates energy lost into this

target

Rotates follicle closer to surface, so laser light

penetrates deeper into the hair shaft

Techniques and Guidelines

1. Patient Selection

2. Laser settings

3. Patient prep

4. Follow-up

17

Fitzpatrick Skin Types

I Always burns, never tans

II Always burns, sometimes tans

III Sometimes burns, always tans

IV Rarely burns, always tans

V Moderately pigmented

VI Black skin

18

Patient Skin Types

It is critical to understand the skin type of the

patient to provide the best results

Look for the presence of tan

Tan skin does not respond the same way as natural

dark skin

Tan skin should be treated with the 100 ms option

19

Patient Skin Types

Nd- YAG is cleared to treat all skin types

(Fitzpatrick I-VI).

It can treat tanned skin, but avoid treating

patients with a recent severe or lengthy

exposure.

20

Patient Hair Types

• Terminal hair, not vellous hair

• Pigmented hair

– Black, brown, red, dark blonde can achieve a long lasting result.

– Light blonde or white can experience temporary loss for up to 3 months.

– Recommend electrolysis as a treatment for permanent removal of discrete white hair

21

Number of Treatments

Temporary hair removal achieved in a single

treatment

Amount of long-term hair reduction varies

between patients

Higher fluence results in increased long-term

hair reduction

Typically 3-5 treatment are required for

nearly complete long-term hair loss

Darker skin may require more treatments

22

Treatment Intervals

• Wait for regrowth (harder to schedule)

• 1 month/2 months (dependent on body

location - face will be shorter time between

treatments than body)

• Take hair growth cycles into consideration…

23

How often are treatments?

1 treatment every 6-10 weeks depending on

body part.

Location TelogenMonths

AnagenMonths

TotalMonths

Back 3-6 3-6 6-12

Thigh 3-6 3-6 6-12

Arm 3-5 1-2 4-7

Calf 3-4 4-5 7-9

Axilla 2-3 3-4 5-7

Upper Lip 1-2 3-4 4-6

Bikini 3-4 2-3 5-7

24

Setting Expectations

No two patients are alike, treatment outcome cannot

always be predicted: Never give promise of 100%

reduction

Clearly define permanent hair reduction

Describe need for multiple treatments:

3-5 treatments generally required

For darker skin types IV-VI, 6-10 sometimes required, since lower fluences are used

Provide expectations in writing (e.g. patient consent) that patients can sign, retain copy

25

Potential Patient Risks

Scarring: has not been reported in clinical

studies

Hypo- or Hyperpigmentation rare and transient;

usually clears in 2- 6 months; fluence and skin

type dependent

Perifollicular erythema /edema - common,

resolves in hours/days

Local blisters - high fluence/dark skin

26

Patient Contraindications

History of keloidal scarring

Active infections: herpetic lesions, cold sores (place on

anti-viral medication pre-tx)

Tattoos, permanent make-up, pigmented lesions (can

treat around them)

Use of photosensitizing medications such as Accutane

(isotrenoin), tetracycline

Electrolysis, waxing or plucking in last 6 weeks (target

has been removed)

Pregnancy

27

Parameter SelectionFluence: The highest tolerable fluence will provide the

greatest efficacy

Pulse width: If the hair shaft is not relatively large and the

skin is not relatively dark, then the Auto Mode will provide

the highest efficacy; Optimal pulse width may change after 1

or more treatments

Optimizing fluence and pulse width safely is our goal

28

Recommended Settings - Lighter Skin Types

Skin

Type

Starting Fluence (Test Spots)

Tolerated

Fluences

Pulse Duration

I 32 J/cm2

Wait 15-30 min

Increment 2-5 J/cm2

15-60J/cm2 Auto

30 ms high hair

density

II 28 J/cm2

Wait 15-30 min

Increment 2-5 J/cm2

15-60J/cm2 Auto

30 ms high hair

density

III 24 J/cm2

Wait 15-30 min

Increment 2-5 J/cm2

15-45J/cm2 Auto – finer

30 ms – coarser or

high hair density

29

Recommended Settings Darker Skin Types

Skin

Type

Starting Fluence (Test Spots)

Tolerated

Fluences

Pulse Duration

IV 16-20 J/cm2

Wait 15-30 min

Increment 2-3 J/cm2

10-40J/cm2

20-70J/cm2

30 ms finer hair

100 ms coarser hair or

higher density

400 ms coarse hairs

V 12-16 J/cm2

Wait 48-72 hours

Increment 2-3 J/cm2

10-35J/cm2

20-60J/cm2

100 ms

400ms coarse hair or hair

not responding to lower

fluence

VI 8-12 J/cm2

Wait 48-72 hours

Increment 1-2 J/cm2

10-30J/cm2

20-40J/cm2

100 ms

400 ms

30

Skin Type Starting Fluences (Test Spots)Tolerated

Fluences

Pulse

Duration

All Skin

Types –Tanned

Skin

Use low range of fluences

recommended for one skin type

darker than patient’s skin type

(e.g. treat tanned skin type III as

skin type IV).

Perform test spots on areas with

same degree of tan as area to be

treated.

n/a 100 ms

Recommended Settings Tanned Skin

31

Eye Safety

• Can cause severe retinal injury.

• No treatment within bony orbit of eye (outer canthus). Treatment of eyebrows not recommended.

