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REVIEW ARTICLES

Laser Hair Removal: A Review

STEPHANIE D. GAN, MD, AND EMMY M. GRABER, MD*

BACKGROUND Unwanted hair growth is a common aesthetic problem. Laser hair removal has emerged as a
leading treatment option for long-term depilation.
OBJECTIVES To extensively review the literature on laser hair removal pertaining to its theoretical basis,
current laser and light-based devices, and their complications. Special treatment recommendations for darker
skin types were considered.
MATERIALS AND METHODS A comprehensive literature search related to the long-pulse alexandrite
(755 nm), long-pulse diode (810 nm), long-pulse neodymium-doped yttrium aluminum garnet (Nd:YAG;
1,064 nm), and intense pulsed light (IPL) system, as well as newer home-use devices, was conducted.
RESULTS The literature supports the use of the alexandrite, diode, Nd:YAG and IPL devices for long-term
hair removal. Because of its longer wavelength, the Nd:YAG is the best laser system to use for pigmented skin.
Further research is needed regarding the safety and efficacy of home-use devices.
CONCLUSION Current in-office laser hair removal devices effectively provide a durable solution for
unwanted hair removal.
The authors have indicated no significant interest with commercial supporters.

U nwanted hair is a common aesthetic problem

in many cultures. Hirsutism, excess hair
growth in androgen-dependent areas, and hypertri-
lasting from a few minutes for the face to several
hours for the back, limited its practical use. Shortly
thereafter, the quality-switched neodymium-doped
chosis, greater hair density at any body site, may yttrium aluminium garnet (Nd:YAG) laser in com-
affect psychologic health by causing depression and bination with a carbon-based topical suspension
anxiety. Hair removal through shaving, waxing, became the first laser hair removal treatment that the
plucking, chemical depilatories, and electrolysis can Food and Drug Administration (FDA) approved.
improve one’s quality of life,1 but many of these Upon laser-induced heating, the carbon particles
techniques provide temporary solutions to unwanted served to selectively damage the hair follicles in
hair. Although electrolysis may permanently remove contact.5 Hair regrowth was delayed by up to
hair, it is a slow and operator-dependent procedure 3 months but not permanently.6 Today’s laser
with variable efficacy.2,3 devices provide longer-lasting results due to targeted
destruction of the germinative cells in hair
Laser treatment has emerged as the criterion stan- follicle bulge.
dard in hair depilation. It provides a longer-lasting
hair-free period than other methods. In 1996, the Anderson and Parrish’s principle of selective photo-
694-nm ruby laser was the first laser device formally thermolysis explains the mechanism behind such
studied for hair removal.4 Long treatment times, light-based therapies.7 Lasers emit light onto the

*Both authors are affiliated with School of Medicine, Boston University and Boston Medical Center, Boston,
Massachusetts

© 2013 by the American Society for Dermatologic Surgery, Inc.  Published by Wiley Periodicals, Inc. 
ISSN: 1076-0512  Dermatol Surg 2013;39:823–838  DOI: 10.1111/dsu.12116

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LASER HAIR REMOVAL: A REVIEW

