Human Reproduction Update, Vol.8, No.2 pp.

169±181, 2002

Laser hair reduction in the hirsute patient: a critical

assessment

Luis A.Sanchez1, Marilda Perez and Ricardo Azziz1,2,3

Departments of 1Obstetrics and Gynecology and 2Medicine, The University of Alabama at Birmingham, Birmingham, Alabama,
USA
3
To whom correspondence should be addressed at: Department of Obstetrics and Gynecology, The University of Alabama at
Birmingham, 618 South 20th Street, 549 OHB, Birmingham, AL 35233±7333, USA. E-mail: razziz@uabmc.edu

Hirsutism affects 5±10% of unselected women, depending on ethnicity and de®nition. The past two decades have seen
the development of lasers for the removal of unwanted hair, using selective destruction of the hair follicle without
damage to adjacent tissues. Selective photothermolysis relies on the absorption of a brief radiation pulse by speci®c
pigmented targets, which generates and con®nes the heat to that selected target. In general, laser hair removal is
most successful in patients with lighter skin colours and dark coloured hairs. Some studies have documented the
results of laser hair removal in a controlled setting, although few have extended their observations beyond 1 year. In
general, treatment with the ruby, alexandrite or diode lasers, or the use of intense pulsed light results in similar
success rates, although these are somewhat lower for the neodymium:Yttrium±Aluminum±Garnet (nd:YAG) laser.
Overall, laser hair removal should not be considered `permanent', at least when considering the current data
available. Repeated therapies are necessary, although complete alopoecia is rarely achieved and it is unclear at what
point the maximum bene®t is achieved from multiple therapies. While larger prospective, controlled, blinded and
uniform studies are still needed, laser hair removal appears to be a useful adjuvant in the treatment of the hirsute
patient.

Key words: hirsutism/laser hair reduction/lasers/unwanted hair removal

TABLE OF CONTENTS stopping further progression of the disorder, it has only modest
effects in reversing the hair growth process (Azziz et al., 2000).
Introduction
Thus, the optimum treatment of the hirsute patient should
A brief physiology of hair
The differential diagnosis and evaluation of the hirsute patient
incorporate the use of methods to permanently destroy unwanted
Hormonal treatment of hirsutism hairs. To date, electrolysis has been the primary method used for
The physics and mechanism of action of lasers the destruction of these hairs. In fact, and consistent with the large
Laser parameters determining success number of affected women, it has been estimated that electrolysis-
Target tissue and clinical factors assisted hair removal accounts for a ~$1 billion market in the
Results of clinical studies USA alone, with 13106 women spending an average of $1000 per
Complications year on the procedure (Moretti and Miller, 1996). The worldwide
Summary market has been estimated to be >$3 billion. An additional
References 803106 women spend $500 million on depilatory products.
During the past two decades we have seen the development of
lasers for the removal of unwanted hair. The main objective of
laser therapy for hair removal is to selectively cause thermal
Introduction
damage of the hair follicle without destroying adjacent tissues, a
Hirsutism is de®ned as the presence in women of terminal hairs in process termed selective photothermolysis. Unfortunately, the
a male-like pattern, and affects between 5±10% of women numbers of lasers available for hair reduction multiply daily,
surveyed (Ferriman and Gallwey, 1961; McKnight, 1964; Hartz et many different treatment protocols are utilized and results are
al., 1979; Knochenhauer et al., 1998). The presence of hirsutism unclear, which has only served to confuse both practitioners and
is generally a sign of an underlying disorder, principally androgen patients regarding the value and limitations of these techniques. In
excess. While hormonal therapy is generally successful in this review we will brie¯y discuss the physiology of hair growth

Ó European Society of Human Reproduction and Embryology 169

L.A.Sanchez, M.Perez and R.Azziz
and the differential diagnosis and hormonal treatment of
hirsutism. More extensively, we will address the physics and
mechanisms of action of laser hair reduction, and the reported
success and complications of these procedures.
A brief physiology of hair
The physiology of hair growth and development has been recently
reviewed (Azziz et al., 2000). In brief, there are ~503106 hair
follicles, generally associated with a sebaceous gland (i.e. forming
the pilo-sebaceous unit) covering the body, of which 20% are in
the scalp. The only areas free of hair follicles are the soles of the
feet, the palms of the hands, and the lips. Few new hair follicles
are formed after birth, and their numbers begin to decline after the
age of 40 years. Hence, a generalized thinning of the hair is
normal with ageing. There are no differences in follicle numbers
between genders within each racial/ethnic group, and the visible
difference in appearance between men and women does not relate
to differences in the number of hair follicles, but rather to the type
of hairs arising from these follicles.
Hair is composed of a column of compressed keratinized
melanocytes that grow towards the skin surface within the outer
hair sheath, from the dermal papilla (Figure 1). In general, there
are three types of hair (Montagna and Van Scott, 1958; Uno,
1986; Hashimoto, 1988; Randall, 1994; Paus and Cotsarelis,
1999). Lanugo is a dense, soft hair over the surface of the fetus
which is shed sometime late in gestation or early post-partum.
Vellus hairs are the soft, short, ®ne and usually non-pigmented
hairs that cover the apparently hairless areas of the body. They
usually measure <2 mm in length. Terminal hairs are long, coarse
and pigmented. In contrast to vellus and lanugo hairs, terminal
hairs contain a central dense core of kertinocytes, the medulla,
which gives the hair more rigidity and pigmentation (Figure 1).
Terminal hairs makes up the eyebrows, eyelashes, scalp hair,
pubic and axillary hair, etc. Follicles producing vellus hairs can be
transformed by a number of hormones, particularly androgens, to
produce terminal hairs. Although the process of terminalization of
the hair follicle may take a number of growth cycles to complete,
Figure 1. Anatomy of a pilosebaceous unit containing a terminal hair follicle.
170
it is not reversible thereafter. The growth cycle of hair can be
divided into three phases (Kligman, 1959; Uno, 1986; Paus and
Cotsarelis, 1999). The active growing phase (anagen) is followed
by an involutional stage (catagen), in which the hair stops
growing and the hair bud shrinks. The telogen phase, in which the
hair is shed, completes the growth cycle. The overall length of a
hair is determined primarily by the duration of the anagen phase.
Human hair appears to grow continuously because the growth
cycles of the different hair follicles are in dysynchrony with each
other.
A number of hormones affect hair growth, with thyroid and
growth hormone producing a generalized growth in hair (Randall,
1994; Deplewski and Rosen®eld, 2000). For example, hyperthyr-
oidism results in a ®ne friable hair which is easily lost, while
hypothyroidism produces a course, brittle hair which is also easily
broken, and which is often associated with hair loss from the
lateral eyebrows. Progesterone and estrogens have only minimal
effects on hair growth. Androgens are the most important
determinant of the type of hairs distributed throughout the body
(Uno, 1986; Randall, 1994; Paus and Cotsarelis, 1999). The
principle circulating androgen, testosterone, is converted in the
hair follicle by 5a-reductase to dihydrotestosterone (DHT).
Testosterone, and the more potent DHT, stimulate the dermal
papilla to produce a terminal medullated hair. Other weaker
androgens, such as androstenedione and dehydroepiandrosterone
(DHEA), can also be metabolized in the skin to testosterone and
DHT to produce excessive hair growth.
The effect of androgens on hair growth is skin area-speci®c,
due to local variations in androgen receptor and 5a-reductase
content (Randall, 1994; Azziz et al., 2000). While the effect of
androgens on hairs (i.e. terminalization of vellus hairs) will be
more readily apparent in skin areas with a greater number of hair
follicles, hair follicle density does not correlate with follicular
sensitivity to androgens. Some areas of the body, termed non-
sexual skin (e.g. that of the eyelashes, eyebrows, and lateral and
occipital aspects of the scalp), are relatively independent of the
effect of androgens. Alternatively, other areas (i.e. ambosexual
skin) are quite sensitive to androgens, and hair follicles are
terminalized even in the presence of relatively low levels of
androgens. These include the pubic area and the axilla, which
begin to develop terminal hair even in early puberty when only
minimal increases in adrenal androgens are observed. Finally,
other areas of skin respond only to high levels of androgens (i.e.
sexual skin) and include the chest, abdomen, back, thighs, upper
arms and face. The presence of terminal hairs in these areas is
characteristically masculine, and if present in women is
considered pathological, i.e. hirsutism.
The differential diagnosis and evaluation of the hirsute
patient
It should be noted that hirsutism, above all else, should be
principally considered a sign of an underlying endocrine or
metabolic disorder, and these patients should undergo a thorough
evaluation as soon as possible. The vast majority of the causes of
hirsutism are androgenic (Azziz et al., 2000) (Table I). Non-
androgenic causes of hirsutism are relatively rare. For example,
10±15% of acromegalics initially present with hirsutism. Since
hair is designed to protect the skin, chronic irritation of the skin

