Optical Hair Removal
Richard J. Off and R. Rox Anderson
Tradltlonal methods of hair removal have proven
unsatlsfactory for many Indlvlduals wlth excesslve
or unwanted hair. In the last few years, several
lasers and xenon fiashlamps have been devel-
oped that promlse to fulfill the need for a practlcal,
safe, and long-lasting method of halr removal.
Aggressive marketing of these has contrlbuted to
thelr popularlty among patients and physlclans.
However, slgnlficant controversy and confuslon
surrounds this field. Thls article provldes a detalled
explanation of the scientific underpinnlngs for optl-
cal halr removal and explores the advantages
and dlsadvantages of the varlous devlces cur-
rently avallable (Nd:YAG, ruby, alexandrlte, dlode
lasers, and xenon flashlamp). Treatment and safety
guldellnes are provlded to asslst the practltloner In
the use of these devlces. Although the field of
optical halt removal Is stlll in Its infancy, Inltlal
reports of long-term efficacy are encouraglng.
Copyright 9 1999 by W.B, Saunders Company
AIR, IN ITS AMOUNT and distribution, plays an
H important role in defining appearance in contem-
porary society. For example, plentiful scalp hair on
men is equated with youth, as evidenced by the
popularity of hair transplantation surgery. On the other
hand, excessive hair on certain body sites is considered
taboo. Women are subjected to pressure from peers and
advertising to maintain hairless skin. The presence of
hair on areas such as the face, armpits, or legs is often
deemed socially unacceptable. Individuals with severe
excess hair may suffer emotional distress and have
difficulty functioning in society.
Physicians and patients alike have yearned for a safe
and permanent method of hair removal. Traditional
treatments of excessive hair have included shaving,
plucking, waxing, chemical depilatories, and electroly-
sis. These techniques have been limited by their
inconvenience, pain, and risk of scarring. Electrolysis
has been touted as a permanent method of hair removal
but has not been adequately studied and is impractical
for epilation of large numbers of hairs. There is little
doubt that electrolysis (direct current) or electrother-
molysis (radiofrequency [RF] current) can provide
permanent hair removal in some cases, but the efficacy
appears to be extremely variable and operator-depen-
dent.
The need for an improved method of hair removal
has recently been approached using lasers and xenon
flashlamps, and there is now a proliferation of optical
devices marketed specifically for hair removal. Despite
aggressive marketing, relatively little published, scien-
Seminars in Cutaneous Medicine and Surgery, Vol 18, No 2 (June), 1999:pp 149-I58
tific data is available for assessing the permanency of
hair removal. Nevertheless, patients and many physi-
cians have embraced this technology. This article will
describe the scientific basis for optical hair removal and
will sort through the marketing hype surrounding
competing laser systems.
Anatomy and Growth Cycle
of the Hair Follicle
The hair follicle is a remarkably complex structure
with a unique, anatomically and hormonally regulated,
cyclical pattern of growth. By convention, the hair
follicle in vertical sections is divided into three parts:
the lower portion, the isthmus, and the infundibulum.
The lower portion of the follicle occupies the area
below the insertion of the arrector pill muscle and
includes the hair bulb and dermal papilla. The hair
bulb is invaginated by the dermal papilla, a neurovascu-
lar structure that supplies the cells of the rapidly
proliferating matrix, which forms the hair shaft. The
mid-portion of the follicle between the insertion of the
arrector pill muscle and the entrance of the sebaceous
duct is known as the isthmus. The infundibulum, or
upper part of the follicle, is that portion of the follicle
located above the entrance of the sebaceous duct and
communicates directly to the skin surface.
Hair follicles cycle from growing (anagen) phase to
resting (telogen) phase through an intermediate phase
called catagen. During anagen, rapidly dividing matrix
cells in the bulb differentiate into the hair and the inner
root sheath, both of which migrate outward as the hair
lengthens. Anagen bulbs are situated deeply in the
dermis or in the subcutaneous fat, 2 to 7 mm below the
skin surface. During catagen, the lower portion of the
follicle, including melanocytes in the matrix, under-
goes apoptosis and degenerates. 1 The lower follicle
shrinks to a thin epithelial cord, which retracts upward
and is later traversed by the dermal papilla. The follicle
decreases to approximately one third of its former
length, and its lowermost portion comes to lie at the
level of attachment of the arrector pill muscle. 2 The
From Wellman Laboratories of Photomedicine, and the Beth
Israel Deaconess Medical Center, Harvard Medical School, Mas-
sachusetts General Hospital, Boston, MA.
Address reprint requests to Richard J. Ort, MD, Wellman
Laboratories of Photomedicine, Harvard Medical School, Massa-
chusetts General Hospital, 55 Fruit St, Boston, MA 02114.
Copyright 9 1999 by W.B. Saunders Company
1085-5629/99/1802-0009510.00/0
149
]50
ensuing telogen phase represents a stage of follicular
quiescence. When regrowth begins in early anagen, a
burst of epithelial cell division occurs near the inser-
tion of the arrector pili, a new matrix is formed, and
hair growth resumes as the epithelial column grows
downward to form a new bulb.
