Laser hair removal-Mechanisms and complications (2024)

Corresponding Author:

Piyu Parth Naik Department of Dermatology, SaudiGerman Hospitals and Clinics, UnitedArab Emirates E-mail: drpiyu85@gmail.com

Abstract

This review provides a study of the complications related to Laser Hair Removal (LHR) along with the complication management pertaining to laser hair removal therapy. Laser hair removal is a widely practiced cosmetic procedure that is considered safe and effective. Comparatively, it is more effective than shaving, waxing, plucking, and epilation in terms of pain, speed, accuracy, and many other factors. Nevertheless, it also has complications like any other procedure. The complications associated with LHR could be immediate or, it might take some time to occur, which depends on various factors. Most of the complications can be prevented by the healthcare provider, while others can be treated with minimal medications. Alongside managing these complications, pre-treatment and post-treatment care must be precisely followed for effective results. The management therapy includes the use of corticosteroids, topical analgesics, selective antiviral agents, emollients, moisturizing creams, and lotions as the aftercare of the procedure and some other agents depending on the type of complication observed in a patient. Hence, there is a broad scope for laser hair removal advancements to avoid complications and achieve the best results.

Keywords

laser hair removal, cosmetic procedures, complications of laser hair removal, burns by laser hair removal,prevention of complications by laser hair removal

Introduction

Laser Hair Removal (LHR) is a method thatinvolves the removal of hair by exposure to laserlight pulses. These pulses help in destroying thehair follicles. Laser hair removal is extensivelyused and practiced in clinics, as well as homesusing various devices with advanced technologydevices. It beams highly concentrated light intohair follicles, resulting in the pigment in thefollicles absorbing the light, thereby destroyingit [1]. LHR applies to all types of skin.

The lasers are used to remove unwanted hairfrom the face, leg, chin, back, arm, underarm,bikini line, and other areas [2].

Benefits of LHR include:

1. Lasers can target dark, coarse hair specifically,leaving the surrounding skin undamaged.

2. It is a speedy process.

3. If patients want permanent hair loss, repeatedLHR helps [2].

LHR is known for the significant delay in hair growth for long periods, not permanent hair loss.Initially, multiple laser hair removal treatmentsare required, followed by maintenancetreatment. Laser hair removal is most useful forpeople having light skin and dark hair.

Factors that contribute to successful and effectiveremoval include hair color and skin type. Here,we use the fundamental principle that involvespigmentation of the hair, which should absorbthe light, but not the skin’s pigmentation.

The laser used should damage only the hairfollicle, leaving the skin unaffected. Therefore,a contrast like dark hair and light skin results inthe best and precise outcomes.

The risk of skin damage is more astoundingwhen the contrast between hair and skin color issmall, but the recent advancement in technologyhas removed these barriers.

Laser hair removal is effective to a lesser extentfor hair colors that do not absorb light well, suchas gray, red, blond, and white. These are a fewlimitations of LHR.

■ Lasers used in Laser Hair Removal:

Ruby hair removal laser: The Ruby hairremoval laser was the first system adopted forpermanent hair removal. This system involvesthe use of a shorter wavelength of 694 nmtargeting melanin, enabling ruby laser ideal forremoving light and thin hair. On the contrary,this laser system is not used for darker skintones. The advantage of this type of laser is thatthe Ruby laser system has a long pause betweenlaser pulses, which aids in decreasing discomfortand is less painful comparatively. The repetitionis slow, and thus ruby laser treatments requiremore time than other hair removal laser systems.The Ruby laser is an effective option for smallertreatment areas [3-5].

■ Alexandrite hair removal lasers:

The Alexandrite laser is a popular fastest systemfor LHR. The Alexandrite laser operates ata wavelength of 755 nm, making it ideal fortargeting the melanin in individuals’ hairfollicles with light to olive skin tones. The lasercan cover a large treatment area, such as theback, in a little time, i.e., less than 30 minutes.The repetition is quite painful (as the laser istypically used at a fast reputation rate) andhence considered one of the least comfortableLHR systems. The development of new deviceshaving built-in cooling devices helps overcomeproblems and improve the patient experience.[3-5]

■Diode hair removal lasers:

Diode machines are newly developed approachesin the field of LHR. They contain an energysource consisting of semiconductors, knownas diodes, grouped to create a laser beam witha longer wavelength of 800-810 nm, allowingdeeper penetration into the hair follicle. Diodelasers are usually considered safe on darker skintypes. They are exemplary for removing thick orcoarse hair, thus making the Diode hair removallaser system popular among men to remove backhair or chest hair. [3-5]

■ Neodymium-doped yttriumaluminum garnet (Nd YAG) hairremoval laser:

Nd YAG system is the advanced system incosmetic laser technology. It offers an effectivehair removal system along with its numerousapplications, including tattoo removal, laser skinresurfacing, and the correction of sun damage.