Table I. Androgenic causes of hirsutism
Diagnosis Approximate prevalence
among hirsute women (%)
PCOS 70±85
IH 5±15
HAIRAN 2±4
21-OH NCAH 1±10
Drug-induced 1±3
ASN 1/300±1/1000
PCOS = polycystic ovarian syndrome; IH = idiopathic hirsutism;
HAIRAN = hyperandrogenic±insulin resistant±Acanthosis nigricans
syndrome; 21-OH NCAH = 21-hydroxylase de®cient non-classic adrenal
hyperplasia; ASN = androgen-secreting neoplasm.
secondary to long-term exposure to caustic substances, environ-
mental toxins etc., will lead to a generalized increase and
coarsening of the hairs in affected areas, including the
transformation of vellus to terminal hairs. Anabolic drugs will
cause a generalized growth of many tissues, particularly hair,
generally leading to vellus hypertrichosis and not hirsutism.
Androgenic causes include the polycystic ovarian syndrome
(PCOS), the hyperandrogenic±insulin-resistant±Acanthosis nigri-
cans (HAIRAN) syndrome, 21-hydroxylase-de®cient non-classic
adrenal hyperplasia (NCAH), drug-related, and very rarely
ovarian or adrenal androgen-secreting neoplasms (ASNs).
Finally, 5±15% of women suffer from idiopathic hirsutism
(Azziz et al., 2000). The most common diagnosis, PCOS,
although endocrinologically and morphologically de®ned, has
also been described as a diagnosis of exclusion. This disorder is
generally attributed to patients who have evidence of ovulatory
dysfunction in the face of either biochemical or clinical evidence
of hyperandrogenism, after the exclusion of related disorders such
as NCAH, HAIRAN syndrome, ASNs, thyroid and hyperprolac-
tinaemia (Zawadzki and Dunaif, 1992). These patients are also at
greater risk for developing infertility, dysfunctional uterine
bleeding, endometrial carcinoma, type 2 diabetes mellitus and
possibly cardiovascular disease.
The diagnosis of idiopathic hirsutism (IH) is also established by
clinical exclusion in a patient who is obviously hirsute, but in
whom the circulating androgens and ovulatory function appear to
be normal (Azziz et al., 2000). However, it should be noted that
~40% of eumenorrhoeic hirsute women are actually anovulatory,
and hence probably suffer from PCOS and not IH (Azziz et al.,
1998). In general, a thorough history and physical examination
should be performed.
The hormonal evaluation of the hirsute patient has been
reviewed (Azziz, 2000; Azziz et al., 2000). The laboratory
evaluation of the hirsute patient should be targeted to excluding
related disorders (NCAH, thyroid dysfunction, hyperprolactinae-
mia) and evaluating ovulatory function (e.g. by obtaining a
progesterone level between days 22 and 24 of the menstrual cycle
in the hirsute eumenorrhoeic patient). The measurement of
circulating androgen levels, including total testosterone, free
testosterone and DHEAS are useful primarily in the minimally or
non-hirsute oligo-ovulatory patient, to exclude the presence of
Lasers in hirsutism
androgen excess as the cause of the ovulatory dysfunction.
However, these measurements have limited diagnostic utility in
the patient who is frankly hirsute, and have a low positive
predictive value for adrenal or ovarian ASNs (Waggoner et al.,
1999).
Hormonal treatment of hirsutism
Hirsutism is not only cosmetically dis®guring, but can also be a
signi®cant handicap to a young woman's social life and emotional
stability. Hence, treatment should be undertaken as soon as the
diagnosis is established in order to minimize the number of
terminalized hair follicles. Nonetheless, these patients require
long-term follow-up counselling and emotional support since this
problem can be particularly distressing.
The hormonal therapy of hirsutism consists of medications that
either suppress androgen production or free androgen levels, or
block androgen action. Ovarian androgen suppression can be
accomplished with combination oral contraceptives, long-acting
GnRH analogues, ketoconazole or insulin-sensitizing drugs.
However, the transient suppression of ovarian androgens achieved
using surgery, such as laparoscopic ovarian drilling, has little
effect on hair growth. Furthermore, adrenal androgen suppression
using glucocorticoids also has a limited effect, if any, on
hirsutism. Overall, the impact of androgen suppression alone on
unwanted hair growth is relatively modest, and most women with
clinically signi®cant hirsutism will require the addition of
medications to block androgen action. These drugs include
androgen receptor blockers such as spironolactone, ¯utamide and
cyproterone acetate (which is also a progestin that can inhibit
ovarian androgen secretion by suppressing pituitary gonadotro-
phins). Androgen blockers also includes ®nasteride, which
decreases androgen-dependent hair growth by inhibiting 5a-
reductase and the peripheral conversion of testosterone to DHT.
Overall, all drugs that block androgen action provide similar
results, such that side-effects will the most important feature in
determining patient preference (Venturoli et al., 1999; Moghetti
et al., 2000).
Therapy for hirsutism may take 6 or 8 months before a
difference is observed. Furthermore, we need to emphasize that
the main purposes of hormonal therapy are to correct the
underlying problem, stop new hairs from growing and potentially
slow the growth of terminal hairs already present. Although
hormonal therapy alone will sometimes produce a thinning and
loss of pigmentation of terminal hairs, it generally will not reverse
the terminalization of hairs.
In addition to hormonal suppression and androgen blockade,
hirsute patients require the removal by mechanical means of any
remaining unwanted terminalized hairs. While many patients
resort to shaving, bleaching or depilating with satisfactory results,
the use of plucking and/or waxing in androgenized skin areas
should be discouraged. These latter techniques not only do not kill
the hair follicles, but also may induce folliculitis and damage of
the hair shaft with subsequent development of in-grown hairs and
further facial damage. What hirsute patients require is the
permanent destruction of those follicles producing the unwanted
terminal hairs. Techniques to accomplish this include electrology
and, potentially, laser hair reduction.
171
L.A.Sanchez, M.Perez and R.Azziz
The physics and mechanism of action of lasers for hair
removal
The generation of laser (light ampli®cation by the stimulated
emission of radiation) light begins when a lasing medium (i.e. a
gas, crystal, liquid or semiconductor) is excited (energized).
Various sources of excitation are available, including light from a
¯ashlamp, continuous light, radio frequency, high voltage
discharge, diodes and even light from another laser. As the lasing
medium is excited, the medium's molecules are stimulated to a
higher energy level. These excited molecules tend to sponta-
neously decay to their original lower energy level (ground state)
releasing a photon, and the laser light generated in the process has
various properties including monochromaticity coherent, colli-
mated and high irradiance. Laser light is concentrated in a narrow
range of wavelengths, producing the purest (most monochro-
matic) light available. All emitted photons bear a constant phase
relationship with each other in both time and phase, such that the
light is said to be coherent. In turn, all laser light photons travel in
the same direction with low divergence, such that the light is
considered to be collimated. Finally, laser light has high
irradiance, since all the light is concentrated into a narrow spatial
band resulting in a high radiant power per unit area.
The main mechanism of laser therapy for unwanted hair is the
selective destruction of the hair follicle without damage to
adjacent tissues. Selective photothermolysis relies on the selective
absorption of a brief radiation pulse by speci®c pigmented targets,
which generates and con®nes the heat to that selected target. It is
absolutely necessary that the target has greater optical absorption,
at least at some speci®c wavelength, than the surrounding tissues.
This requirement can be met either by choosing endogenous
pigmented targets (e.g. those containing melanin) or by using
stains or dyes to label the target. Speci®cally, selective thermal
damage of a pigmented target structure will occur when suf®cient
¯uence is delivered at a speci®c wavelength (and which is
preferentially absorbed by the target tissue) during a time equal to
or less than the thermal relaxation time of the target (Anderson
and Parrish, 1983). We should note a few common terms used in
Figure 2. Absorption spectrum of melanin, oxyhaemoglobin and water, relative to the wavelengths of lasers currently used for hair reduction.
172
describing laser light. Energy refers to the amount of photons
delivered and is measured in joules (J). Power is measured in
watts (W) and refers to the delivery rate of energy (1 W = 1 J/s).
Fluence is the total energy delivered per unit area and is measured
in J/cm2. Pulse duration is the amount of time the laser energy is
applied [generally in nanoseconds (ns)]. The pulse frequency is
measured in hertz (1 Hz = 1 pulse/s). Wavelength is measured in
nanometers (nm) and refers to the distance between the peaks of
the light waves (light having the peculiarity of having both
waveform and particulate properties). Overall, wavelength is used
to characterize the type of light.
Once light strikes the skin, the energy can be re¯ected,
scattered, absorbed or transmitted. Approximately 5% of visible
light is re¯ected at the keratinized layer of the epidermis. In turn,
because of its high content of collagen, elastin and blood vessel
walls, the dermis primarily scatters light (including laser light).
Only absorbed light has a direct tissue effect, causing thermal,
chemical or mechanical tissue damage. Thermal damage may
range from simple protein denaturation to cellular vaporization
and carbon formation. Chromophores are substances that
preferentially absorb light; they may be endogenous (melanin,
haemoglobin or oxyhaemoglobin) or exogenous (tattoo ink). The
heating (and destruction) of laser-irradiated tissue due to direct
absorption of laser light is a function of various laser (e.g. power,
spot size, irradiation time and repetition rate) and tissue
parameters (absorption and scattering coef®cients, density, heat
capacity and thermal conductivity) (Van Gemert and Welch,
1989).
Laser parameters determining the success of laser hair
reduction
In general, three characteristics of the laser need to be taken into
account when considering hair destruction by photothermolysis:
wavelength, ¯uence and pulse duration. The longer the wave-
length, the deeper the laser light penetrates the skin. The
epidermis limits the amount of light that passes deeply into the