Hair coloration is a result of both the type and
amount of melanin within the hair shaft. Melanin
production occurs only during the anagen phase, by
melanocytes in the bulb that transfer melanin granules
to hair keratinocytes. Distinct types of melanosomes
exist in hair of different color. Dark hair contains large
numbers of eumelanin granules, whereas light hair
contains mostly pheomelanin. Red hair contains aptly
named erythromelanin granules, rich in pheomelanin.
In gray hair, melanocytes show degenerative changes
such as vacuoles and poorly melanized melanosomes,
whereas in white hair melanocytes are greatly reduced
in number or are absent} In addition to a wide range of
hair colors, the diameter of hair varies by about an
order of magnitude. Large (terminal) hairs are gener-
ally those of cosmetic concern.
The hair follicle is a self-renewing structure and
contains a population of stem cells capable of regenerat-
ing the follicle. 4 It was initially proposed that follicular
stem cells reside within or near the matrix of the hair
bulb. 5,6 However, Cotsarelis et al7 have identified a
population of slow-cycling stem cells in murine fol-
licles that are located in a bulge coming off the outer
root sheath. The bulge is located at the site of attach-
ment of the arrector pili muscle, approximately 1 mm
below the skin surface. This represents the lower end of
the permanent portion of the hair follicle. 7 Recently,
follicular stem cells expressing cytokeratin 15 and [~1
integrin have been identified by the same laboratol~. 8 It
is now believed that, during late telogen or early
anagen, the bulge stem cells are activated by signals
from cells of the dermal papilla. The stem ceils prolifer-
ate briefly to form more differentiated cells of the
epithelial downgrowth before returning to their nor-
mal, noncycling state in mid-anagen.4
The duration of anagen and telogen phases, as well
as the percentage of hairs in each phase, are regulated
according to body location. Body sites with long hair
(eg, scalp) have a prolonged anagen phase, whereas
areas with short hair (eg, legs) have a short anagen
phase and somewhat longer telogen phase. In the adult
scalp, the anagen phase lasts at least 3 years, catagen
lasts about 3 weeks, and telogen lasts about 3 months}
At any given time, about 84% of scalp hairs are in
anagen phase, 2% in catagen phase, and 14% in
telogen.2 In contrast, about half to three fourths of leg
or arm hair is in the telogen phase at any given time,
and telogen may last for over 6 months on the legs. 9
Any method of hair treatment that induces telogen
could therefore produce a prolonged lack of new hair
ORT AND ANDERSON
growth, and one would not expect to know if hair loss
is permanent for about 6 months after treatment.
Hypertrichosis and Hirsutism
Patients seeking treatment for excess hair may pre~
sent in a variety of settings. Many individuals inherit a
tendency toward hypertrichosis, which is defined as an
increase in hair growth that is not androgen dependent
and is usually of nonendocrine origin}~ Certain medi-
cations such as phenytoin, cyclosporine, and cortisone
may result in hypertrichosis. 11 Patients who have had
wounds reconstructed with hair-bearing skin grafts
may also seek permanent hair removal.
In women, excessive hair growth may be a manifesta-
tion of hirsutism, in which growth of terminal hair
occurs on androgen dependent areas of the body such
as the upper lip, chin, chest, lower abdomen, and
thighs. Other cutaneous signs such as acne, androge-
netic alopecia, and acanthosis nigricans may be ob-
served in hirsute women. 11 Many hirsute women suffer
from underlying polycystic ovary syndrome. Hirsutism
may herald the full syndrome of systemic virilization,
which includes deepening of the voice, increased
muscle bulk, hypertension, striae distensae, and clitero-
megaly, l~ Systemic virilization, especially when of
rapid onset, may be a manifestation of an underlying
androgen-secreting neoplasm} 1 Appropriate labora-
tory tests, including levels of free testosterone and
dehydroepiandrosterone-sulfate (DHEA-S), should be
used to exclude elevated androgens as the cause of
hirsutism.
Traditional Treatment Methods
A host of treatment modalities exist. Methods for
temporary hair removal include shaving, plucking,
bleaching, waxing, and the use of chemical depilato-
ries} 2 Many women are loathe to shave facial skin
because of the masculine connotations as well as the
mistaken belief that shaving will coarsen hair or make
it grow faster} ~ The hair loss induced by plucking and
waxing can last from several weeks up to a few months,
but these techniques are painful and can cause postin-
flammatory hyperpigmentation, folliculitis, ingrown
hairs, and even scarring} 2 Bleaching does not remove
hair but can make hair less visible in light-skinned
individuals. Chemical depilatories most commonly
contain thioglycolates that dissolve hairs by disrupting
disulfide bonds. 12 Depilatories are useful agents be-
cause they generally remove some of the hair shaft
below the skin surface, n However, they are messy to
use and are irritating, especially when used on the face.
Hirsute women can be treated with antiandrogenic
medications such as oral contraceptives, spironolac-
tone, or cyproterone acetate} ~ However, these can
cause troublesome side effects and usually lead to only
OPTICAL HAIR REMOVAL
partial and temporary improvement. In the early twen-
tieth century, radiograph machines were widely used
for removal of facial hair in women, with the disastrous
complication of subsequent carcinogenesis. Soft radio-
graph (grenz ray) generators were later recognized to
pose lower risk and to produce useful temporary
alopecia. Grenz rays were then used for decades to treat
tinea capitis and other scalp disorders before the arrival
of effective medicines.
