Low-Fluence 1,064-nm Laser Hair Reduction for

Pseudofolliculitis Barbae in Skin Types IV, V, and VI

RAFAEL SCHULZE, MD, KEN J. MEEHAN, PA-C, ANTONIA LOPEZ, PA-C, KASINA SWEENEY, MD,
DOUG WINSTANLEY, DO, WILLIAM APRUZZESE, MPH,y AND E. VICTOR ROSS, MD

PURPOSE To evaluate the efficacy of a 1,064-nm neodymium-doped yttrium aluminium garnet

(Nd:YAG) laser using lower than traditional fluences (22–40 J/cm2 ) for treatment of pseudofolliculitis
barbae (PFB).
METHODS Twenty-two patients with PFB refractory to conservative therapy received five weekly
treatments over the anterior neck using a 1,064-nm Nd:YAG laser at 12 J/cm2. Pulse duration was 20 ms
with 10 mm spot size. Topical anesthesia was not used. Treatments were completed 15 minutes after
patient arrival. Patients presented for 2- and 4-week follow-up. Ten evaluators used a Global Assessment
Scale (GAS) to assess dyspigmentation, papule counts, and cobblestoning by comparing baseline to
4-week follow-up visit photographs. Hair and papule counts were performed on five patients and
compared with the GAS. Investigators recorded adverse effects using a visual analog and side effects
scale.
RESULTS Eleven patients demonstrated 83% improvement on the GAS (po.01). There was a mean
reduction of 59.5% in dyspigmentation (po.03), 91.2% in papule count (po.01), and 75.6% in cobble-
stoning (po.02). Patients reported 1 out of 10 on both adverse effects scales.
CONCLUSION Low-fluence 1,064-nm laser treatment achieved significant temporary reduction in PFB.
Subjects noted minimal pain without topical anesthesia.
The loan of the Starlux Laser Device and financial support for a research assistant was received from the U.S.
Army Medical Research and Material Command, Fort Detrick, Maryland.

P seudofolliculitis barbae (PFB) is an acneiform

eruption of the bearded area usually seen in
dark-skinned individuals with thick, tightly curled
hair. Typically, the hair shafts curve directly back
into adjacent skin or penetrate through the follicular
epithelium into the superficial dermis. The subse-
quent foreign body inflammatory reaction leads to
discomfort, pigment alteration, infection, scarring,
and a potentially decreased ability for the affected
person to shave. Chemical depilatories, topical
corticosteroids, topical retinoids, topical antibiotics,
and eflornithine hydrochloride cream are helpful in
the management of PFB.1 Growing a beard is usually
curative. In refractory cases, permanent laser hair
removal with the long-pulse neodymium-doped
yttrium aluminium garnet (Nd:YAG) laser has been
shown to decrease the severity of PFB in
dark-skinned individuals.2–6 This wavelength is safe
and effective. Because of its penetration, the
1,064-nm wavelength allows for a greater ratio of
hair bulb to epidermal heating than shorter
wavelengths, especially in patients with Fitzpatrick
skin type IV through VI.7
Traditional 1,064-nm laser fluences (defined as
22–40 J/cm2)2–5 produce significant discomfort in a
normal bearded subject. Blistering and subsequent
pigmentary changes have been reported in patients
with type V to VI skin.8 Patients often require topical
anesthesia with prolonged application times, ranging
from 45 to 90 minutes. Treatments are usually
scheduled every 4 to 6 weeks. Theoretically, the aim

Dermatology Department, Naval Medical Center San Diego, San Diego, California; yPalomar Medical Technologies,
Boston, Massachusetts

& 2008 by the American Society for Dermatologic Surgery, Inc.  Published by Wiley Periodicals, Inc. 
ISSN: 1076-0512  Dermatol Surg 2009;35:98–107  DOI: 10.1111/j.1524-4725.2008.34388.x

