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HIRSUTISM AND HYPERTRICHOSIS:

the role of photo-induced “permanent hair reduction”

Dr. Tzermias ChristopherGREECE

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HIRSUTISM

Excessive growth of coarse terminal hair in a pattern more characteristic

of adult men.

9-15% college aged females have severe

hirsutism

HYPERTRICHOSIS

Presence of excess hair in any body site.

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CAUSES OF HIRSUTISMAdrenal

Congenital adrenal hyperplasia• 21-hydroxylase deficiency• 11-hydroxylase deficiency

• 3b-hydroxysteroid deficiencyCushing syndrome

Androgen-secreting ovarian neoplasms

OvarianSevere insulin resistance

Androgen secreting ovarian neoplasmsCombined adrenal and ovarian

Polycystic ovary syndromeIdiopathic hirsutism

Exogenous androgensAnabolic steroid

Postmenopausal androgen therapy

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CAUSES OF HYPERTRICHOSISCongenital.

Hypertrichosis lanuginosaIatrogenic

Cyclosporin, streptomycin, cortisone, penicillamine

Hereditary disordersPorphyria cutanea tarda,

epidermolysis bullosa, Hurler’s syndrome

Long standing inflammatory changes

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PHYSICAL METHODS FOR CONTROLLING HIRSUTISM AND HYPERTRICHOSIS

• Shaving• Waxing• Plucking• Bleaching

• Chemical depilatories• Electrolysis: galvanic, thermolysis

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NEW: EFLORNOTHINE.

Inhibitor of ornithine decarboxylase, necessary for the biosynthesis

of polyamines required for cell division and differentiation.

A supplementary method.

Applied twice daily 8 hours apart.Visible results after 8 weeks.

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Laser hair removal is based on theory of Selective Photothermolysis:

Selective thermal damage of a pigmented target will occur when sufficient fluence at

a wavelength mostly absorbed by the target is delivered during a time equal to or less than thermal relaxation time of

the target.

For hair removal FOLLICULAR MELANIN is the chromophore

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Which is the follicular target?

The bulb: 2-7cm below epidermisThe bulge: 1.5cm below epidermis

Heating the bulge without damaging the bulb

allows regrowth.

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A vascular mechanism might also be implicated.

• Reduction of blood supply to hair follicles

causes miniaturization

• Complete blood supply depletion causes fibrosis

Anrian RM:J Cutan Laser Ther 2000;49-51

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How does hair growth cycle affect laser hair removal?

Early anagen is more suitable because:• The bulb is more superficially located

near the bulge• Melanogenesis is evident • Bulge cells are rapidly dividing, making

them more susceptible to damage HOWEVER a study has shown that

damage is not confined to anagen hair

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Given that hair in a specific region are not all in anagen,

hair removal sessions have to be repeated.

WHEN?• Practically about the time hair begin to

reappear at the skin surface.• Multiple treatments are given at 1 to

3months intervals.

HOWEVER, excellent results have been obtained with shortened treatment intervals.

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Important parameters for successful hair removal

WavelengthPulse duration

FluenceSpot size

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Wavelength

Two factors need to be considered• The depth of laser penetration• The selectivity of target absorption

Most appropriate wavelengths:600-1200m

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Longer wavelengths• Penetrate deeper• Interfere less with epidermal

melanin• More suitable for darker skin types

and deeply pigmented hair

Shorter wavelengths• Absorbed better by melanin• More suitable for fair skinned

individuals and lighter hair colors

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Pulse duration

Should be between the TRT of the basal layer of the epidermis

and the follicle: 0.5 to 35 msec

Fluence

Higher fluences are more effective.

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Longer pulse durations• Allow for better heat diffusion to the stem cells_surrounding the hair shafts• The epidermis is better spared• Proportionally increased fluences

should be used.

HOWEVER the long-pulsed Alexandrite laser has given equivalent results at 6 months follow up at pulse

durations 5, 10 and 20msec.Nanni et Alster:Laser Surg Med 1999;24:332-

337

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NEW THEORY

THE EXTENDED THEORY OF SELECTIVE PHOTOTHERMOLYSIS

Longer pulse widths would be more effective

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Points of the extended theory of selective photothermolysis

• The weakly absorbing part of the target (bulge) has to be damaged by heat diffusion from the highly

pigmented/strongly absorbing one (hair shaft and matrix cells).• TDT (Thermal Damage Time) is the delay

between chromophore heating and distant target heating.• The pulse width should be made shorter

than or equal to TDT-beyond 400msec

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Points of the extended theory of selective photothermolysis

• The EMR wavelength should maximize contrast between the absorption coefficient of the pigmented area and that of the tissue surrounding the target.