dermis, reducing the effects of lasers on the germinative hair cells
(Tong et al., 1987). It is possible to continue to obtain greater
tissue depths using longer optical wavelengths, until the laser light
reaches a wavelength of ~1500±2000 nm (near infrared spectrum)
where adsorption by water (and which is present in all human
tissues) begins, diminishing transmittance and increasing the risk
of collateral burns. Alternatively, the best wavelengths used to
target follicular pigment are in the red and infrared range of the
electromagnetic spectrum (600±1200 nm). It should be noted that
the absorption of light by melanin decreases with longer
wavelengths, and that oxyhaemoglobin and melanin have similar
absorption at wavelengths at 750±850 nm (DiBernardo et al.,
1999) (Figure 2). In addition, the larger the spot size, the deeper
the laser light will penetrate. To avoid epidermal damage due to
its melanin content, the skin's surface is usually cooled during
treatment. In general, the ¯uence of the laser should be greater
than or equal to the threshold ¯uence for tissue destruction.
The laser pulse width plays an important role in determining
selective photothermolysis, as suggested by the thermal transfer
theory (Anderson and Parrish, 1983). The duration of the laser
pulse has to be shorter than the thermal relaxation time of the hair
follicle in order to minimize collateral thermal damage. We note
that lasers may be continuous mode or pulsed. A continuous mode
laser emits a continuous stream of light as long as the medium is
excited, resulting in heating and vaporization of the target tissue.
Alternatively, a pulsed laser will emit light only in short amounts,
which may vary from femtoseconds (quadrillionths of a second)
to as long as seconds. High energy, ultra-short pulses of laser light
cause extremely rapid heating of the target, with an ultra-rapid
expansion of the thermal plasma. As the plasma collapses, the
shock wave causes mechanical disruption of the target. The
simplest way to pulse a laser is to use a mechanical shutter,
similar to that in a camera, which works down to the millisecond
(ms) range. Flash lamps (similar to those used in photographic
Figure 3. Frequency of side-effects overall among 900 patients assessed retrospectively after hair reduction with either Q-switched neodymium:Yttrium±
Aluminum±Garnet, alexandrite lasers or long-pulsed ruby according to Fitzpatrick skin phototype (lights skin colour studied is type I and darkest skin colour was
type V) (modi®ed with permission from Nanni and Alster, 1999).
Lasers in hirsutism
strobe lights) can also be used to produce low millisecond range
pulses. Pulses in the micro- to nanosecond range are produced
using Q-switching (quality or gain-switching).
The ideal laser pulse duration should be between the thermal
relaxation time of the epidermis (3±10 ms) and the thermal
relaxation time of the hair follicle (40±100 ms for terminal hair
follicles measuring 200±300 mm in diameter (Van Gemert and
Welch, 1989; Dierickx et al., 1998). Results after treatment of
hair follicles are expected to be better with longer pulsed lasers
when compared with shorter pulsed ones. However, the
therapeutic difference between longer and shorter pulsed lasers
may be minimal. For example, Wimmershoff et al. found 50±75%
reduction 6 weeks after a single treatment, and a 25% reduction 6
months after two to four treatments using a 5 ms long-pulsed ruby
laser. Although a heterogeneous population with different skin
types and hair colour was evaluated in this study, these results are
similar to those published for shorter wavelengths (Wimmershoff
et al., 2000)
Target tissue and clinical factors determining ef®cacy of
laser hair reduction
Various tissue and clinical parameters affect the ef®cacy of laser-
induced hair removal, including skin type, hair colour and hair
growth phase. To permanently remove hair with lasers we ®rst
need to identify which part of the hair follicle needs to be
destroyed, and ®nd an adequate site within this structure to absorb
the laser light. Two hair structures have been targeted for
destruction in order to attempt to achieve permanent hair damage:
the hair bulb and the hair bulge (Figure 1). Notably the laser light
must penetrate the skin, since the bulge is located 1±1.5 mm and
the hair bulb 3±7 mm deep within the skin. For the targeted
destruction of hair follicles, surrounding tissues should not be
heated to minimize the risk of adverse sequelae, such as scarring
173
L.A.Sanchez, M.Perez and R.Azziz
and hyperpigmentation. Hence melanin in the hair, or an
exogenous chromophore, is targeted for laser heating.
Skin and hair pigmentation
Laser-induced selective photothermolysis depends on the selec-
tive absorption of laser light by the speci®c structure being
targeted for heating, while the absorption by surrounding tissues
should be minimized. Hence, the best candidates for laser-induced
selective photothermolysis are patients with lighter skin
(Fitzpatrick types I±IV) (Fitzpatrick, 1988) and dark brown or
black hairs (Williams et al., 1998). While successful hair removal
with either lasers or intense pulsed light has been occasionally
reported in patients with Fitzpatrick skins types V and VI
(Johnson and Dovale, 1999; Adrian and Shay, 2000; Greppi,
2001), it is clear that the incidence of complications such as burns,
scarring and hypo- or hyper-pigmentation increases with the
degree of skin pigmentation (Liew et al., 1999a) (Figure 3). It
should be noted that complications are not limited to patients with
genetically determined dark skin, but also to those patients with
darker skin due to other reasons, such as sun-tanning and
lentiginous photoageing.
In addition to the degree of contrast between skin and hair, the
colour or pigmentation of the hair alone, i.e. its melanin content,
has also been suggested to be a determining factor in the success
rate of laser hair removal. In fact, in clinical studies patients with
darker hair respond better after repeated treatments (Williams et
al., 1998; Liew et al., 1999b). Nonetheless, con¯icting data exists
as to whether the melanin content of the hair is a signi®cant
determinant of the ef®cacy of laser damage to the hair (Liew et
al., 1999c; Liew, 1999), suggesting that a greater proportion of
the viable cells of hairs with higher melanin content will be
destroyed every time a laser treatment is administrated. To
increase the amount of laser light selectively absorbed by the hair
follicles, various investigators have resorted to the use of an
exogenously applied chromophore. For example, a formulation
containing rhodamine-6G-loaded microspheres dispersed into
silicone vehicles has been demonstrated to penetrate deeply into
the follicular duct (up to 282 mm) after ethanol application to the
skin (Sumian et al., 1999).
Table II. Laser for hair removal: results of prospective controlled clinical studies
Author and year Type of laser No. of
subjects
Grossman et al., 1996 Ruby 13
Dierickx et al., 1998 Ruby 7 2 years
Polderman et al., 2000 Ruby 30
Wimmershoff et al., 2000 Ruby 74
Nanni and Alster, 1997 Nd:YAG 12
McDaniel et al., 1999 Alexandrite 22
Lou et al., 2000 Diode laser 18
a
Statistically signi®cant difference compared with control area.
b
Based on four subjects having <50% regrowth of hair.
Rx = treatment.
174
Hair growth cycle
In mice, Lin and colleagues noted that the ability of lasers to
cause follicle destruction depended, at least in part, on the phase
of the hair growth cycle (Lin et al., 1998). Using a ruby laser at
¯uences ranging from 1.47±3.16 J/cm2, these investigators noted
that in animals treated during the anagen (active growth) phase
there was a heterogeneous, but widespread, injury to the follicular
epithelium that extended along its entire length, increasing with
increasing ¯uence. However, no follicular damage was observed
in catagen (resting) or telogen (shedding) stage follicles at any of
the ¯uences used. Full hair regrowth occurred 28±56 days after
laser exposure administered during the catagen or telogen phases
for all ¯uence levels. In contrast, regrowth after laser treatment in
the anagen phase was ¯uence-dependent, with moderate to full
regrowth at 1.47 J/cm2 and none to sparse regrowth occurring at
3.16 J/cm2. Nonetheless, in a study using human ex-vivo scalp
skin Liew and colleagues noted that the proportion of hairs in the
anagen phase did not contribute solely to the ef®cacy of ruby laser
hair removal (Liew et al., 1999d). These investigators suggested
that when re-growth of hair occurs after laser therapy, it is simply
from follicles that received inadequate treatment.
The exact effect that lasers have on the hair follicle to cause
permanent hair reduction remains unclear. Dierickx and collea-
gues suggested that laser damage induces a process of
miniaturization of the coarse terminal hair-producing follicles,
transforming them into hair follicles that produce vellus-like
hairs, resulting in a non-scarring alopoecia (Dierickx et al., 1998).
Histological examination 2 years after laser treatment has
demonstrates a decrease in the number of terminal hair follicles
and a reciprocal increase in the number of miniature or vellus hair
follicles. Since the size of the hair is dependent on the size of the
papilla and the bulb of the hair follicle (Van Scott and Ekel,
1958), it has been proposed that laser therapy miniaturizes the
papilla and the bulb either by the direct photothermal injury of
these structures, or through the injury of other structures in the
follicle which control the formation of the bulb with each anagen
cycle. Interestingly, the histological changes of the hair follicle
after lasers are similar to those described in patients with
androgenetic alopoecia (Abell, 1984).
Follow-up No. of Interval between Hair
treatments treatments reduction (%)
6 months 1 ± 30a,b
1 ± 64a
3 months 3 1 month: face; 3 38±49a
months: arm/pubis
6 months 1±4 6 weeks 1 Rx: <25 2±4 Rx: 26±50
6 months 1 ± 0
6 months 1±2 2 months 8±56
20 months 2 4 weeks 46a