98

of the 1,064-nm laser treatment is long-lasting or
permanent hair reduction via conductive thermal
diffusion causing lethal damage to the hair bulb and
bulge area from the melanosome-containing hair
shaft and matrix,7 although patients treated at
the highest possible fluence eventually become
symptomatic within 12 to 18 months of their final
treatment.
The purpose of this study was to determine whether
PFB could be mitigated using a weekly treatment
protocol. We evaluated a 1,064-nm Nd:YAG laser
using a fluence of 12 J/cm2 in patients with PFB and
Fitzpatrick skin types IV, V, and VI.
Methods
Subjects
Twenty-two patients were evaluated in a prospective
interventional pilot study. All subjects were volun-
teers and were accessioned through the Dermatology
Department, Naval Medical Center San Diego, San
Diego, California. Participants were first screened
for Fitzpatrick skin types IV, V, and VI and then
enrolled consecutively. Written informed consent
was obtained. Subjects consented to a 9-week pro-
tocol involving five weekly treatments for PFB;
specifically, they consented to continue hair groom-
ing techniques used before accession into the study
(e.g., those who normally used clippers to groom
were instructed to continue to use clippers even if
they noted significant improvement during the
study). Regardless of grooming technique, patients
were required to shave the morning of each treat-
ment session and each follow-up evaluation. Of the
22 patients, one was a woman who had been diag-
nosed with ovarian hirsutism due to polycystic ovary
syndrome with secondary PFB. Ages ranged from
21 to 42, with a mean age of 24.3. With approval
from the Naval Medical Center San Diego Institu-
tional Review Board, patients were informed of the
purpose of the study and signed an Authorization to
use and/or Disclose Protected Health Information
for Research (covered under the Health Insurance
SCHULZE ET AL
Portability and Accountability Act), a California
Experimental Subject’s Bill of Rights, and a consent
form for Voluntary Participation in a Clinical
Investigation (Research). Inclusion criteria were
active duty man or woman aged 18 or older with
Fitzpatrick skin types IV to VI. All presented with
PFB for at least 1 year refractory to topical retinoids,
topical antibiotics, and topical steroids and evalu-
ated by a participating dermatologist. Exclusion
criteria were history of vitiligo, photosensitivity,
keloids, herpes simplex in the treatment area, or any
chronic medical conditions that could potentially
impair wound healing, such as diabetes mellitus or
collagen vascular disorders.
Procedure
Investigators treated patients using a laser (StarLux
Lux 1,064 handpiece, Palomar Medical Technolo-
gies, Burlington, MA) that was modified to produce
the required low fluence using a 20-ms pulse width
and a 10-mm spot size. An energy meter (Ophir
Optronics, Jerusalem, Israel) measured the energy
density at 12 J/cm2. These energy settings were based
on previous work by one of the authors (KM).
The Lux 1,064 handpiece contains a water-cooled
sapphire window held to 171C. A clear precooled gel
(Aquasonic, Parker Laboratories, Fairfield, NJ) was
applied to the treatment area, which assisted in
gliding the handpiece and cooling the surface by
transferring heat and light out of the skin. Frequency
was maintained at 1.0 Hz. Treatment was adminis-
tered with gentle pressure and a 10% to 20% over-
lap between pulses. A single pass was used during
each treatment session. The number of pulses was
noted after each patient visit. All patients were
treated for PFB localized to the anterior neck area;
some elected to extend treatment to the chin and
cheek areas. In two previous dose-ranging pilot
studies with low fluence settings using the same laser
platform, treated areas showed significant improve-
ment over control sites in all patients completing the
protocols. This observation is consistent with many
previous studies,3–5 and in essence, a control site was
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omitted because of its limited refinement in the
significant improvements anticipated in side-by-side
photographic comparisons.
Before each session, patients were photographed
using a digital SLR camera (Fuji FinePix S2 Pro, Fuji
Photo Film Co., Tokyo, Japan) with a lens attach-
ment (Nikon AF Micro Nikkor 60 mm, Nikon, To-
kyo, Japan). Pictures included full anterior neck, left
and right lateral neck, and chin and cheek area at 451
angles. Pain levels and side effects were recorded at
each treatment visit using a visual analog scale and a
side effects scale (Tables 1 and 2). Patients departed
the treatment facility on average 15 minutes after
their arrival. After completing the treatment phase,
subjects returned at 2 and 4 weeks post-treatment
for additional pictures and management of any
adverse effects.
TABLE 2. Side Effects Scale
Scale Side Effects
0 None
1 Mild erythema
2 Moderate erythema
3 Severe erythema
4 Edema/perifollicular edema
5 Graying of skin
6 Whitening of skin
7 Wrinkling of skin
8 Blistering
(Table 3). Evaluators were not informed of the
scoring scheme. Dyspigmentation based on the
affected area of hyperpigmentation noted over the
anterior neck was given the least weight. Evaluators