Nd YAG laser machines produce two differenttypes of light 1064 nm and 532 nm. Here, the1064 nm wavelength targets the hair folliclesfar beneath the skin’s surface, and the 532 nm(unless frequency doubling is introduced inlaser design) wavelength penetrates the folliclescloser to the skin surface. At this 1064 nmwavelength, carbon is a better chromophore (acolored chemical compound that absorbs light)than melanin. Therefore, before treatment, acarbon lotion is applied to the skin allowing itsabsorption by the unwanted body hair. Since thelaser targets the carbon instead of melanin, Nd-YAG laser is considered safe for all skin types,including tan skin tones. [3-5]

■ Intense pulsed light (IPL) hairremoval

IPL does not involve a laser, but the equivalentform of intense pulsed light like lasers. IPLinitiates photo-thermolysis by pulsing thermalenergy that is absorbed by the melanin in thehair follicle. The advantages of intense pulsedlight are its customizable wavelength, energylevel, and pulse duration. [3-5]

■ Complications related to Laser HairRemoval

Immediate Complications:

Burns

Nowadays, burns from laser have becomecommon. The burns occurred due to the laser ischaracterized into three types-

1. The first-degree burns are not severe and donot require special treatment as it usuallyheals with time.

2. The second and third-degree may result inblistering, pigmentation, and scarring of theskin [6].

Blistering

Blistering is a result of a second-degree burn.This occurs due to the inexperienced orunqualifies technicians performing the lasertherapy. Blisters are excruciating and may causediscomfort. If left untreated, they may lead toscarring and pigmentation changes [6].

Hyperpigmentation

Hyperpigmentation is the term referred to thedarkening of the skin. It usually fades withinthree months but can also last as long as six toeight months. It is generally observed in patients with darker skin and is treated with excessivelaser energies or epidermal cooling [6].

Hypopigmentation

Hypopigmentation is the lightening of the skinthat occurs when the laser beam is absorbedby the skin partially rather than absorption byhair follicles. The beam disturbs or leads to animbalance of melanin production. This can lastup to two months but can be permanent insevere cases [6].

Scarring

Scarring is usually a complication related to laserburns. Improper use of laser machines usuallyleads to scarring [6].

Crusting

At times, laser irritates the hair follicles leadingto slight bleeding or scab formation. It usuallyoccurs in people who have ingrown hairs.The primary reason for crusting is laser overtreatment[6].

Palpable Purpura

Purpura is referred to as bleeding under the skinthat causes purple spots or rashes. Purpura istemporary and usually heals and disappears in3-5 days. It is a usual complication of tannedskin; therefore, it is not advised to get laserremoval on tanned skin [6].

Skin Irritation or Erythema

Laser removal usually causes temporaryirritation with slight swelling and redness in thetreated area. This usually disappears within afew hours or on the application of ice packs [7](FIGURE 1).

Late Complications:

Folliculitis

Folliculitis is an inflammation of hair follicles.It is presented with red pimples with hair inthe center of each one. These pimples may havepus in them, causing itching & burning of theskin. It is a common complication in malesundergoing laser removal [8,9].

Contact Dermatitis

Contact dermatitis is a type of inflammationthat appears as redness, swelling, itching, andoccasional blisters causing discomfort. Thisis a usual complication with the face and feet.Dermatitis heals within a day of treatmentunless it is not scratched or bought into contactwith chemicals.

Paradoxical Hypertrichosis

Paradoxical hypertrichosis is an uncommoncondition (0.6%-10%), but certainly foundcommon in few ethnic groups and anatomicregions like Asian, and the Mediterranean.Paradoxical hypertrichosis commonly occurs onthe face and neck. The Individual with the darkerskin tone is at a higher risk. The pathogenesis ofparadoxical hypertrichosis is widely unknown[9,10].