Figure 4. The hair density in 10 subjects during and after three treatment sessions (Treat 1, 2 and 3) with a long-pulsed ruby laser (25 and 40 J/cm2), electrology or
wax epilation is depicted. Each subject was treated on the face, forearms or pubic area. The graph depicts the results of all sites combined, at 6±8, 8±10 and 12
months after the ®rst treatment session (modi®ed with permission from Polderman et al., 2000, Dermatol. Surg. 26 240±243. Published by Blackwell Science,
Oxford, UK).
Results of clinical studies of laser hair reduction
Goldman and colleagues ®rst described the injury of pigmented
hair follicles by a ruby laser in 1963 (Goldman et al., 1963).
Subsequently, Oshiro and Maruyama noted hair loss after
treatment of nevi with ruby lasers (Oshiro and Maruyama,
1983). However, severe epidermal damage in the epilated area
was also reported, suggesting that laser technology was not a safe
method for the removal of unwanted hairs. The possibility of
selectively destroying hair follicles without causing extensive
epidermal damage was suggested with the introduction of the
concept of selective photothermolysis (Anderson and Parrish,
1983). Selective photothermolysis is possible when the target
preferentially absorbs the laser wavelength selected and the light
exposure time (pulse duration) is shorter than the time it takes for
heat to dissipate from the target into the surrounding tissues.
Grossman and colleagues reported the ®rst clinical controlled
study of laser hair reduction in 1996 using the ruby laser
(Grossman et al., 1996). Lasers useful in hair removal may be
grouped into three categories based on the type of laser or light
source each employs: (i) red light systems (694 nm ruby); (ii)
infrared light systems [755 nm alexandrite, 800 nm semiconduc-
tor diode, or 1064 nm neodymium:Yttrium±Aluminum±Garnet
(nd:YAG)]; and (iii) intense pulsed light (IPL) sources (590±1200
nm). The currently available clinical data for each of these lasers
will be discussed. Studies that are controlled and prospective are
summarized in Table II.
Ruby lasers
The ruby laser was ®rst developed in 1956 (Maiman, 1966) and
produces a laser beam of 694 nm, using a xenon ¯ashlamp to
excite a ruby crystal. There are two different types of ruby lasers
Lasers in hirsutism
available, the normal (continuous) mode and the Q-switched
version. In the Q-switched type, the beam of light is ampli®ed
before emission is performed. The photon energy output or
¯uence of the Q-switched ruby laser is equivalent to that of a
normal mode ruby system, but it is delivered over nanoseconds
rather than milliseconds. The power (energy per unit of time:
Joules per second or watts) is therefore a thousand times greater
than that of the normal mode long-pulsed ruby laser. However, as
indicated above, while the Q-switched laser has a higher irradiant
power, it does not allow for adequate heat transfer to the lasered
tissue that results in an inadequate kill rate of hair follicles.
Currently, hair removal is effected using the long-pulsed (1±5 ms)
normal-mode ruby lasers.
The ruby laser is the best studied laser system used in hair
removal. In 1996 Grossman and colleagues reported on the ®rst
controlled clinical trial using a normal mode ruby laser system in
12 men and one woman volunteer with dark or brown hair
(Grossman et al., 1996). Different skin areas were pre-treated by
shaving or waxing, and laser treatment was applied to waxed and
shaved areas of skin using ¯uencies of 30±60 J/cm2 with 270 ms
pulses. Control sites in the same subjects (which had also been
shaved or waxed) were left untreated by the laser. The follow-up
was performed at 1, 3 and 6 months after laser treatment, during
which the number of terminal hairs in the areas (treated and
control) were evaluated by counting the number of terminal hairs.
At 6 months after a single treatment, 4/13 subjects had <50% of
hair regrowth as evaluated by hair counting, but only in shaved
areas. At the 6 month evaluation a signi®cant amount of hair loss
was observed only in those skin areas that were initially shaven
and then treated by laser at the highest ¯uence (60 J/cm2).
Transient hyperpigmentation was observed in three (23%)
175
L.A.Sanchez, M.Perez and R.Azziz
subjects. In a subsequent report these same investigators
published the results of a 2 year follow-up in seven individuals
(Dierickx et al., 1998). At the 1 and 2 year follow-ups there was
signi®cantly less hair only in the skin areas that had been initially
shaven and then treated with the ruby laser (at all ¯uences) when
compared with the untreated control skin areas. A total of four
individuals had laser-induced alopecia in the treated areas, a result
evident by the 6 month evaluation.
Subsequently, a number of reports have documented the results
of hair removal with the ruby laser, studying patients with varying
types of skin and using different laser parameters. The published
hair reduction rates have ranged from 37 to 72% 3 months after
one to three treatments, to a 38±49% hair reduction 1 year after
three treatment sessions (Williams et al., 1998; Liew et al.,
1999b; Sommer et al., 1999; Campos et al., 2000a; Polderman et
al., 2000; Wimmershoff et al., 2000). In controlled studies, the
use of a ruby laser (one to four sessions) proved to be more
ef®cacious for hair reduction than shaving or waxing only
(Grossman et al., 1996; Dietrickx et al., 1998; Polderman et al.,
2000; Wimmershoff et al., 2000).
As expected, multiple treatments at 3±5 week intervals produce
a greater degree of hair reduction than a single session (Sommer
et al., 1999). A prospective, controlled study compared ruby laser
with hot wax and needle electrolysis for hair removal (Polderman