• The EMR power should be limited to prevent absorption loss in the pigmented area but sufficient to achieve a temperature of the pigmented area higher than the target damage temperature.

Altshuler et al: Laser Surg Med 2001;29:416-432

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SpotsGreater photon density is present deeper in the tissue for larger spots but the

dermal/epidermal damage ratio is increased.A larger spot size causes more pain than a

smaller spot at identical fluencies.Eremia et al: Derm Surg 2000;26:667-669

The use of larger spot sizes improves the growth delay of hairs measured 1 month after treatment.

Baumler et al: derm Surg 2002;28(2):118

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Protecting the epidermis

= Skin cooling• Contact cooling (sapphire cooled handpiece)• Cooling gel• Dynamic cooling device ( DCD ) (short bursts of cryogen delivered prior to

laser pulse)• Cold air

Postcooling is useful to minimize pain and edema.

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Follicular responses to laser treatment

Bulb damage• Induction of telogen• Growth delay = Hair similar in number but lighter and thinner Bulge damage• Miniaturization of hair = Permanent vellus like hair Bulb and bulge damage• Complete degeneration of the follicle = Fibrosis

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Laser treatment usually produces complete but temporary hair loss

for 1 to 3 months followed by partial but permanent hair loss.

Temporary= delay in hair growthPermanent=stable for a period longer than the complete hair

growth cycle.

Follicular responses to laser treatment

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HISTORY For laser hair removal

1. Medications• Hypertrichosis inducing(cyclosporine, minoxidil, steroids)• Isotretinoin• Topical retinoids, glycolic acid2. Diseases• Inflections(hepatitis, herpes, HIV)• Neoplasms(androgen producing)• Endocrine(polycystic ovary disease, Cushing’s)• Cutaneous(psoriasis, vitiligo, keloids)3. Other procedures• Lasers, chemical peels4. Previous treatments for hair removal5. Pregnancy6. Tattoos.

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Contraindications

Absolute• Recently suntanned skin• Photosensitizing medications• Photosensitivity at relevant wavelength• Epilepsy triggered by light

Relative• Keloids, vitiligo, psoriasis• Recent retinoid intake • Pregnacy

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Pretreatment instructions

Six weeks before

• Use a broad spectrum sunscreen• Use a bleaching cream ( for darker skin types )• No plucking, waxing, eletrlolysis• Only shaving or depilatory creams

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Day before treatment• Shave the area• Start a prophylactic anti-viral, when

indicated

Day of treatment• Area clean and free of make-up• 1 or 2 hours before apply a thick layer

of EMLA cream under occlusion, if needed

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After treatment

• Ice packs ( reduce pain and minimize swelling)

• Complete prophylactic course of anti-viral• Topical antibiotic if blistering occurs• Mild topical steroid cream ( reduces swelling

and erythema)• Avoid scratching or picking • Avoid sun exposure and use a sunscreen • Do apply make-up the day of treatment• Damaged hair is shed during the first week

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Technique

• Laser parameters individualized• Do test sites if uncertain• The treatment fluence should be at 75% of the

Nikolsky threshold fluence • Slightly overlap laser pulses • If a chilled tip is provided, press firmly to increase

the depth of penetation and to extravasate vessels• The sapphire contact cooling tip should be wiped

clean every 5 to 10 pulses to remove debris• The endpoint is perifollicular edema and erythema

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Side effects• Transient erythema ( 97%)• Perifollicular edema ( 97%)• Treatment pain ( 81%)• Folliculitis ( 14%)• Pigmentary changes Transient hyperpigmentation ( 10%) Transient hypopigmentation ( 10%) Permanent pigmentary changes in dark skinned

individuals ( rare)• Crusting ( 9%)• Purpura ( 7%)• Erosions ( 1%)

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Other side effects

• Blistering• Scarring ( if postoperative infection or overaggressive treatment)• Lightening of tattoos• Loss of freckles or pigmented lesions• Activation of HSV infection• Isomorphic phenomenon

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In Mediterranean skin transformation of vellus hair

to terminal ones• In treated areas • In non treated areas next to treated ones.