Evaluation

Investigators took photographs at Weeks 1, 2, 3, 4,

5, 7, and 9. Ten experienced dermatologists not as-
sociated with the study evaluated photographs from
Weeks 1 and 9; a single view of the anterior neck
from the chin margin to the lower neck was used.
Evaluators assessed patients using a Global Assess-
ment Scale (GAS) based on three categories: dys-
pigmentation, papule counts, and cobblestoning
(Figure 1). Each category was evaluated on a scale.
After assessing pre- and post-treatment pictures, the
results for dyspigmentation, papule counts, and
cobblestoning were scored using weighted values

TABLE 1. Pain Level Scale

Scale Pain Level

0 No pain
1 Mild discomfort
2 Mild pain
3 Mild to moderate pain
4 Moderate pain
5 Moderate to severe pain
6 Severe 1
7 Severe 2
8 Severe 3
9 Severe 4 Figure 1. Sample Global Assessment Scale evaluation form
without scores.

100 D E R M AT O L O G I C S U R G E RY
 SCHULZE ET AL

TABLE 3. Global Assessment Scale

Category Scale Description Pretreatment Postreatment Score

Dyspigmentation 0–10% area Localized, spotty 0

11–30% area Patches 1
31–50% area Moderately widespread patches 2
51–70% area Widespread patches 3
470% area Very widespread patches 4
Papule count 0–10 Papule count 0
11–20 Papule count 4
21–30 Papule count 8
31–40 Papule count 12
440 Papule count 16
Cobblestoning 0–10% area No coalescing papules 0
11–30% area Some papules present with 2
coalescence into a plaque
31–50% area Many papules present with 4
coalescence into a plaque
51–70% area Most papules present with diffuse 6
coalescence/matting
470% area Almost all papules 8
coalesce into a plaque

also estimated the number of PFB papules using a
range of values on a scale. Papule counts were
weighted with scores four times that for dyspig-
mentation. Lastly, the evaluators estimated cobble-
stoning, defined as the area covered by papules that
coalesced into plaques over the anterior neck.
Cobblestoning was weighted with scores two times
that for dyspigmentation.
Before evaluating pre- and post-treatment photo-
graphs, archival pictures with anterior neck lesions
representative of each description on the scale were
displayed to familiarize evaluators with the GAS.
With cobblestoning, for example, evaluators were
shown anterior neck area photographs representing
the five descriptions in the cobblestoning scale, with
papules coalescing into plaques affecting 0% to
10%, 11% to 30%, 31% to 50%, 51% to 70%, and
more than 70% of the neck area (Figure 2). Care was
taken to familiarize evaluators with the GAS using
photographs of patients not participating in the
current study.
In addition to the GAS, we used hair and papule
counts in our evaluation. We budgeted our time and
effort by restricting total hair count to approxi-
mately 3,000 hairs; specifically, we would randomly
select a patient, count hairs and papules, and then
randomly select another patient to count hairs and
papules. We stopped randomly selecting patients
once hair counts reached 3,000 hairs. As a result, a
subset of five representative patients who completed
the study was also evaluated by counting individual
hairs and papules. Using lateral neck photographs
from Weeks 1 and 9, similar rectangular areas were
outlined (Figure 3). Hairs and papules were identi-
fied by zooming into photographs over outlined
areas. Investigators counted individual hairs and
papules using a digital image database (Mirror,
Canfield Scientific, Fairfield, NJ). We compared the
hair and papule counts with the GAS results for this
subset of patients.
Results
Thirteen of the 22 enrollees completed the study.
Three patients did not complete all five weekly
treatments, three did not present for the 2-week
follow-up pictures, and three did not present for
photographs at 4 weeks post-treatment. The reasons
for attrition included the high operational tempo of
the military during the study that imposed unex-

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Figure 2. Anterior neck photographs shown to familiarize evaluators with the cobblestoning scale. To present the complete
Global Assessment Scale, similar graded pictures were shown for dyspigmentation and papule counts. Note: these pictures
do not represent results of this study.

pected deployments, permanent changes of station,
and nonadherence. Of the 13 patients, two worsened
from baseline to 4 weeks post-treatment after they
changed their grooming technique; without inform-
ing investigators, these patients switched from using
clippers to shaving with a razor blade during the
treatment phase. The GAS scores showed 94.5%
worsening of PFB from baseline for one patient and
41.3% worsening for the other. These patients did
not follow the study protocol by not maintaining
grooming techniques used before accession into the
study (i.e., hair clippers for both patients) and were
excluded from analysis.
Treatments were well tolerated without topical
anesthetics. Patients reported adverse events as 1
using a 10-point visual analog scale: mild discomfort
lasting less than 1 hour post-treatment. It was our

Figure 3. Patient 2 photographs used for hair and papule counts. Results presented in Table 5.