et al., 2000) (Figure 4). Three sessions of ruby laser treatment (25
or 40 J/cm2, 0.8 ms pulses) at intervals of 1 month (for face,
n = 10) or 3 months (pubic or arm areas, n = 10 each) produced
signi®cant hair reduction evident at 6 months (on the face) and 8
months (on the arms and pubis). The same number of sessions
with needle electrolysis or hot wax groups did not produce
signi®cant changes in hair counts by the 12 month follow-up (or
~3 months after the last treatment session). Nonetheless, it is
unclear whether comparing three sessions of electrolysis with
three sessions of laser is fair, considering the fact that several
treatments with electrolysis are usually needed to obtain a
permanent reduction in hair growth (Richards and Meharg, 1995)
and the signi®cant differential in cost. In general, higher ¯uencies
have a better success in hair removal, although side-effects
logically increase (Dierickx et al., 1998; Campos et al., 2000a;
Polderman et al., 2000).
Almost all side-effects demonstrated in the published clinical
trials have been temporary, including erythema, pigmentary
changes and blistering. Hyperpigmentation in skin types II±II
has been observed in up to 12% (Williams et al., 1998); blistering
and hypopigmentation may occur in 8±12% of patients with type
V skin (Liew et al., 1999b). In one study, a pain rate of 14% was
reported (Salomon, 1998). A patient suffering from solar-induced
post-in¯ammatory hyperpigmentation has been described after
hair removal with a ruby laser (Hasan et al., 1999); and
unfortunately, after 4 months of intense medical therapy most
of the affected areas remained hyperpigmented. Cellular carcino-
genesis is a theoretical possibility, since free radicals at the hair
shaft produced by the conversion of light into heat may cause
DNA damage. However, basal cell hyperproliferation within the
skin, thought to be a mechanism of burn wound carcinogenesis,
does not appear to occur after exposure to ruby laser radiation at a
common clinical dose of 11 J/cm2 (Liew et al., 1999e).
Overall, clinical results with the ruby laser have not been as
good as theory would predict. The less than expected success may
176
result, at least in part, from the intrinsic variations of skin and hair
present in humans. For example, heterogeneous temperature
increases were achieved in the hair follicles of skin studied ex
vivo within the same area following ruby laser treatment (Topping
et al., 2000). This suggests that differences exist even between
follicles located in the same general area of skin and that these
differences result in an amount of heat transfer. These ®ndings are
compatible with the fact that the rate of heat transfer by a speci®c
body affected by the same amount of energy depends on the
molecular composition of that body. For hair follicles, it is logical
to think that their molecular composition varies even in the same
person and in the same area. The heterogeneous heat transfer
suggests that the bulge and bulb areas of the hair follicles may
frequently not receive enough heat to be destroyed and result in
permanent hair removal. In addition, human hair growth is
asynchronous, which means that at any one point in time, hair
follicles are in different stages of growth in the same area of skin.
It is possible that the sensitivity of the hair follicle to laser energy
may vary along the hair growth cycle, affecting the rate of
permanent hair removal. However, a recent study demonstrated
no correlation between the proportion of hairs in anagen at the
time of laser administration and the ef®cacy of laser hair removal
(Liew et al., 1999c). Skin pigmentation may also decrease laser
effectiveness secondary to absorption of the laser light by skin
melanin. However, no decrease in the ef®cacy of laser hair
reduction has been observed in darker skins with repeated
treatment.
Use of nd:YAG lasers
The nd:YAG laser has been proposed as an effective method of
hair removal for several reasons (Littler, 1999). Firstly, its longer
wavelength (1064 nm) allows for better skin penetration of the
energy than the ruby laser. Although the deepest hair follicles are
often located at 4±5 mm in depth, lasers of shorter wavelength
may not penetrate as deeply. Secondly, lasers with wavelengths
well above 1000 nm have the inconvenience of being absorbed by
water, diminishing transmittance and increasing the risk of side-
effects. The nd:YAG laser, with a wavelength of ~1000 nm,
results in relatively less absorbed by cutaneous chromophores,
potentially diminishing the incidence of side-effects while
enhancing skin penetration. Finally, the nd:YAG laser system
can treat a large amount of skin surface quickly, with its 7±8 mm
beam size.
Because of its lesser absorption by melanin, some protocols call
for patients receiving nd:YAG treatment to ®rst undergo wax
epilation and the topical application of a carbon-based suspension
(Goldberg et al., 1997; Nanni and Alster, 1997). This solution,
when massaged onto the skin, ®lls the follicles with the
exogenous chromophore, potentially increasing the absorption
of the laser light into the area of the follicle. Because the
chromophore may also coat other parts of the skin (e.g. stratum
corneum) improved methods of dye delivery have been proposed
(Sumian et al., 1999). Most nd:YAG machines are Q-switched,
with pulses ranging from 10 ns to 30 ms, although nd:YAG
equipment delivering non-Q-switched long pulses is also avail-
able (SmartEpil, Deka-MeLa, Calenzano, Italy).
A single prospective controlled trial has demonstrated that one
treatment session with a Q-switched nd:YAG laser with topically
applied carbon dye results in a greater reduction of hairs