Due to induction in the dermis, or activation of the bulge?

Personal observationBetter long term results if laser is combined

with enzymes applied by iontophoresis

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A variable but statistically significant increase in sebum excretion has been

noted after laser hair removal.

Although a reduction in sebaceous gland size has been observed, a decreased resistance to sebum outflow following miniaturization of the hair shaft might

explain this phenomenon.

Manuskiatti et al: J Am Adad Dermatol 1999;41:176-80

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Safety

• Retinal injury

• Cross contamination with contact cooling devices

• Plume generated irritating the respiratory tract

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Comparing electrolysis to laser hair removal

Advantages• Permanent results

• Cheep

Disadvantages• Painful

• Time consuming• Multiple sessions

• Scars • Acne formation • Ingrown hair

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Lasers for hair removal

Long pulse rubyLong pulse Alexandrite

DiodeQ-Switched Nd:YAGLong pulsed Nd:YAG

Non laser devicesIntense pulsed light sources

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LONG PULSE RUBY (694)System name Pulse

DurationFluence (J/cm2)

Spot size(mm)

Repetition rate

Epitouch Ruby(Sharplan/Esc, Needham, MA)

1.2 msec 10-40 3-6 1.2Hz

E-2000 (Palomar, Lexington, MA)

3 - 100msec

10-40 10, 20 1 Hz

Ruby Star (Aesculap, Irvine, CA)

2msec 25-40 7 1 Hz

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Advantages

Greater absorption by melanin

Disadvantages

• Low depth of penetration• Non suitable for patients with skin type

greater than III

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Hair counts are reduced by 30% after a single treatment with the ruby laser and by 60% after 3 or 4 treatments.

Dierickx C: Derm Clin 2002; 20(1):135-146

Persistent hair loss was noted at 1 to 2 years follow up, greatest in

sites treated at the highest fluence with Ruby Laser.

Dierickx et al: Arch Dermatol 1998;134:837-844

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LONG PULSED ALEXANDRITE (755)

System name Pulse duration

Fluence (J/cm2)

Spot size(mm)

Repetition rate

Apogee (Cynosure Chelmsford, MA)

5, 10,20 , 40 msec

5-50 10, 12.5,15

Up to 5 Hz

Gentle-Lase (Candela, Wayland,MA)

3 msec 10-100 8, 10, 12,15, 18

1 Hz

Epitouch ALEX (Sharplan/ESC, Needham, MA)

2 msec 10-25 5, 10 1-5 Hz

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Advantages• Greater depth of penetration

• Selective absorption of laser energy by follicular melanin

Disadvantages

• Absorption of laser energy by the competing chromophore: oxyhemoglobin.

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40-56% reduction of hair growth on lip, legs and back was noted

at 6 months after 1 treatment with the variable pulsed Alexandrite laser.

McDaniel et al:Derm Syrg 1999;25:425-430

Alexandrite laser vs Diode

Equivalent clinical and histologic responses are obtained.

Handrick et Alster: Derm Syrg 2001;27(7):622

Eremia et al: Derm Surg 2001;27(!!):925-92

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DIODE LASER (800)

System name

Pulse duration

Fluence (J/cm2)

Spot size (mm)

Repetition rate

Lightsheer(Coherent)

5-1000msec 10-60 12X12 Up to 2 Hz

Apex-800(Iriderm)

10-30msec Up to 40 7, 9, 11 Up to 4 Hz

Laserlite(Diomed)

50-250msec Up to 60W 2, 4 Up to 5 Hz

Epistar (Niked)

Up to 100msec

Up to 50 4, 7 Up to 15 Hz

SLP1000(Palomar)

200-1000 msec

Up to 100 10 Up to 3 Hz

MedioStar(Aesculap)

50msec Up to 60 12X12 4 Hz

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Advantages

• Optical penetration into dermis is better at 800nm

• Individuals with darker skin can be treated more safely

Disadvantages

• 30% less absorption by melanin at 800nm compared to 694nm.

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Higher fluences and multiple treatments with the diode laser produce better long-term resultsCampos et al:J Am Acad Dermatol 2000;43:442-7

20 months after 2 treatments at variable anatomic sites with the diode laser 33-44% hair reduction was noted with minimal side effects.

Lou et al: Derm Surg26:428-432

Tripple pulsing does not increas hair reduction, while multiple treatments are associated with

more effective hair reduction both short and lonh-term.