102 D E R M AT O L O G I C S U R G E RY

observation that treatments over the mandible bone
caused the most discomfort. Acutely, surface hair
stubs appeared to fragment intermittently during
irradiation, emitting a characteristic odor. On a
longer-term basis, it was not uncommon for patients
to note delayed hair growth over the treated areas
after two treatments. The epidermis in all three skin
types tolerated the fluences well.
Overall improvement using the GAS was 83%
(po.01), with a 59.5% reduction in dyspigmenta-
tion (po.03), a 91.2% reduction in papule counts
(po.01), and a 75.6% reduction in cobblestoning
(po.02) (Table 4). Interrater variability was less
than 5%. Examples of patient improvement in dys-
pigmentation, papules, and cobblestoning are shown
in Figures 4, 5, and 6, respectively.
In addition to the GAS, a subset of five patients was
evaluated using hair and papule counts. Average
overall improvement in hair and papule counts was
86.5% (Table 5). These same five patients improved
90.7% according to the GAS (po.046).
Discussion
The data show that 1,064-nm Nd:YAG laser using
low fluences can reduce dyspigmentation, papules,
and cobblestoning associated with PFB. In addition,
this study introduces a GAS for PFB. Our experience
with the scale demonstrates that the GAS improve-
ment (Table 4) correlates well with a more pains-
taking method of counting hairs and papules
(Table 5). By reducing the fluence and increasing the
frequency of treatments, we were able to produce
TABLE 4. Using the Global Assessment Scale, This Table Shows Percent Improvement by Comparing
Pretreatment Score to Post-Treatment Score in Each Category
Pre-Treatment Score
Category Avg (SD)
Dyspigmentation 2.20 (0.78)
Papules 10.07 (4.13)
Cobblestoning 3.95 (1.83)
Overall score improvement 5.41 (4.13)
SCHULZE ET AL
results comparable with those reported in the
literature.
In a previous study, Ross and colleagues used a
1,064-nm long-pulse Nd:YAG laser for PFB in
darker skin types, with 80% to 90% average
reduction in bump counts 1 month after one
treatment. Fluences ranged between 50 and 70 J/cm2,
and pulse duration was fixed at 50 ms.4 Subse-
quently, Weaver and Sagaral reported 98% and
88% fewer PFB papules than in controls at 1 and 2
months, respectively, after two monthly treatments
using energy fluences from 24 to 40 J/cm2 and pulse
duration between 40 and 50 ms.5
Traditional laser hair reduction has relied on pulse
widths and fluences aimed at complete thermal
destruction of the hair follicle. Based on histology,
the mechanism of injury with a millisecond
1,064-nm light source seems directed at hair bulb
and outer root sheath.2,7 Conductive thermal
damage from melanin, the primary chromophore, is
the most likely explanation for hair bulb and outer
root sheath damage.7 Many studies have validated
the long-term effectiveness of higher fluences with
1,064-nm wavelength on hair reduction and
treatment of PFB.2–5
Studies with 1,064-nm lasers using traditional
settings for PFB required topical anesthetic prepa-
rations. Ross and colleagues reported a mean pain
score of 4 to 5 out of 10 with fluences of 50 to
70 J/cm2 even when using a topical anesthetic
(eutectic mixture of lidocaine and prilocaine
(EMLA)).4 Using fluences of 30 to 50 J/cm2,
Post-Treatment Score
Avg (SD) %D p-Value
0.89 (0.62) 59.5 .03
0.89 (3.30) 91.2 .01
0.96 (1.08) 75.6 .02
0.91 (0.04) 83.08 .01
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Figure 4. This patient represents significant improvement in dyspigmentation. Using the Global Assessment Scale (GAS),
evaluators noted an average 96%, 93%, and 92% improvement in pseudofolliculitis barbae papule, dyspigmentation, and
cobblestoning scores, respectively. Overall GAS score improvement was 94%.