Figure 5. Mean percentage facial hair regrowth after a single treatment with wax epilation followed by Q-switched neodymium:Yttrium±Aluminum±Garnet
(nd:YAG) laser with topically applied carbon dye (Wax + Carbon + Laser), or Q-switched nd:YAG laser alone preceded by wax epilation (Wax + Laser), or Q-
switched nd:YAG laser alone (Laser Alone) or wax epilation alone (Control) (modi®ed with permission from Nanni and Alster, 1997, Arch Dermotol. 133, 1546±
1549. Copyrighted (1997) American Medical Association.
compared with laser alone, waxing and laser, or waxing alone at
the 1 month evaluation (Nanni and Alster, 1997) (Figure 5). Short
term hair reduction in the range of 20± 60% has been obtained
with the long-pulsed nd:YAG lasers (Bencini et al. 1999;
Goldberg and Samady, 2000). However, in the controlled study
of Nanni and colleagues using a single treatment episode, a 100%
hair regrowth was observed at 6 months (Nanni and Alster, 1997).
Longer-term results are not available.
Overall, clinical studies have demonstrated less hair reduction
with the nd:YAG laser compared with those results published
with the ruby or alexandrite lasers (Goldberg et al., 1997; Bencini
et al., 1999; Goldberg and Samady, 2000). One study comparing
treatments with the Q-switched nd:YAG laser and a long-pulsed
alexandrite laser suggested that the former was more effective for
the treatment of axillary hair growth (Rogers et al., 1999).
However, inexplicably the investigators seriously biased their
study by treating patients with only one session of the alexandrite
laser, and for only one pass; in contrast, they used three passes
over the skin with the nd:YAG laser in two separate treatment
sessions 4 weeks apart. Even then, the differences in hair
reduction at 3 months were minimal (19 versus 27% for the
alexandrite versus nd:YAG laser respectively). As with other laser
systems, repeated treatments seem to have better ef®cacy
compared with single treatments (Bencini et al., 1999).
However, the optimum treatment interval has not yet been
established.
Theoretical considerations to improve the performance of the
nd:YAG laser have been proposed, including an improvement in
the exogenous chromophores used; however, these issues remain
to be proved. Although the nd:YAG laser usually achieves less
dramatic results than other laser systems available for hair
reduction, due to its decreased absorption by melanin, it may
Lasers in hirsutism
cause less incidence of epidermal side-effects, including blistering
and abnormal pigmentation (Nanni and Alster, 1999). In addition,
the nd;YAG laser may be useful in the treatment of lighter hairs,
when used with the topically applied carbon suspension.
Long-pulsed alexandrite laser
There are a number of potential advantages to using the long-
pulsed alexandrite laser for hair removal. The long-pulsed
alexandrite laser systems are compact and can be used in small
rooms if adequate ventilation is available. Their ¯exible ®beroptic
arm is easy to manipulate and provides access to hard-to-reach
body areas. The spot size (5±7mm) and frequency (1±5 Hz)
improves the possibility of rapidly treating large body areas.
Melanin absorption is somewhat less at the wavelength of the
alexandrite (755 nm) compared with the ruby (694 nm) laser,
suggesting that epidermal damage may be less in patients with
darker skin. Consistent with this theoretical advantage, one report
of 150 subjects with Fitzpatrick skin types IV±VI treated with
repeated sessions using the alexandrite laser (18 J/cm2, 40 ms)
reported only a 2% complication rate (Garcia et al., 2000).
However, pigmentary changes and blistering have also been
reported in up to 14 and 15% of treated patients respectively, and
especially in women with darker skin types (Nanni and Alster,
1998; Lloyd and Mirkov, 2000). Treatment sessions can be
painful when higher ¯uences and faster repetition rates are used,
or when treating sensitive body areas like the upper lip or bikini
areas, and anesthetizing solutions (e.g. lidocaine/prilocaine
cream) are often used pretreatment.
The reported success rate of hair removal using the alexandrite
laser has ranged from 40± 80% at 6 months after several
treatments (Boss et al., 1999; McDaniel et al., 1999; Garcia et al.,
2000; Gorgu et al., 2000; Lloyd and Mirkov, 2000). In a
177
L.A.Sanchez, M.Perez and R.Azziz
controlled randomized study using a single treatment session on
various skin areas, using a single pulse (5, 10 or 20 ms)
alexandrite laser (20 J/cm2), investigators reported ~40% reduc-
tion in hair growth 6 months after treatment (McDaniel et al.,
1999). This increased to >50% (on the upper lip) if a second
treatment was performed after 8 weeks. An uncontrolled study,
using a uniform protocol, demonstrated a mean of 74% hair
reduction 1 year after ®ve treatment sessions at the bikini area
(Lloyd and Mirkov, 2000). A prospective study compared four
sessions of electrolysis at 3 week intervals to three sessions of
alexandrite laser treatment at 4 week intervals for axillary hair
removal (Gorgu et al., 2000). Six months after the ®rst treatment,
a 35.28% hair reduction was demonstrated in the electrolysis
group compared with 74.06% in the alexandrite laser group. In
this study, patients preferred laser epilation to electrolysis, even
though they understood that it was not permanent.
It does not appear that the use of longer-pulsed alexandrite
lasers provides greater therapeutic ef®cacy than shorter pulses.
One study compared the success rate of pulses of 5, 10 and 20 ms
(McDaniel et al., 1999). The 5 ms pulse provided the greatest