For several decades, electrolysis has been the only
acceptable method of permanently removing hair. Dur-
ing galvanic electrolysis, a needle carrying direct elec-
tric current is inserted down an individual hair follicle.
The current destroys the follicle by producing sodium
hydroxide within the follicle. In the method known as
thermolysis, a high-frequency alternating current is
passed down the needle, which destroys the follicle
through the production of heat. 13 This is, essentially, a
form of electrosurgery similar to that widely used in
surgery for tissue destruction and hemostasis. When
properly performed, electrolysis can produce perma-
nent hair loss. However, the process is tedious, time
consuming, variable, painful, and can result in postin-
flammatory hyperpigmentation and scarring. The poten-
tial for electrolysis to produce permanent hair removal
is not disputed, but success ranges widely and has not
been adequately studied. Electrolysis is not a practical
alternative for individuals with large areas or numbers
of excessive hair.
Hair Removal by Light
Lasers were initially used to remove hair from skin
grafts and flaps) 4A5 as well as to treat trichiasis. 16-Is
However, hair follicles were not targeted selectively in
these reports. The selective thermal destruction of a
target by light is described by the principle of selective
photothermolysis. 19 In selective photothermolysis, en-
ergy is delivered at a wavelength well absorbed by the
target, within a time period less than or equal to the
thermal relaxation time of the target. When the proper
pulse duration, wavelength, and fluence are used,
selective damage to structures such as hair follicles
occurs.
During laser treatment, thermal damage must be
limited to the follicle itself to avoid nonspecific tissue
injury. The greatest thermally selective damage is
obtained when pulse duration is about equal to or less
than the thermal relaxation time of the follicle, which is
estimated to be about 40 to 100 milliseconds (ms) for
terminal hair follicles with a diameter of 200 to 300
l~m.2~ In addition, the ideal pulse duration should
exceed the thermal relaxation time of epidermis (ap-
proximately 3 to 10 ms), in order to allow extraction of
heat from the epidermis (skin surface cooling) during
the laser pulse. 2~
151
Both the bulge and dermal papilla appear to be
important targets for laser treatment. 2~ In order to
damage these structures, some conduction of heat must
occur during the laser pulse. The importance of pulse
duration is well illustrated by the Q-switched ruby
laser (QSRL), which delivers pulses in the nanosecond
(ns) (10 -9 seconds) range and has been used for over a
decade to treat tattoos and pigmented lesions. The
QSRL can induce leukotrichia and cause a temporary
hair growth delay by damaging pigment-containing
cells, but does not inactivate the follicle itself.22 On the
other hand, the normal mode ruby laser produces
pulses of about 1 ms (10 -3 seconds) and targets the
entire hair follicle epithelium by allowing thermal
conduction from the pigmented hair shaft and pig-
mented epithelial cells to the entire follicle structure.
The use of a longer pulse width necessitates the use of
higher fluences because the pulse heats a larger volume
of tissue. Thus, hair removal is probably best accom-
plished using pulses in the millisecond time domain.
Melanin functions as a natural chromophore over a
wide range of wavelengths, up to about 1,100 nanom-
eters (nm). 23 Most lasers currently used for hair re-
moval deliver red or near infrared wavelengths that
target melanin (specifically, eumelanin) within the hair
follicle. The ability of these devices to damage follicles
therefore depends on the amount and type of melanin
within the follicle. Wavelengths in the red and near
infrared range are poorly absorbed by competing chro-
mophores such as hemoglobin, and penetrate deeply
into the dermis. Approximately 10% to 20% of incident
light in the 700 to 1,100 nm region traverses the
dermis, such that the entire living hair follicle is
accessible to these wavelengths. Large-diameter expo-
sure spots (eg, > 10 mm) suffer substantially less loss of
intensity with depth into the dermis compared with
small-diameter exposure spots. This is because optical
scattering by dermal collagen causes light to diffuse as
it penetrates into the dermis. The papillae of terminal
hair follicles are deep, lying in the lower dermis or
subcutaneous fat, and are thought to be important
targets for laser hair removal. The ideal exposure spot
size for optical hair removal is probably about 10 mm
or greater.
It has been shown that hair follicles can be damaged
by targeting chromophores other than melanin. Several
alternative techniques have been developed. For ex-
ample, Q-switched Nd:YAG lasers have been used to
target topically applied carbon particles massaged into
hair follicles. This was the first method of laser hair
removal cleared by the Food and Drug Administration
(FDA), but appears to be impermanent. Light can also
be used to photochemically activate an exogenously
administered or induced photosensitizer within hair
follicles, a technique known as photodynamic therapy.