Guardiano and Norwood noted a mean
visual analog scale score of 34.5 7 23.3 out of
100 with the use of EMLA and 35.7 7 23.8 with
the use of lidocaine.9 Weaver and Sagaral found
that treatments appeared to be well tolerated with-
out topical anesthetics using fluences of 24 to 40 J/
cm2 and a pulse duration of 40 to 50 ms; however,
they did not formally evaluate pain during the
study.5
The intense pain associated with laser hair reduction
for PFB at higher fluences is most likely due to
the density, thickness, and darkness of the hairs.
Contributors to the pain include conductive heating
of the hair follicle during selective targeting of the
hair bulb melanin, conductive heating from the
melanin in the germinative layer, heating of hemo-
globin, and volumetric heating of tissue water.7
In this study, all patients reported a score of 1 out of

Figure 5. This patient demonstrated significant improvement in pseudofolliculitis barbae (PFB). Evaluators noted 83%, 68%,
and 86% improvement in PFB, dyspigmentation, and cobblestoning scores, respectively. Overall Global Assessment Scale
score improvement was 81%.

104 D E R M AT O L O G I C S U R G E RY
 SCHULZE ET AL

Figure 6. Cobblestoning (coalescing papules) significantly improved in this patient. On average, evaluators noted 92%, 69%,
and 91% reduction in papules, dyspigmentation, and cobblestoning scores, respectively. Overall Global Assessment Scale
score improvement was 87%.

10 on a visual analog scale without topical anesthesia. melanosome to neighboring hair matrix keratin-
Presumably, reduced subjective pain with low-fluence ocytes. Over the course of five treatments, we
treatments is due to less conductive heating of the hair speculate that the low-fluence 1,064-nm light source
follicle, surrounding volume of tissue water, confines thermal damage to the matrix and dermal
hemoglobin, and surrounding free nerve endings. papilla in the hair bulb area. In an anagen hair bulb,
hair matrix keratinocytes are among the most rapidly
The low fluences used in this study were purposely proliferating cell populations in the mammalian body.
aimed at slightly insulting the hair follicle rather than Just below Auber’s line, which runs along the widest
thermal destruction of the hair follicle. We theorize part of the hair bulb, the growth fraction of the hair
that the decreased fluence reduces the distance of root germinative cells approaches 100% (exceeding
thermal conduction, limiting heat transfer from the that of most malignant tumors).10 In comparison, the
growth fraction of normal stratum germinativum is
40% to 60%.11 The lower fluence is not sufficient to
TABLE 5. Average Overall Improvement in Hair
destroy the hair bulge. On the contrary, heat diffusion
and Papule Counts Was 86.5%
most probably remains within the bulb, incites ther-
Hair Counts Papule Counts mal injury within the germinative matrix of rapidly
# of Hairs # of Papules proliferating hair keratinocytes, and impairs mitotic
processes in an anagen hair. Orringer and colleagues
Patient# Pre Post %D Pre Post %D recently demonstrated that immunohistochemical
1 287 22 92.3 71 3 95.8 staining of laser-irradiated hair did not result in acute
2 930 200 78.5 31 6 80.6 changes consistent with destruction of follicular stem
7 314 98 68.8 63 4 93.7
cells; the authors speculated that their study may
13 667 38 94.3 17 2 88.2
21 418 70 83.3 37 4 89.2 support the idea of sublethal thermal injury.12
Total 2,616 469 83.4 219 19 89.5
The idea of a more localized thermal injury to the
Using Global Assessment Scale, these patients’ scores improved
90.7% (Po.046). hair bulb, theoretically, is akin to chemotherapeutic