degree of bene®t, if objectively assessed, for all sites and
assessments periods (1, 3 and 6 months) combined; although a
greater degree of hair reduction was observed for the 10 ms if
only the 6 month data was analysed. Another study, using only a
subjective assessment of hair growth, did not ®nd a difference
between treatment with 2 and 20 ms pulses (Boss et al., 1999),
although the investigators found that the short pulse alexandrite
laser was ®ve times faster to apply than the long pulse instrument.
Diode laser
In this system the energy is emitted by multiple arrays of
semiconductor diodes. They are compact and portable, run on
standard 120 volt current and, do not require a cooling or
ventilation system. The diode laser system generates a laser light
of ~800 nm wavelength. In a prospective controlled trial this laser
demonstrated a signi®cant reduction in hair growth (Lou et al.,
2000). Overall, clinical studies with the diode laser system have
reported variable success rates range from 65±75% hair reduction
at 3 months after one to two treatments with ¯uences of 10±40 J/
cm2, to >75% hair reduction in 91% of subjects 8 months after
three to four treatments at 40 J/cm2 (Williams et al., 1999;
Campos et al., 2000b; Lou et al., 2000; Handrick and Alster,
2001). As expected, repeated treatments, generally at 4 weeks
intervals, appears to improve results (Lou et al., 2000; Handrick
and Alster, 2001), although not all investigators agree (Williams
et al., 1999a). Alternatively, con¯icting data exists whether the
¯uence of the laser, at least between 15 and 40 J/cm2, affects
therapeutic success (Campos et al., 2000b; Lou et al., 2000). Less
¯uence may be required to achieve the same ef®cacy in more
pigmented skin (Williams et al., 1999). In general, the diode laser
system has been found better tolerated by patients with darker
skin types (V±VI) than the ruby laser (Adrian and Shay, 2000;
Greppi, 2001); possibly because its energy is ~30% less absorbed
by melanin than that of the ruby laser, but with better optical
penetration (Campos et al., 2000b). Although the incidence of
pigmentary skin changes has been as high as 29%, most of these
changes are transient and well tolerated (Campos et al., 2000b;
Lou et al., 2000).
178
Intense pulsed light (IPL) source
This technique is not a real laser system because it delivers broad
spectrum, non-coherent radiation with wavelengths of 550±1200
nm. The speci®c light parameters (wavelength, number of pulses,
pulse duration, delay between pulses and energy ¯uence) are
selected by computer according to skin type and hair colour of the
individual. A set of four ®lters is available to select the speci®c
wavelength needed. In general, ®lters with higher cut-off values
are used with darker skin types. Spot sizes of 10345 and 8335
mm are available. Refrigerator-cooled gel is recommended when
higher energy light pulses are going to be used.
The ®rst published report of the use of IPL for hair removal was
for the treatment of terminal beard hairs in two transsexual
patients (Raulin et al., 1997). Histological evaluation at the time
revealed hair follicle atrophy. After 6 months (13 and 41
sessions), hair was practically absent with no pigmentary or
textural changes noted. After a single treatment, hair reductions
ranging from 33 to 60% are observed at 6 months after treatment
(Gold et al., 1997; Weiss et al., 1999). Repeated treatments
appear to improve outcome (Schroeter et al., 1999), although
more than three treatments do not appear to increase the success
rate (Sadick et al., 2000). Treatment with IPL may be useful for
light coloured hair (Gold et al., 1999; Schroeter et al., 1999),
although more treatment sessions are generally required. A few
patients with Fitzpatrick skin types V±VI have been successfully
treated with this method (Johnson and Dovale, 1999; Weiss et al.,
1999). No prospective randomized studies comparing the use of
IPL for hair removal with a control area (i.e. no treatment) are
available.
Long-term hair removal has been claimed using IPL. In a non-
controlled study of 14 subjects treated with this technology, and
followed for >12 months after their last treatment (mean 6 SD:
16.0 6 3.9 months), a mean of 83% hair reduction was obtained
after two to six treatments (Sadick et al., 2000). The secondary
effects included transient hyperpigmentation in 9% and crusting
in 6% of patients. The authors attributed the high success rate
obtained to the ability of this technology to provide energy of long
wavelengths, selected high-energy ¯uences on a speci®c range
and long-pulse durations. However, the results from this study
should be interpreted with caution due to the absence of controls
and the lack of a uniform treatment and follow-up protocol. Other
studies using the same technology have reported a similar
ef®cacy, but a higher hyperpigmentation rate of 20% (Schroeter
et al., 1999).
Complications of laser hair reduction
Most serious complications during laser hair reduction occur as a
consequence of inadvertent contact between the laser beam and
non-targeted tissues. Laser with visible light is transmitted by the
cornea and can in¯ict retinal haemorrhage, necrosis and scarring,
resulting in permanent visual ®elds defects (Aghassi et al., 1999).
After laser-assisted hair removal, most patients experience
erythema and oedema lasting no more than 48 h. Blistering or
crusting may occur in 10±15% of patients (Figure 6). Temporary
hyperpigmentation occurs in 14±25% of patients and hypopig-
mentation occurs in 10±17%. It is highly recommended that
patients avoid sun exposure after laser treatment to prevent solar-