skin surface that is reflected, scattered, transmitted, the heated tissue to cool to half its peak temperature.
or absorbed. At specific peak wavelengths in the red If the pulse duration is longer than the TRT, heat
to near-infrared range of electromagnetic radiation dissipates from the chromophore before irrevers-
(600–1100 nm), absorbed light energy heats the ible thermal damage occurs; if the pulse duration
target chromophore in the skin. The most common is much shorter than the TRT, excessive damage
chromophores are melanin, oxyhemoglobin, tattoo may occur; and if the laser exposure time is just
pigment, water, and collagen. Selective tissue shorter than the TRT, the chromophore cannot
destruction occurs when optimal parameters of disperse its heat, and thermal damage is confined to
wavelength, fluence, and pulse duration confine the target.8
heating and subsequent injury to the desired chro-
mophore without dissipation to surrounding tissues. Thermal relaxation time is directly related to the
The hair follicle is a unique structure in that there is chromophore’s size. Smaller targets such as tattoo
spatial separation of the chromophore (melanin) pigment and melanin heat and cool more quickly
within the hair shaft and the biological “target” than larger structures such as blood vessels. Quality-
stem cells in the bulge region. Wavelengths of 600 to switched lasers operate in the nanosecond range and
1100 nm favor absorption by melanin in the hair are used to target these smaller chromophores.
matrix. Long-pulse ruby (694 nm), long-pulse alex- Long-pulse lasers perform in the millisecond
andrite (755 nm), long-pulse diode (810 nm), long- range, best approximating the TRT of hair
pulse Nd:YAG (1,064 nm), and intense pulsed light follicles (10–100 ms).9,10
(IPL) (590–1200 nm) destroy hair photothermally
by emitting wavelengths within this range. Melanin Epidermal melanin competitively absorbs the same
absorbs light better at lower wavelengths (Figure 1). wavelengths used for hair removal. In darker-
Melanin absorbs light energy, converts it into heat, skinned individuals, the greater epidermal melanin
and then diffuses it, which causes collateral damage content competes with the hair follicle for light
to the bulge cells. Fluence and pulse duration absorption, increasing the risk of thermal blisters
influence the amount of heat absorbed. Fluence, or and hyperpigmentation. Moreover, a reduction in
energy density (J/cm2), determines the peak temper- the total amount of energy that is able to reach the
ature reached within the target structure. Pulse melanin deep in the hair shaft decreases the overall
duration is the length of time spent at a given efficacy per pulse. For these reasons, the ideal
temperature. The most selective thermal damage candidate for laser hair removal would have fair,
occurs when the pulse duration approaches the untanned skin and dark hair.11
thermal relaxation time (TRT) of the target chro-
mophore. TRT is defined as the time necessary for Lasers with longer wavelengths such as the diode
(810 nm) and Nd:YAG (1,064 nm) effect less epi-
dermal melanin absorption and fewer potential
adverse events than those with shorter wavelengths.
The long-pulse Nd:YAG laser provides effective and
durable hair loss at 6 months after treatment in
darker skin types (skin phototypes IV-VI) with no
signs of dyspigmentation or burns 12 (Figure 2). The
Nd:YAG laser is considered the best laser to use
when treating darkly pigmented skin such as skin
phototypes IV to VI. The IPL and alexandrite
Figure 1. Absorption spectra of skin chromophores. From (755 nm) laser, which do not penetrate as deeply,
Reference 8. Reprinted with permission. are more suitable for lighter skin types I to III

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GAN AND GRABER

(A) (B)

Figure 2. Axillary hair in an individual with darker skin before (A) and after (B) treatment using a long-pulse 1,064-nm
neodymium-doped yttrium aluminum garnet laser. From Reference 12. Reprinted with permission.

TABLE 1. Suggested Skin Type–Based Laser Recommendations and Initial Treatment Parameters
Laser Wavelength, nm Skin Type Fluence, J/cm2 Pulse Duration, ms
19–23
Long-pulse alexandrite 755 I, II, III 15–25 5–20
Diode15,29,30,34,37–43 800–810 III, IV, V 5–15 5–30
Neodymium-doped yttrium 1064 IV, V, VI 30–50 20–30
aluminum garnet44–47,50
Intense pulsed light (IPL) 590–1200 Typically I, II; Depends Depends on
depends on on skin skin type
device type

Initial treatment parameters should start at a more-conservative dosing when treating facial skin.
There will be variation in suggested parameters from different devices even in the same category (e.g., different Alexandrite lasers may
have disparate parameters). These are simply general guidelines.