• Ocular Hazard Zone:– 164 feet / 50 m

– Laser light focused by the lens of the eye onto retina has a high fluence

• Proper eye protection MANDATORY for ALL people in the room!

32

Pre-Treatment Steps

Take baseline photographs

Help patients remember density and diameter of

hair before treatment

Mark area to be treated

Never use black marker, red is best

Shave area, remove all cut hair, sanitize skin

Depilatory cream can be used, but may irritate

skin

Perform test spots

33

Local Anesthesia

Assess discomfort tolerance during test spots

Most often used for male backs, front necks

Other typical areas for low-threshold patients:

Upper lip, bikini lines

Frequently used local anesthesia:

Emla, Ela-max

Dental sensitivity:

Gauze, dental guards (especially with dental work)

34

Operator Techniques

Secure wrist strap!

Pick and placeMost effective in smaller areas

Slide and glideAllows more rapid coverage on larger areas

Thin (< 1 mm) layer of gel enables friction-free movement

Pattern in gel enables tracking of treated areas

Keep the ChillTip flat on the skin surface and at a 90o

angle

Inspect and clean tip frequently during treatment!

35

Clinical End Points

Look for laser-tissue interaction, don’t just

depend on written parameters

End-points that indicate fluence and/or

pulsewidth must be changed:

Skin graying

Skin separation

End points listed on following slides are

normal and desirable

36

Positive Clinical End Points

Perifollicular erythema: – Initial redness from ChillTip and pressure decreases

– Erythema around treated hair increases after a few minutes

37

Positive Clinical End Points

Perifollicular edemaSwelling around the follicle (bumps) several minutes after treatment

38

Positive Clinical End Points

Singed hair:

Hair from follicle ejected or vaporized

Can see singed hair on skin or on tip

Gel becomes brownish

Odor of singed hair present

39

Patient Results – Long Term

Before 46 months after last treatment

2 treatments at 30 J/cm2, 30 ms

2 treatments at 40 J/cm2, 30 ms

Chin, Female Skin Type IV

40

Patient Results – Long Term

Before 24 months after last treatment

40 J/cm2

Treatments 1-3: 30 ms

Leg, Female Skin Type II

41

LightSheer Results

Female, Skin type III - Chin

Pre 36 months after 5 Tx.

42

LightSheer Results

Female, Skin type IV - Chin

46 months after 4 TxPre

43

LightSheer Results

Male, Skin type IV - Beard

Pre 5 months after 3 Tx

44

ND YAG Results

Female, Skin type II - Bikini

Pre 8 months after 3 Tx

45

IPL Results

Female, Skin type IV - Axila

Pre 4 months after 3 Tx

Courtesy C. Dierickx, M.D.

46

Patient Results

Before 4 months after last treatment

22-24 J/cm2

Treatments 1-3: 30 ms

Axilla, Female Skin Type V

47

Patient Results

Before 3 months after last treatment

22 J/cm2

Treatments 1-4: 30 ms

Sacral Region, Female Skin Type V

48

Post-Treatment

Sunburned sensation is common

Suggest cool compresses or soothing cream of gel (e.g. aloe vera)

Describe crusty spots that may occur

Clean area 2x daily with mild soap

Sunscreen for 6 weeks over area

Describe singed hair and shedding process

49

Richards-Meharg Table (Hair Growth Cycle Duration)

AREA OF BODY ANAGEN TELOGEN

Scalp 2-6 Years 3-4 Months

Beard/Chin 1 Year 10 Weeks

Upper Lip 16 Weeks 6 Weeks

Eyebrows 4-8 Weeks 3 Months

Ear 4-8 Weeks 3 Months

Legs 24 Weeks 16 Weeks

Arms 18 Weeks 13 Weeks

Axilla 4 Months 3 Months

Pubic 3 Months 4 Months

50

Pseudofolliculitis Barbae

Commonly referred to as “razor bumps”

Not a true “folliculitis”as name implies

Inflammatory foreign body response to a sharp

hair shaft

51

ND- YAG Treatment of PFB in skin types IV-VI

Study by Fran E. Cook-Bolden, MDEthnic Skin Specialty Group

New York, NY, USA

79%

86%

0.74

0.76

0.78

0.8

0.82

0.84

0.86

Male Female

Mean % Reduction of Lesions from Baseline

Female

Male

52

Potential Risks

Perifollicular edema/erythema

Favorable post-treatment response

Usually resolves w/in 24 hours

Local blisters - too high fluence, dark skin

Hyper/Hypopigmentation

Transient, should clear within 2-12 months,

Fluence and skin type dependent

Scarring – Extremely rare

The ND-YAG laser System

The first system FDA cleared for hair

removal that was designed for hair removal

from the ground up

The clinical trials influenced the design and

parameters chosen

54

ND-YAG Clearances

FDA cleared to advertise “Permanent Hair

Reduction”:

For all skin types (I-VI), including tanned skin

Long-term studies have proven the efficacy

Also FDA cleared for the treatment of leg veins,

benign pigmented lesions and pseudofolliculitis

barbae

55

Neodymium:YAG

Melanin

absorption at 1064

nm higher then

diode laser.

56

diode Contradiction

The low absorption by melanin makes it potentially

safer in darker skin but it requires a thick, dark hair

to be effective

Therefore for thin and medium hair, and brown

hair, the diode has limited effectiveness

For lighter skin patients there is no advantage to

the 800 nm wavelength

THANK YOU

57