Figure 6. Frequency of side-effects among 900 patients assessed retrospectively after hair reduction with either Q-switched neodymium:Yttrium±Aluminum±
Garnet, long-pulsed ruby or alexandrite lasers (modi®ed with permission from Nanni and Alster, 1999, permission as for Figure 5).
induced post-in¯ammatory hyperpigmentation (Hasan et al.,
1999). Dyspigmentation is less common with the use of longer
wavelengths, as in the alexandrite or diode lasers and longer pulse
durations (Nanni and Alster, 1998). In general, complications are
more common in patients with darker skin (see Figure 3).
Prophylactic treatment of patients with a history of oro-labial
herpes simplex virus has been recommended before treatment of
upper lip or chin areas to avoid a laser-induced ¯are-up of the
disease onto already in¯amed skin (Bjerring et al., 1998).
Summary
Overall, laser hair reduction is a promising technique for the
treatment of the hirsute patient. Nonetheless, we should note that
most studies have been uncontrolled and included <50 patients,
none have been blinded, and all have used a variety of treatment
protocols, equipment, skin types and hair colours. In general, laser
hair removal is most successful in patients with Fitzpatrick skin
colours I±IV, who have dark coloured hairs. Repeated therapies
are necessary, although complete alopecia is rarely achieved and
it is unclear at what point the maximum bene®t is achieved from
multiple therapies. In general, treatment with the ruby, alexandrite
or diode lasers, or the IPL results in similar success rates,
although it somewhat lower for the nd:YAG laser.
Laser hair removal should not be considered as `permanent', at
least considering the current data available. To quote the Food
and Drugs Administration (FDA), `Manufacturers should be
aware that receiving an FDA clearance for general permission to
market their devices does not permit them to advertise the lasers
for either hair removal or wrinkle treatment, even though hair
removal or wrinkle treatment may be a by-product of any cleared
laser procedure. Further, manufacturers may not claim that laser
hair reduction is either painless or permanent unless the FDA
determines that there are suf®cient data to demonstrate such
Lasers in hirsutism
results. Several manufacturers received FDA permission to claim,
`permanent reduction,' NOT `permanent removal' for their
lasers... Permanent hair reduction is de®ned as the long-term,
stable reduction in the number of hairs re-growing after a
treatment regime, which may include several sessions... [and]
does not necessarily imply the elimination of all hairs in the
treatment area' (http://www.fda.gov/cdrh/consumer/laserfacts.
html). We should note that, contrary to the Center for Drug
Evaluation and Research (CDER), the Center for Devices and
Radiological Health (CDRH) of the FDA reviews the manufac-
turer's data from investigational studies only to see if the product
does what it claims to do effectively and does not present any
unreasonable risks to the patient. It does not compare equipment
either with regards to safety or ef®cacy.
Several key questions remained to be answered. Exactly what
part of the hair follicle has to be destroyed in order to attain
permanent hair removal, and should we strive to destroy the
whole follicle, or only a speci®c part of this structure? Is an
exogenous pigment necessary for the best targeting, and if it is,
how do we best impregnate the hair follicle with this pigment?
How does laser hair removal compare with electrology in
permanently reducing hair, if only electrology were performed
with a more realistic frequency? Is the therapeutic outcome of
patients with hirsutism better or worse than that of women with
other types of unwanted hair? Does concomitant hormonal
therapy improve or hinder the results of laser hair removal?
How do we best minimize damage to surrounding structures and
minimize the risk of burns and pigmentation abnormalities? Only
larger prospective, controlled, blinded and uniform studies will be
able to provide us with these answers.
Acknowledgements
This work was supported in part by NIH grants 2R01-HD29364 and 1-K24-
HD01346±01 (to R.A.).
179
L.A.Sanchez, M.Perez and R.Azziz
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Submitted on August 28, 2001; accepted on February 5, 2002
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