because there is a greater risk of epidermal melanin until a portion of hair follicles recover and com-
activation with shorter wavelengths (Table 1). mence another anagen cycle.14 Validating this
observation, after one treatment with the diode
The mechanism of action of laser hair removal is laser, hair regrowth ranged from 22% to 31%
reflected in the immediate histologic changes in the 1 month follow-up and then plateaued at 65% to
skin, as well as its effects on the hair growth cycle. 75% from 3-month to 20-month follow-up.15
Microscopically, treated follicles display immediate
changes of keratinocyte swelling, scattered apoptotic Herein, we review the laser and light-based devices
and necrotic keratinocytes, and full-thickness used for hair removal and their potential complica-
necrosis of the follicles depending on the amount of tions. The discussion will include the long-pulse
energy absorbed. Permanent hair removal with alexandrite, long-pulse diode, long-pulse Nd:YAG,
complete dropout of follicles is achieved in only IPL system, and newer home-use devices. We con-
15% to 30% of treated hairs at each treatment at clude with an approach to relevant patient selection
optimal parameters. More commonly, temporary criteria and various treatment considerations that a
hair loss occurs through induction of a telogen-like proceduralist should understand before using lasers
state in which the hair follicles are at “rest” and no for hair removal.
hair growth is occurring. Histologically, most folli-
cles are in the telogen phase 1 month after treat-
Alexandrite Laser
ment, whereas fibrosis with a foreign body giant cell
reaction replaces others.13 There is a period of In 1997, Finkel and colleagues first reported effective
alopecia lasting from several weeks to a few months hair removal on the face, arms, legs, and bikini line

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LASER HAIR REMOVAL: A REVIEW

with the long-pulse 755-nm alexandrite laser.16 59%.15,24–28 In skin treated with the diode laser,
Long-term efficacy for the long-pulsed alexandrite histologic analysis showed a statistically significant
laser ranges from 65% to 80.6%.17,18 Equivalent hair reduction in hair density and thickness.29
removal for up to 6 months can be achieved using the
alexandrite laser with pulse durations of 5, 10, and Lasers with longer wavelengths such as the diode
20 ms.19 Noninferiority studies demonstrate equiv- and the 1,064-nm Nd:YAG lasers are preferred
alent efficacy of the alexandrite laser and other when treating darker skin types because they result
similar laser devices. Bouzari and colleagues did not in fewer side effects such as pain and postinflam-
find any significant difference in efficacy between the matory hyperpigmentation than lasers with shorter
alexandrite and diode lasers when treating patients wavelengths. Longer wavelengths induce less
with skin types I to V.20 Similarly, Handrick and epidermal melanin absorption. Efficacy of hair
Alster found equivalent clinical and histologic removal between the diode and the Nd:YAG lasers is
responses using a long-pulse alexandrite and long- inconsistent among studies. Li and colleagues
pulse diode laser in treating skin types I to IV, showed greater hair removal efficacy using the diode
although the diode had more side effects than the laser (78.6%) than with the long-pulse Nd:YAG
alexandrite laser.21 Treating patients with skin types I laser (64.5%),31 whereas Chan and colleagues did
to IV sequentially with the diode followed by not find a difference.30 The diode laser was less
alexandrite laser did not produce greater mean hair painful than the Nd:YAG when treating Asian
reduction than an equivalent number of treatments skin.30–32 Most studies have found few and transient
with the alexandrite laser alone, although the former side effects using the diode laser to treat patients
was associated with more side effects of folliculitis, with skin types III to V.
erythema, and blistering.22 The long-pulse alexan-
drite laser and long-pulse diode laser have been Studies using the diode laser have recently suggested
shown to have similar efficacy whether used indi- a shift away from the criterion standard high-fluence
vidually or sequentially when treating skin types I to devices in favor of a low-fluence (5–15 J/cm2)
IV. Because the alexandrite laser is capable of shorter approach. The latter provides comparable hair
pulse durations than the diode laser, the alexandrite reduction, less discomfort, and fewer adverse effects
laser may be better suited for treating fine vellus hairs. even when treating phototype V skin and tanned
individuals.33–39 The most common side effects were
The long- and short-pulse alexandrite lasers show no slight and transient erythema and pigmentary
statistically significant difference from IPL in efficacy changes. No long-term adverse effects were noted.
in skin types II to IV. Transient side effects including The mechanism of hair removal using low-fluence
erythema, edema, and paradoxical hair growth were devices may be through an induction of hair mini-
greatest with the long-pulse alexandrite and least aturization of coarse terminal hairs. In contrast to
with the IPL system.23 In summary, the alexandrite photodestruction of stem cells using the conven-
laser effectively removes hair with results compara- tional technique, low-fluence lasers may also trigger
ble with those of the diode laser and IPL devices. We photomodulation of germinative cells, leading to
suggest using the alexandrite laser on skin types I to altered hair growth.13 Individuals with skin photo-
III because of the paucity of competing epidermal types III to V can be effectively and safely treated at
melanin and low risk of laser-induced dyspigmen- low fluences (5–15 J/cm2) using the diode laser.
tation or burns.