Fox Fordyce

Fox Fordyce is a sporadic inflammatory diseaseof apocrine sweat glands, followed by laser hairremoval. Laser removal is the primary causeof auxiliary fox Fordyce. The laser is said todamage the follicular infundibulum leading toepidermal detachment and delayed keratinocyte maturation. It is characterized by pruritic skincoloredfollicular papules appearing on glandbearingareas [11].

Leukotrichia

Leukotrichia is a scientific term for white hair.The common complication is caused due toexcessive absorption of the laser beam by hairfollicles resulting in the reduction or absence ofmelanin by the destruction of the melanocyte. Itmay be temporary or permanent.

Hyperhidrosis and Bromhidrosis

Bromhidrosis is a foul-smelling body odorcaused by the sweat that encounters bacteriaon the skin resulting in the release of smell.The strategy behind this is colonization byodor-producing bacteria in the hairs. With hairremoval, the bacteria start colonizing the skin,resulting in a changed flora of skin presentedwith an increased odor [12].

Hyperhidrosis is abnormally excessive sweating.Avoid exercise and hot showers for at least 24hours after laser removal, as this could lead toinfection or ingrown hairs [13] (FIGURE 2).

Ocular Complications

Lasers can cause reversible and irreversibledamage to the eye. Various cases of uveitis, iritis,and iris atrophy have been reported after laserprocedures. Ocular complications are causeddue to the penetration of laser into differentlayers of eyes damaging the area being exposed.Therefore, the use of protective equipment isencouraged and recommended [13].

Equipment related Hazards:

Laser devices are powerful tools that areequipped for various indications, but these arealso harmful to patients in many ways. Trainedprofessionals should practice laser hair removalas the equipment is quite complicated, and thelasers can damage the skin.

The handling of this equipment presentsan important task for the professional as heis responsible for preventing complicationsrelated to the equipment. The persons in thelaser rooms should wear all protective safetyequipment to avoid damage due to the laser.There should be controlled access, proper use ofprotective devices, monitoring of testing of laseroperations.

Laser Safety

Preventing fires

• Overheating of the room should be avoided.

• The presence of oxygen cylinders or openoxygen outlets should be handled withutmost care.

• The use of alcohol-based cleansers should beavoided.

• Electrical hazards are to be avoided

• Hair bearing areas not undergoing lasertherapy should be covered with a moistenedgauze.

• When not in use, the laser should be kept instandby mode.

• Controlled people should access laser rooms.

• No use of reflective material in the laserroom, and the patients should be asked toremove any metallic chains or ornamentsbefore the procedure.

• In case of emergencies, there should be easyaccess to the emergency switch-off button[13].

Personnel safety

• Eye protection is compulsory in the controlledaccess area for patients as well as physicians.

• The protection should be as per therecommendation of the device manufacturer[15].

■ Preventive measures to preventcomplications

It is important to know that certain precautionsshould be kept in view while undergoing LaserHair Removal. There is an advantage that ifone follows these, the best results are achieved.While the disadvantage is that avoidingthings may lead to various complicationsfollowing the procedure. In 1983 Parrish andAnderson suggested the theory of selectivephotothermolysis. As per Parrish and Andersonwavelength should be completely absorbed bythe chromophore in the targeted tissue andshould not be absorbed by the surroundingtissue therefore, laser should be delivered in apulse duration which is equal or less than thethermal relaxation time or TRT (time requiredby an object to cool down by 50%). If thedelivery time exceeds thermal relaxation time,then the energy gets dissipated to the nearbytissue, resulting in tissue damage. Not onlyTRT but fluence also play a critical role in tissuedamage. Fluence reaching the target tissue mustbe equal or exceed the threshold fluence to resultin tissue damage. The same can be managed bycontrolling two different parameters, which iswavelength and pulse duration [16].

Wavelength: after selecting the chromophore’sproper wavelength, the practitioner shoulddeliver the maximum number of photons tothe targeted chromophore. This can be doneeffectively by altering pulse duration and fluence[17].

Pulse duration: to avoid thermal injury to theepidermis, a pulse duration of longer than 10ms must be considered. For follicle damage, pulse duration must be larger than the folliclecooling time, i.e., 100 ms. By combining thesetwo concepts, the ideal pulse duration must bebetween 10 ms-100 ms.

■ Other then above, some of thecommon general preventivemeasures are:

• The areas where you want to get the hairremoval done should not be tanned. This isadvised as tanning can have an impact on theeffectiveness of the treatment.