In black-haired mice, alopecia caused by normal-
152 ORT A N D A N D E R S O N

mode ruby laser treatment is strongly dependent on the
phase of the hair growth cycle. 1 Anagen hairs treated
with the laser exhibit a fluence-dependent reduction or
complete loss of hair, whereas catagen and telogen
hairs are resistant to laser irradiation. At first, this
result may seem paradoxical given that dermal papilla
are located deeply during anagen and much more
superficially during telogen. However, in the telogen
phase there is no active melanin production. Although
this animal study suggests that the anagen:telogen ratio
may affect the ability of lasers to inhibit hair growth at
different body sites, there are major differences be-
tween mice and humans. In mice, the intradermal
portion of telogen hairs has essentially no melanin. In
contrast, human telogen hair follicles still retain a
pigmented hair shaft well into the dermis. Clinically, it
appears that even telogen follicles are damaged by
optical pulses. The efficacy of ruby, alexandrite, and
flashlamp devices for hair removal strongly suggests
that the intradermal hair shaft in humans acts as a
sufficient light absorber. The first published report of
laser hair removal was provided by Grossman et al, 2~
who showed that removal of the intradermal hair shaft
(by wax epilation) reduced efficacy compared with
shaving before ruby laser exposure. Thus, it is likely in
humans that both anagen and telogen hair follicles are
affected by optical pulses that target melanin.
Light must pass through the pigmented epidermis
before reaching hair follicles. Therefore, melanin in the
epidermis acts as a competing site for light absorption
and for tissue injuDz. In fair skinned persons with dark
hair, this is not a problem. However, when a tan or dark
constitutive skin color is present, epidermal injury
becomes a major concern. This is especially true if the
hair is also fine, or light in color (eg, blonde). In
essence, for any given laser hair removal system that
targets follicular melanin, the effective fluence is deter-
mined mainly by hair color, whereas the tolerated
fluence is determined mainly by skin color. The toler-
ated fluence can be increased substantially by various
means, however, some of which are now built into
different hair removal laser systems. Most of these
involve cooling the skin surface either before, during,
and/or after the optical pulse. The tolerated fluence can
also be increased by optical manipulations, such as
more closely matching the refractive index of the
delivery device to that of skin. Forceful compression of
the skin can also be used with some handpiece designs,
which momentarily clears blood from the dermis and
brings the follicle targets closer to the skin surface
during light exposure.
Skin cooling always consists of conducting heat
away from the skin surface. The simplest and probably
least effective method is to simply apply a transparent
gel (such as used for ultrasound imaging) to the skin,
through which optical pulses can be delivered. More
aggressive cooling methods that have been built into
treatment devices include actively cooled sapphire
windows or a cryogen-spray apparatus attached to the
treatment system handpiece. These provide faster cool-
ing to lower temperatures and the option for cooling
the epidermis and upper dermis without substantially
cooling the hair follicle targets before a pulse is
delivered. The cryogen-spray cooling method was origi-
nally conceived for epidermal sparing during portwine
stain treatment and produces the greatest temperature
gradient across the epidermis. Clinical comparisons of
cooling methods have not yet been reported. However,
it is clear that all of them provide some protection
against epidermal injury in pigmented skin and that
actively cooled sapphire and cryogen-spray cooling is
more protective than passive methods.
SPECIFIC LASER SYSTEMS
A table summarizing different commercially-avail-
able hair removal devices is presented (Table 1). The
FDA initially used electrolysis as a historical standard
to evaluate laser treatment efficacy, despite the lack of
good data on electrolysis. To receive FDA clearance,

Table I . Optical Hair Removal

Pulse Spol Maximum
Device Wavelength Duration Size Ruence Speed Cooling
(Company) (nm) (ms) (mm) (J/cm2) (Hz) Device Caramels

Sofflight(Thermolase) 1,064 10-20 ns 7-10 2-3 10 Not needed Carbon makes no

difference?
Epilaser (Palomar) 694 3 7-10 10-40 0.5 Cold sapphire FDA cleared for perma-
nent hair reduction
Epitouch (Sharplan) 694 1.2 4-6 20-40 1.2 Gel --
GentleLase (Candela) 755 3 7-15 10-100 1 DynamicCooling Device --
Epitoueh (Sharplan) 755 2 5-10 5-50 5 Gel --
LPIR (Cynosure) 755 5, 10, 20 7-10 5-20 1 Gel Multiple pulses
Lighlsheer(Palomar) 800 5-30 9 x 9 10-40 1 Cold sapphire --
Flashlamp (ESC) Variable from Variable 8 x 33 or 10 x 45 Variable <1 Gel Multiple pulses
550-1,200
OPTICALHAIRREMOVAL
lasers must demonstrate a 30% decrease in hair growth
3 months after a single treatment. 24 As noted previ-
ously, this criterion clearly does not equate with
permanent hair loss because the duration of telogen
can easily exceed 3 months. For example, a treatment
that merely fractures the hair shaft below the skin
surface can cause reduction of hair for more than 3
months on the legs. A more functional definition of
permanent hair removal has been proposed, based on
the cyclic growth phases for hair follicles. Permanent
hair loss can be defined as a significant reduction in the
number of terminal hairs, which is stable for a period
longer than the complete growth cycle of hair follicles
at a given body site. 25 At the time of writing of this
article, there are four lasers that have received FDA
clearance for hair removal: the Q-switched Nd:YAG-
plus-topical-carbon, long pulse ruby, alexandrite, and
diode lasers. In addition, a xenon flashlamp has been
cleared by the FDA for hair removal. Only a ruby laser
has been cleared by FDA for permanent hair reduction.