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drugs affecting actively proliferating hair follicles to
produce anagen effluvium.13 The weekly treatments
in this study may repetitively compound the mitotic
inhibition, resulting in a thinned, weakened hair
shaft that is susceptible to fracture with minimal
trauma and may ultimately cause complete failure to
form hair. The mitotic inhibition can explain the
patients’ observation of slower hair regrowth early
in the study. On the other hand, once treatments are
discontinued, we would anticipate that hair would
regain its full proliferative capacity, with exacerba-
tion of PFB.
The smaller peak power required for lower
fluences allows for miniaturization of the device.
At traditional 1,064-nm laser hair removal settings,
a light-emitting device would operate at peak optical
powers at least twice that required for the low-
fluence settings used in this study. For example, using
a 1,064-nm wavelength with a 10-mm spot size,
20-ms pulse width, and 24-J/cm2 (twice the fluence
used in this study but still appropriate for type VI
skin), the optical peak power would be
approximately 940 watts, versus approximately
390 watts of peak power needed with the low-
fluence settings. With the technology available today,
the therapy unit would be a fraction of the size of
current hair-reduction devices. Peak power output
can be further reduced by adjusting three variables:
decreasing the spot size, increasing the pulse dura-
tion, and advances in technology. Longer pulse
duration could negate the relatively painless treat-
ment protocol because of greater conductive thermal
diffusion to the nearby tissue water, hemoglobin, and
surrounding free nerve endings. Smaller spot size
could significantly increase the treatment time
because of an exponential decrease in treatment
area. Lower fluences with other wavelengths or
intense pulsed light sources might produce similar
results and may be manufactured with even greater
portability. The paramount issue to be addressed
before its availability is safety.
A non-physician-operated hair-reduction device is
not a novel concept. In fact, a physician-directed,
106 D E R M AT O L O G I C S U R G E RY
home-based hair removal device (SpaTouch,
Radiancy, Orangeburg, NY) was evaluated for
Fitzpatrick skin types I to IV.14 This flash-lamp
device uses intense-pulse light with wavelengths
filtered to emit between 550 and 800 nm, a spot size
of 22  55 mm2, and fluence of 10 J/cm2. Rohrer and
colleagues conducted a study with 73 patients.
A physician determined the skin type and set the
appropriate fluence, after which patients adminis-
tered two self-treatments over various body areas.
Mean hair reduction was 33.6% 4 weeks after the
first treatment, 44.3% 2 weeks after the last treat-
ment, and 32.3% 12 weeks post-treatment. The rate
of adverse effects (which included crusting, blister-
ing, hyperpigmentation, and hypopigmentation) was
comparable with that of a physician operating a
similar device, thus enabling the authors to conclude
that non-healthcare professionals can safely and
effectively use this device. Notably, the SpaTouch
device was not tested in patients with skin types
V and VI because the shorter wavelengths have a
potentially greater risk of epidermal damage in
darker-skinned patients.
Because only limited research using low-fluence
1,064-nm treatments appears in the literature, the
incidence of side effects is unknown. Previous studies
using the 1,064-nm Nd:YAG at traditional fluences
have noted occasional hyperpigmentation, hypopig-
mentation, crusting, and blistering.8 In this study,
none of those adverse effects was noted. Transient
perifollicular erythema and edema have been
reported, although as stated by Lanigan, effective
laser hair removal requires such reactions, and these
should not be considered side effects. One rare side
effect of laser hair removal is paradoxical hyper
trichosis, which has been estimated to occur in
0.01% to 1.9% of treated patients, but it has not
been reported using lower fluences.15
Low-fluence treatments should be considered an
adjunct to current grooming methods. First, because
we speculate that anagen follicles are only partially
affected, the results are not considered permanent,
and some hairs continue to grow, albeit more thinly.

Second, controlling PFB is dependent on grooming
method.
Two patients were dropped from our protocol for
changing their grooming techniques during the
study. They were young military servicemen who
had switched from grooming with clippers to
shaving with a razor blade to ‘‘look better’’ for the
weekends. During the low-fluence treatments,
photographs continued to show improvement, but at
2 and 4 weeks post-treatment, photos showed
increasing papule counts. This potentially demon-
strates that these patients would have to continue
low-fluence treatments as an adjunct to shaving with
a razorblade to prevent PFB recurrence.
This nonadherence to the protocol also helps high-
light a limitation in our study design. The majority of
patients were satisfied with their improved appear-
ance and therefore cooperative with the treatment
phase of the study, but six patients failed to appear
for their follow-up evaluations. In hindsight, the
study design could have been improved by offering
additional treatments after the last follow-up eval-
uation. Another drawback to the study was limiting
individual hair counts to a certain number. As a
result, we only compared five patients with the GAS,
and it decreased the correlation between the two
measures. After review of the literature, a validated
severity scoring for PFB is nonexistent. We introduce
the GAS as an attempt to evaluate three features of
the disease, but it is not a validated measurement
instrument. A future study might include examina-
tion of the hair matrix for immunohistochemical
changes that may substantiate our theory of laser-
mediated anagen effluvium. An additional downside
to our approach was the weekly treatments, which
may be impractical in an office-based setting with
limited appointments, although the likelihood of
portable therapy units would make low-fluence PFB
treatment much more practical in the future.
SCHULZE ET AL
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Address correspondence and reprint requests to: Rafael
Schulze, MD, Brooke Army and Wilford Hall Medical
Centers, P.O. Box 340347, Fort Sam Houston, TX 78234,
or e-mail: rafael.schulze@us.army.mil
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