Lou et al: Derm Surg;26:428-432

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At 30 and 100msec pulse durations and flyences between 15 and 40 J/cm2 has been proved effective and safe for

type V and VI African American patients.

Longer pulse durations enabled the delivery of higher fluences with only transient pigmentary disturbances.

Adrian et al: j Cutan Laser Ther 2000;2:183-190

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What about suntanned individuals?A super long-pulsed (200-100msec) 810nm

diode laser was used in suntanned patients. 34% hair reduction was noted after 1 or 2 treatments and this rate was affected by the variable fluencies and pulse durations.

Side effects were observed only with the highest fluences and pulse durations.

Super long pulse technology allows for safer delivery of much higher fluences.

Rogachefsy et al: J Cutan Laser Ther2001;3:57-62

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Nd:YAG LASER Q-SWITCHED Nd:YAG (1064)

System name

Pulse duration

Fluence (J/cm2)

Spot size(mm)

Repetition rate

Softlight (Thermolase, San Diego, CA)

10ns 2-3 7mm 10 Hz

Medlite IV (ConBio, Dublin, Ca)

5-7ns 12 3-8 1,2,5,10 Hz

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Q-switched Nd:YAG systems although capable of including delayed regrowth are ineffective

regarding long-term hair removal.Nani et Alster: J Am Acad Dermatol 1999;41:165-171

A larger pulsed Q-switched Nd:YAG laser (30msec) was found more effective than Q-switched (nanoseconds) Nd:YAG and

with minimal side effects. However, results were not evaluated long-

term .

Goldberg et Samady: Derm Surg 2000; 26:109-113

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LONG PULSED ND:YAG (1064)System name Pulse

durationFluence (J/cm2)

Spot size(mm)

Repetition rate

Gentle YAG(Candela, Wayland,MA)

3msec Up to 12mm 1 Hz

CoolGlide (Atlus)

1-300msec Up to 300 3,5,7,10

Up to 2 Hz

Lyra (Laserscope San Jose, CA)

10-100msec

Up to 60 1.5,3,5,10 Up to 4 Hz

Vasculight (ESC,Needham, MA)

1-14msec Up to 65 6

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Advantages • Deeply penetrating (5 to 7mm)• Safe option for patients with III or IV phototype • The only laser approved for pseudofolliculitis

barbae

Disadvantages

• Reduced absorption by melanin• Higher treatment fluences are needed to

damage hair

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At 1 year follow up after 3 treatments delivered

on monthly basis with the long-pulsed Nd:YAG laser

at fluences 40-50 J/cm2 70 to 90% hair reduction was noted in

darkly pigmented individuals. The good results were confirmed

histologically and minimal side effects were recorded.

Alster at al: Arch Dermatol 2001;137:885-889

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Greater than 50% hair reduction was documented 1 year after 5 treatments with the long-pulsed Nd:YAG laser, whereas 0% after 1

treatment.

Blond hair, although less effectively, can also be removed.

Lorenz et al: Lasers Surg Med 2002;30(2):127

Areas characterized by thinner skin ( axillae ) are more responsive to laser

treatment than those with thicker skin ( chin, legs ).

?Skin thickness rather than hair growth cycle affects clinical outcome.

Alster et al: Arch Dermatol 2001; 137:885-88

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Different fluences with long-pulsed Nd-YAG laser (50,80 or 100 J/cm2) do not affect the outcome

Hair reduction was 29%, 29% and 27% respectively at 3 months follow up.

Coldberg et Silapunt: Derm Surg 2001;27(5):434-6

On the contary, histologic evaluation of skin biopsies taken after treatment with the long-pulsed

Nd:YAG laser revealed the degree of hair follicle damage is

dependent on the fluence applied.Fournier et al: J Cutan Laser Ther 2000;2(3):125-130

Comparing the efficacy and complications of long pulsed Nd:YAG and diode laser

similar results were obtained. Chan et al: Derm Surg 2001;27(11):950-4

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INTENSE PULSED LIGHT SOURSES (IPLS)

System namePulse duration

Fluence (J/cm2)

Spot Size(mm)Repetition rate

590-1200 Epilight (ESC, Needham, MA)

15-100 Up to 45 10X45,8X35

0.5 Hz

600-950 Ellipse (Danish Dermatologic development, Hoersholm, Denmark)

0.2-50msec Up to 21 10X48 0.25 Hz

500-1200 Esteloux (Palomar, Lexington, MA)

10-100msec

Up to 12 16X46 Up to 1 Hz

400-1200 Spatouch (Radiancy, Orandeburge, NY)

35msec Up to 7 22X55 0.25 Hz

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Advantages• Both longer and shorter wavelengths may be necessary

to achieve maximal hair removal in different body sites and hair colors.