Q-Switched NcI:YAG Laser
In 1996, the FDA cleared for marketing a laser
technique for hair removal that combined Q-switched
Nd:YAG laser treatment with pretreatment wax epila-
tion and application of carbon-containing solution
(Softlight, Thermolase Corp, La Jolla, CA). The QS
Nd:YAG laser delivers light at a wavelength of 1,064
nm (near infrared range), with a pulse duration of 10 to
20 ns. Eumelanin absorption is relatively poor at 1,064
nm, although it has long been known that QS Nd:YAG
laser pulses are capable of damaging pigmented hair
follicles.26 At present, the typical laser used delivers a 7
mm beam at a fluence of 2 to 3 J/cm 2 and a repetition
rate of 10 Hz. An exogenous chromophore in the form
of carbon particles is applied to the skin before laser
irradiation. A carbon suspension, similar to india ink,
is massaged on the skin and partially taken into hair
follicles. Absorption of a QS Nd:YAG laser pulse by a
carbon particle produces a rapid temperature rise,
cavitation (sudden vaporization of water), and local
shock waves, causing thermal and mechanical damage
to the follicleY
The Softlight system was marketed aggressively in
the United States along with over-optimistic articles in
the popular press, despite a lack of any evidence
showing long-term efficacy Nanni and Alster2s recently
evaluated the effectiveness of the QS Nd:YAG laser for
hair removal with and without the pretreatment appli-
cation of wax and carbon solution. Laser-treated sites
exhibited a reduction of hair regrowth at 3 months
follow-up, even when the carbon suspension was not
applied, All of the hair grew back within 6 months. The
ability of QS Nd:YAG laser pulses to induce a growth
delay (even without the presence of carbon) is presum-
ably due to absorption by melanin within the follicle.29
153
Failures of the Softlight carbon-plus-laser treatment
led to a modified approach recently described by the
company, in which smaller carbon particles are applied
to the skin followed by a low-fluence treatment with
the Nd:YAG laser to propel the particles into the
follicle.3~ A second laser pass is then performed using
higher fluences to target the carbon particles within the
follicle. It is unknown whether this modification has
any clinical value.
Long-pulsed Ruby Laser
Ruby was the first laser ever made and was first
reported for dermatological uses by Dr Leon Goldman
in the 1960s. 31,32 Over the last decade, the Q-switched
ruby laser has been used extensively to treat pigmented
lesions and tattoos. A more recent application of the
long-pulse ruby laser is the treatment of unwanted hair.
Two ruby laser systems cleared by the FDA are now
available for hair removal: the Epilaser (Palomar Medi-
cal, Lexington, MA) and the Epitouch (Sharplan/ESC,
Israel). Each delivers pulses of deep red light at a
wavelength of 694 nm.
The Epilaser has been the most widely used. It
delivers a 3 ms pulse with fluence of 10 to 40 J/cm 2 and
spot size of 7 to 10 mm. Pulses are delivered at a
repetition rate of 0.5 Hz. An actively cooled sapphire
handpiece is placed directly in contact with the skin to
protect the epidermis. For further protection, the
handpiece provides a convergent beam and is used with
firm pressure against the skin. Epilaser is also cleared
for treatment of pigmented lesions. The Epitouch is a
dual-mode ruby laser that can operate in either a
Q-switched mode to treat tattoos and pigmented le-
sions or in a tong pulsed normal mode to target hair
follicles. In the long pulse mode, Epitouch delivers a
1.2 ms pulse at a spot size of 4 to 6 mm and repetition
rate of 1.2 Hz. It can achieve a fluence of 40J/cm 2 at the
smaller spot size, A cooling gel is applied to help
protect the epidermis from thermal damage.
Grossman et al 2~initially reported selective injury to
hair follicles by the long pulse ruby laser. Pulses of 0.27
ms duration were delivered to shaved or wax-epilated
areas using a beam diameter of 6 mm and fluences of 20
to 60 J/cm 2. Thirteen patients with fair skin and brown
or black hair were treated on the thighs or back and
followed for 6 months after a single treatment. Alopecia
due to a hair growth delay was induced for 1 to 3
months in all subjects over the entire range of fluences,
at both shaved and epilated sites. At 6 months, a
statistically significant decrease in hair growth was
observed in the shaved sites treated at the highest
fluence. Biopsies obtained in four subjects immediately
after treatment showed selective thermal damage to
pigmented hair follicles, with vaporization of the hair
shafts, large patches of necrosis in the follicular epithe-
154
lium, and occasional rupture with perifollicular dermal
injury suggestive of steam vents. Transient pigmentary
changes occurred in several patients but scarring was
not observed.
Dierickx et a125 recently published long-term fol-
low-up of patients from the above study. Seven of the
original 13 patients were available for follow-up, four
of whom still had obvious loss of hair 1 to 2 years after
exposure. At 1 and 2 year follow-ups, permanent hair
loss was observed only in the shaved areas for all
fluences. Skin sites treated with the highest fluence (60
J/cm 2) had the greatest amount of hair loss. Biopsies
were obtained from a patient with laser-induced alope-
cia, 1 year after laser exposure at 60 J/cm 2. Analysis of
transverse sections showed a reduction in the number
of terminal hairs with a reciprocal increase in small
vellus-like hairs. The histological picture resembled
androgenetic alopecia because there was no evidence of
fibrosis or loss of hair follicles.33
This small study is the first evidence of both tempo-
rary and permanent hair loss after laser treatment.