• Plucking, bleaching, or waxing should beavoided three weeks prior to the treatment.This is so advised because preserving the rootand the pigment of hair is important for laserremoval success.

• Make sure to shave the area you want to gethair removal done a day or night before thetreatment.

• Wash the area being treated completely andthoroughly to remove any kind of oil presenton the skin before undergoing the treatment.

• Moisturize the area well before and after thelaser for a smooth and better response [18](TABLE 1).

TABLE 1. Pre-treatment care and post-treatment care in laser hair removal procedure [18].

■ Management of complications:

Laser procedures are performed with greatprecautions as they are emerging as majorcosmetic procedures. Laser Hair removal usuallyleads to one or the other complication butmanaging them is an easy task.

• Topical corticosteroid creams may help tominimize the erythema and edema.

• Antibiotic ointment may be prescribed if theepidermal injury is observed.

• Patients are advised to avoid sun exposure.

• Most patients have a mild sunburn-typesensation post-treatment that eventuallyfades in 2-3 hours. Moisturizers and/or coolcompresses can be useful at this time.

• In case of blisters, small blister areas can betreated with Bacitracin TID until they heal.

• Depigmentation therapy was recommendedfor a few patients.

• In case of paradoxical growth, hormonepathologies are tested before prescribing.

• Eflornithine is used in a few cases, butno significant improvement is noticed(TABLE 2).

TABLE 2. Management of complications.

■ The cooling device in laser therapy

In some cases, during laser hair removal, tissueinjuries occur. Dark skin tone patients are moresusceptible to tissue injury during laser hairremoval due to the presence of a high amountof melanin. Melanin absorbs energy from thelaser, which results in heat generation [19].Hence proper measures should be considered toprevent tissue injuries, which are as follow:

Ice-cube cooling: It is one of the most simpleand easy to use method. The ice cube method issuitable for all kind of laser therapy. The ice packis wrapped in a soft cloth and applied for about15 minutes or until the burning sensation exists.Nowadays, it is commonly used in hair removal,wine stains and leg telangiectasia [20].

Sapphire tip cooling: it can be used before,during, and after the laser therapy. It iscommonly used when treatment is with a longerpulse duration (generally more than 10 ms). TheSapphire tip cooling method is easy to use butit* application is limited due to its cost [21,22].

Cryogen spray: it was the first cooling spraywith liquid nitrogen used at a distance of around20 cm from the skin. However, it is not usednowadays as it can result in cryonecrosis.

Dynamic cooling device: it is a new cooling deviceintegrated with a laser machine and uses cryogenspray (nontoxic 1,1,1,2-tetrafluoroethane orR-134a). Cryogen is sprayed just before thelaser pulse and causes selective cooling (200 umof superficial tissue) [23]. It is commonly usedwhen the pulse duration is less than 5 ms.

Zimmer: it can be used before, during, and afterlaser treatment. Without interfering, Zimmer cools down the epidermis, and it can be usedwith any laser device. Zimmer delivers chilled airin the entire procedure and also ensure patientand physician comfort during the procedure.Commonly used during tattoo removal, hairremoval, port-wine stain, and other vascularlesions [24].

However, Zimmer was reported to have anincreased incidence of post-inflammatoryhyperpigmentation [25].

Conclusion

Laser Hair Removal is a commonly usedcosmetic procedure to remove unwanted hair.The principle behind Laser removal is SelectivePhoto thermolysis. The lasers are equippedwith cooling sources like cryogen spray, contactcooling, and air cooling to prevent laser heatingcomplications. The laser therapy mainlydepends on the enumerable factors like haircolor, skin color, the sensitivity of the skin, typeof equipment used, etc. Complications relatedto lasers are widespread and can be treated withminimal care. Burns, scarring, urticaria, etc. are the conditions noticed immediately after thelaser removal. Folliculitis, fox Fordyce and a feware observed after some duration of the therapy.All the complications can be prevented usingpreventive measures followed precisely, andtreatment will be provided based on particularcomplications. The awareness about preventivemeasures and safe removal practices should beclearly delivered to the patient. The practice ofpreventive and safe methods provides a basefor future outlooks, requiring attention andconsideration so that effective measures can bedeveloped to prevent the complications relatedto laser hair removal.

Declarations

Ethical approval: No ethical approval wasrequired.

Competing interests: No competing interests.

Funding: This article was self-funded and noother source of funding present.

Authors’ contribution: Sole author andcontribution.

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