• Using the appropriate cut-off filters both dark skinned and fair skinned individuals can be effectively treated.

Disadvantages• Non selective absorption• Absorption of the wide spectrum by water,

oxyhemoglobin.• Low reproducibility• Large retrangular spots unsuitable for hair bearing areas

with extreme concavities and convexities.• Increased rate of complication.

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NEWER DEVICESA light/heat assisted flashlamp hair removal system emitting light at 400-

1200mm has been evaluated in 12 patients and average 27% hair reduction

4 months after the final treatment.No statistical difference was noted

between 1 and 3 treatments.Mechanism of action: Bulbe thermal

heating raises the temperature of treated hair and surrounding tissue above boby temperature(55-65C) then the delivered light raises the temperature to 75-80C.

Goldberg et Silapunt et Silapunt: J Cutan Thr 2001;3:3-7

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MICROWAVE TECHNOLOGY

Wavelength

System name Pulse

duration

Fluence

(J/cm2)

Spot size

2.2X 10(-1)

MDS (MW, Medical Scottsdale, AZ)

25-30msec 20-28 6X4

This system delivers pulses of microwave energy in conjunction with a spray of coolant to the skin.

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Photo Assisted Epilation:

Practical Tips

Dr. Tzermias ChristopherGREECE

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TANNED SKIN

Treatment of Tanned Skin is unknown at this time.

Based on experience with other lasers BLISTERING and HYPOPIGMENTATION MAY

RESULT.

• Avoid sun exposure after treatments unless sunscreen SPF 25 or greater is applied.

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Expected Responses• Perifollicular edema /erythema; possible responses: welting

(secondary to histamine response), and mild to moderate itching.Untoward Responses• Blistering, hyperpigmentation, hypopigmentation, or purpura,

Herpes simplex activation.Recommendations for preventing untoward effects and/or

decrease discomfort• Ice or cold packs should be applied immediately after treatment,

until area is cool to touch.• Ice as you go; large areas that are divided into sections need to be

cooled as the sections are treated.• Test small areas in inconspicuous locations where treatment will be

given BEFORE treating a large area.• For type V or VI skin, final responses may not often be visible for 1-2

weeks.

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Skin Preparation For Treatment• Topical anesthetics may be used per manufacturers directions.• Remove any topical anesthetics from the skin prior treatment.• Skin must be clean and dry; remove all lotions, perfumes, make-

up, deodorant, etc.• Ethanol should NOT be used to clean skin.• Shave on treatment day before treatment; DO NOT treat long

hair.• DO NOT have patient tweeze, wax of have electrolysis 6 weeks

before treatment.

Reduction of Plume and Hair Odor in Treatment Room

• Use smoke evacuator during treatment; especially for treatment of larger areas. (OSHA standards).

• Wear a laser mask to reduce breathing plume.• Keep room well ventilated to disperse hair odor.

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Treating Face, Nose or Ears

• Insert wet cotton in nose or ears during treatment to reduce DCD spray delivery beyond target.

• When applying laser energy, be sure entire tip of distance gauge is on treatment area to reduce change of pulse or spray extending beyond target,.

• Patients with fillings near front teeth MAY experience a sensitive reaction when laser pulse administered above lip; place wet gauze under upper lip during treatment to reduce this sensation.

• Before treating full beard or head, BE SURE patient wants this area to remain free of hair.

• Before treating the upper lip, make sure patient does NOT have permanent lip makeup/ tattoo, if so, cover with white a product, such as toothpaste.

• Use for a white “gel” pen or makeup stick is appropriate for drawing in treatment area grid.

• Avoid treatment around the eyebrow as ocular damage may occur.

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General Suggestions

• When treating anal area, place wet gauze in anus first. Methane gas is flammable.

• When treating the inside of the thigh, the skin is generally more sensitive. You may need to decrease energy.

Always Hold Laser Handpiece Perpendicular To Site To Apply Laser Energy