Growth delay is thought to result from either precipita-
tion of telogen or recoverable injury during anagen arid
is easily achieved even at low fluences. Permanent hair
loss appears to result from miniaturization of the
follicular bulb and papilla, but a larger number of
patients and samples must be examined to be sure.
Commercially available ruby lasers for hair removal
deliver pulses that are longer than those used in these
studies, which does not affect efficacy.34
Although the efficacy of the long-pulse ruby laser
has been clearly shown, there are significant, dose-
related side effects. Darkly pigmented patients are at
high risk for epidermal injury due to absorption by
epidermal melanin. Clinically, epidermal injury may
manifest as acute vesiculation, crusting, or pigmentary
change. Pigmentary side effects occur with all melanin-
targeting optical hair removal devices, but may be more
common with these ruby lasers. A relative disadvantage
of these first ruby laser systems is that the slow pulse
repetition rate makes it impractical to treat large body
areas. The alexandrite, diode, and flashlamp devices
that followed these ruby lasers are considerably faster,
but not for intrinsic reasons. Similar to other electronic
equipment such as personal computers, there is "leap-
frogging" of speed with each new product in a competi-
tive marketplace. New ruby lasers may therefore emerge
that offer even higher treatment speed.
Alexandrite Lasers
Like the ruby laser, alexandrite lasers target melanin
within the hair follicle. The alexandrite laser wave-
length near 755 nm is absorbed about 20% less strongly
by melanin compared with the ruby laser wavelength of
694 nm. Despite marketing claims, there is probably
ORT AND ANDERSON
little or no advantage of this wavelength over the ruby
laser. Optical scattering in the dermis is such that the
depth of penetration increases slightly with wave-
length, which partially compensates for the weaker
absorption by the target chromophore, melanin. There
are currently three alexandrite laser systems that have
been cleared by FDA for hair removal: the GentleLase
(Candela, Wayland, MA), the Epitouch Alex (Sharplan/
ESC, Israel), and the Long Pulsed Infrared (LPIR) or
Apogee (Cynosure, Chelmsford, MA). All use a fiberop-
tic cable to deliver the light.
The GentleLase emits a pulse duration of 3 ms, spot
size of 7 to 15 ram, and fluence of 10 to 100 J/cm 2 (at
the small spot size), with a repetition rate up to 1 Hz. It
uses timed cryogen-spray cooling at the skin immedi-
ately before the laser pulse. The Epitouch delivers a
pulse duration of 2 ms, spot size of 5 to 10 mm, and
fluence up to 50J/cm 2. It can treat a large area relatively
quickly because of its repetition rate of up to 5 Hz. The
LPIR features a variable split-pulse duration of 5 to 20
ms, spot size of 7 to 10 mm, fluence of 5 to 20 J/cm 2,
and repetition rate of 1 Hz. Both the LPIR and the
Epitouch use a gel to cool the epidermis. The longer
pulse duration of the LPIR is not actually a single pulse,
but rather the time for delivery of a pair of pulses. This
is intended to protect the epidermis by allowing more
time for heat extraction compared with a single, shorter
pulse. Quantitative or comparative studies are not yet
available to test this hypothesis.
Several preliminary studies have documented the
efficacy of the long-pulsed alexandrite laser in hair
removalY -37 These studies have followed patients from
3 to 6 months after the last laser treatment. A definitive
conclusion regarding the ability of the alexandrite laser
to induce permanent hair loss must await the publica-
tion of long-term studies. However, one would expect
that the long-term efficacy of the alexandrite laser
would be similar to that of the ruby laser, given that
both lasers target melanin at relatively similar wave-
lengths, pulse durations, fluences, and spot sizes.
High-Power Diode Laser Array
Semiconductor diode lasers emitting in the near
infrared range are the world's most efficient light source
and are driving the miniaturization of lasers in general.
Visible versions of these devices are commonly used for
slide pointers and other consumer devices. An array of
high-power diode lasers has been developed to target
hair follicles. The Lightsheer diode laser (Palomar;
Lexington MA/Coherent, Palo Alto, CA) was recently
approved by the FDA for hair removal. The emission
wavelength is 800 nm, pulse width 5 to 30 ms, spot size
9 • 9 ram, and fluence 10 to 40 J/cm 2. Cooling is
provided via a sapphire contact handpiece that is
placed directly in contact with the skin. At 800 nm, the
OPTICALHAIRREMOVAL
light emitted by the diode laser targets melanin within
the hair follicle. However, melanin absorption is dimin-
ished at this longer wavelength, similar to that of
alexandrite lasers discussed previously. In general, the
advantages of the diode array laser are its small size,
efficiency, speed, and ability to treat darker skin types
more safely because of the combination of long pulse-
width and active skin cooling.
Several studies have shown the efficacy of the diode
laser for hair removal. 38-4~ One study reported the
treatment of 50 consecutive patients with skin types I
to V, each of whom received a range of fluences given in
one and two treatment sessions. 3s Quantitative hair
counts were performed for 9 months after treatment.
Results indicate that the diode array laser safely in-
duces long-lasting and possibly permanent hair loss. In
another report, the long-term efficacy of the diode laser
after two treatments was superior to that of the long
pulse ruby laser, with fewer pigmentary side effects.39
Flashlamp
An intense xenon flashlamp device called the Epi-
Light (ESC Medical Systems, Israel) has also received
FDA clearance for hair removal. This device delivers
broad-spectrum, incoherent (nonlaser) light from about
550- to 1,200-nm wavelength. One of four different
filters is used to cut off the output below a predeter-
mined wavelength. In general, longer wavelength fil-
ters are used in darkly-pigmented patients. Light is
delivered through a large rectangular handpiece measur-
ing either 10 • 45 or 8 • 35 mm. The device emits a
sequence of 2 to 5 ms-domain pulses separated by a
variable delay between pulses. The series of pulses is
delivered once every few seconds. A gel is applied to
cool the epidermis and improve light coupling to the
skin. 41 The software within the EpiLight device pro-
vides suggested treatment parameters, but most practi-
tioners familiar with the device adjust the output
individually according to their experience.
Successful hair removal with the EpiLight has been
reported at a follow-up period of 8 weeks. 41 Although
data regarding the long-term efficacy of this device are
lacking, it is reasonable to assume that the flashlamp
system will largely mimic the effects of alexandrite
lasers if sufficient fluence is used. This device has been
marketed aggressively and has been a subject of contro-
versy among clinicians. The successful use of the
Epilight machine requires a certain amount of experi-
ence because the numerous treatment parameters are
bewildering to the novice. Unlike most lasers, the
optical pulse energy is not calibrated with each use,
such that treatment dose may need to be arbitrarily
reduced when the flashlamp is replaced. The broad
range of wavelengths delivered by the EpiLight can be
viewed as an advantage or a disadvantage. For example,
155
the range of wavelengths was used to explain why the
Epilight removes all hair colors, but ruby lasers also
remove all hair colors (temporarily). The presence of
longer wavelengths provides better penetration depth
into dermis than ruby or alexandrite lasers, but also
includes wavelengths absorbed by water, which may
increase the risk of adverse effects. Probably the great-
est technical advantage of the Epilight is the large
exposure area, which improves damage of the deep
follicles. However, the slow pulse repetition rate makes
the device equivalent in speed to the diode array and
alexandrite lasers.
Safety with Hair Removal Devices
It is extremely important when using any treatment
device to consider its major safety hazards and how to
minimize risks of injury to patient or physician. As a
class, these optical hair-removal devices probably pose
the greatest risk for serious eye injury out of all devices
we now use in medicine. The Q-switched Nd:YAG laser
used in the Softlight technique is capable of causing
blindness when reflected into the eye from any shiny
object such as the face of a watch, jewelry, or metal
instruments in the room. The beam is invisible; the
retina does not sense pain. The first symptom of
Nd:YAG laser eye exposure is therefore blindness.
Ruby, alexandrite, diode array laser, and the xenon
flashlamp for hair removal are all specifically designed
to destroy melanin-pigmented tissue deep below the
skin surface. The highest concentration of melanin in
the body is in the retina and choroid, which extends all
the way to the front of the eye. At the fluences used for
hair removal, if a pulse from any of these devices is
accidentally delivered to the sclera, massive retinal
injury with subretinal hemorrhage and extensive eye
damage is virtually certain. Even the insertion of
laser-protective eye shields over the cornea does not
provide safety, because they cover only the anterior
surface of the globe. Calculations suggest that human
eye injury will occur with these sources even when
delivered through the intact eyelid and sclera com-
bined. It is therefore never a good idea to attempt
optical hair removal around the immediate vicinity of
the eye itself, without extreme caution and experience.
The flashlamp device presents less risk of eye injury at
a great distance than laser devices because it is a broad,
incoherent source. However, at close (treatment) range,
it is at least as hazardous for eye injury to the patient.
The handpiece in the Epilight flashlamp device con-
tains both lethally high electrical current and flowing
water, which presents a theoretical risk of electrocu-
tion. Although the flashlamp version for treatment of
leg veins has been noted to explode, no injuries have
yet occurred because the blast fragments and electrical
power were contained within the handpiece. Protective
156
eyewear should be worn by both patient and physician
when using any of these hair-removal devices, and the
wavelength range for protective eyewear should in-
clude the emission wavelength(s) of the device.
Another hazard associated with laser hair removal is
noxious substances in the plume of vaporized hair
material. Breathing this plume often causes airway
irritation, presumably because acids are formed when
partially combusted organic materials combine with
water. The smell of burning hair leaking into one's
waiting room is also unlikelyto please many pa~ents. This
is handled with smoke evacuators and excellent ventila-
tion.
Finally, it should be noted that scarring can occur
after any procedure that injures the skin, particularly if
widespread thermal injury or post-treatment infections
occur. The incidence of scarring after laser hair re-
moval, when simple wound care instructions are kept,
is remarkably low (unreported). However, decades of
experience with laser treatment strongly suggest that
certain situations are more likely to cause widespread
thermal injury to the dermis, with subsequent scarring.
Selective photothermolysis was conceived and devel-
oped specifically to avoid the burns caused by long
laser exposure durations. When the time of exposure
exceeds the time for conduction of heat between
adjacent hair follicles, it is essentially certain that
widespread injury will occur at nearly the same fluence
that causes therapeutic effect. This situation occurs
with the use of long pulse durations on areas with
dense hair, such as the beard. In theory, one should
avoid using pulse durations longer than about 30 ms in
this or any other densely hairy area of the body,
especially if active cooling is not available.
Photodynamic Therapy
The use of light to activate an exogenously adminis-
tered, long wavelength photosensitizer is known as
photodynamic therapy (PDT). Although this technique
has been investigated primarily in the treatment of
cutaneous malignancy, it has also been reported to
selectively damage hair follicles, in a small human
study. 42 Aminolevulinicacid (ALA) is the first commit-
ted precursor of heme synthesis. When ALA is present
in excess, cells produce heme until intracellular iron
stores are depleted, and the penultimate heme precur-
sor, protoporphyrin IX, begins to accumulate. Protopor-
phyrin IX is a potent photosensitizer. Topically applied
20% ALA is absorbed by hair follicles and converted to
protoporphyrin IX over a period of several hours.
Subsequent exposure of the skin to red light near 635
nm activates protoporphyrin IX, leading to the forma-
tion of singlet oxygen, which damages follicular cell
membranes. The use of PDT has been reported to
induce partial hair loss in humans for at least 3 months,
ORT AND ANDERSON
depending on ALA concentration and light dose. 42 A
potential advantage of PDT with ALA or one of many
other drugs, is that hair and skin color are not expected
to be important variables, and sources as simple as a
slide projector can potentially be used. Further investi-
gation will help clarify the role of this promising
technique.
TREATMENT GUIDELINES
Laser treatment almost always results in temporary
hair loss, regardless of hair color Or which particular
device is used. However, the ability to achieve long-
lasting hair removal depends to a large extent on hair
color, treatment fluence, and spot size. Individuals
seeking to remove dark hair can be informed with some
confidence that long-lasting hair removal is likely to be
attained, when high fluences (~30 J/cm 2) can be
delivered by ruby or alexandrite lasers over a spot size
of at least 7 mm diameter. Under these conditions, the
average long-term hair loss per treatment is about 20%
to 30%, based on studies performed with ruby lasers.
Multiple treatment sessions are therefore usually re-
quired to achieve nearly complete hair loss, although
this does occur in a minority of subjects with dark hair
after a single treatment. Individuals with blonde, red,
gray, or white hair should be informed that laser
treatment is unlikely to produce long-lasting hair
removal. However, such patients may be willing to
undergo treatments spaced about 2 to 4 months apart
as necessary to maintain temporary hair loss.
Fair-skinned individuals are the ideal candidates for
laser hair removal. Such patients tolerate the use of
higher fluences, resulting in more effective treatment.
Caution is advised when treating darkly pigmented
individuals. The use of cooling devices, longer wave-
lengths, and longer pulsewidths (eg, 800 nm diode
array laser) helps to limit acute epidermal damage and
pigmentary change in these patients. When assessing
individuals with a suntan, it is usually prudent to delay
treatment for several months until fading of the tan
occurs. The Softlight system may provide the best
option for dark-skinned patients willing to accept
temporary hair loss.
Laser devices that target melanin within the follicle are
more effective when the pigmented hair shaft is present
within the foliicle. Consequently, plucking and waxing
of hairs before treatment is discouraged. Patients should
be instructed to depilate, clip, or shave the areas to be
treated on the day before treatment. Shaving may also be
performed by the staff immediately before treatment in
those patients who are reluctant to shave. Topical
anesthetics such as EMLA cream (Astra Pharmaceuti-
cals, Westborough, MA) may be used to lessen discom-
fort of treatment, but many patients tolerate laser hair
removal without anesthesia.
OPTICAL HAIR REMOVAL
In general, the highest tolerated fluence (based on
pain and evidence of epidermal injury) should be
delivered with the largest spot size appropriate, in a
slightly overlapping pattern. It is helpful to perform
test spots in inconspicuous areas with different flu-
ences to assess response to treatment. A grid may be
used to facilitate placement of laser pulses. The clinical
endpoint of perifollicular erythema developing within
a few minutes is desirable. Marked or confluent ery-
thema, whitening, vesiculation, purpura, or Nikolsky's
sign (epidermal separation with lateral stroking) indi-
cates acute epidermal injury from overly aggressive
treatment. Ruby and alexandrite laser treatments gener-
ally vaporize any visible hairs, which creates a sulfur
smelling plume. Hair vaporization is an immediate,
useful sign that appears to be correlated with adequate
treatment fluence.
Post-treatment discomfort can be lessened by the use
of ice packs and a short course of topical steroids, if
necessary. Treated hairs may be shed over the course of
several weeks and should not be confused with bona
fide hair regrowth. Treatment should be repeated
approximately every 6 to 8 weeks when regrowing
hairs are in the early anagen stage. Regrowing hairs are
often more lightly pigmented and of decreased caliber,
which contributes to patient satisfaction with treatment.
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