Diode Neodymium-Doped Yttrium Aluminum Garnet

The hair count reduction reported with the long- The 1,064-nm Nd:YAG laser is considered the best
pulse 810-nm diode laser ranges from 22% to laser for hair removal in patients with darker

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GAN AND GRABER

skin.40–43 The longer wavelength of the Nd:YAG effects were reported for either side. Despite more
allows for less epidermal melanin absorption. pain and inflammation, the Nd:YAG laser produced
Patients with skin types IV to VI can tolerate higher greater hair reduction and a higher level of patient
fluences with minimal adverse events such as epi- satisfaction than the IPL system. Because there is less
dermal burns or dyspigmentation. The long-pulse risk of epidermal melanin absorption, we recom-
Nd:YAG laser did not demonstrate significant long- mend using the Nd:YAG on individuals with skin
term adverse events at high fluences of 50, 80, and type IV to VI.
100 J/cm2 when treating skin phototypes II to IV;
only two subjects treated at the highest fluence
Intense Pulsed Light
developed nonscarring blisters. Greater fluence did
not result in greater hair reduction, with similar In contrast to laser light, which is monochromatic
efficacy in hair reduction demonstrated in the three (produces a single wavelength or narrow band of
treatment groups (27–29%) at 3-month follow-up.44 wavelengths) and has high power density and
In contrast, Rogachefsky and colleagues, treating minimal coherence (divergence), the IPL device uses
primarily subjects with skin type II with the Nd: a xenon polychromatic broadband flashlamp with
YAG, found that higher fluences (60–80 J/cm2) and optical filters to generate noncoherent light beams in
longer pulse durations (50 ms) were correlated with the visible to infrared spectrum (500–1,200 nm).
lower hair counts.45 The subjects’ skin phototype Based on the type of cut-off filters used, an IPL
may explain the disparity in the amount of hair device emits a defined range of wavelengths to reach
reduction between the two studies. In the former the desired depth of the target structures. Similar to
study, subjects with darker skin types require a lasers, IPL technology is based on the principle of
higher fluence to achieve hair loss because the selective photothermolysis. Because of its ability to
epidermal melanin absorbs some of the energy. emit a spectrum of wavelengths, a single light
Greater fluence did not linearly correlate with exposure can excite multiple chromophores in the
greater hair loss. In the latter study and in general, skin (hemoglobin, water, and melanin) at one time.
subjects with lighter skin had less competing epi- Thus, in the hands of an inexperienced physician or
dermal melanin. At a given fluence, a greater nonmedical personnel, complications from nonspe-
proportion of laser energy is able to penetrate to the cific thermal damage could easily ensue.
bulge stem cells than in individuals with darker skin.
Therefore, in lighter-skinned individuals, greater Advantages and disadvantages arise from the dis-
fluence results in a more-linear correlation with the tinct differences in technical qualities and operation
degree of hair loss. In the Rogachefsky study, the between an IPL device and a laser. An advantage of
most acute reactions of erythema, perifollicular IPL is its lower cost. In addition, the large spot size
edema, and pain were associated with greater of an IPL device makes it easy to treat large surface
fluences. As might be predicted, more adverse events areas such as the back, chest, and legs. Treatment
occurred at higher energies and longer pulse dura- duration for a given area is shorter than for a smaller
tions in both studies. spot size. A disadvantage is the heavy weight of the
IPL handpiece, which houses the lamp and lamp-
The Nd:YAG laser and IPL device were compared in cooling device. This can be bulky and somewhat
a recent within-patient, right–left, assessor-blinded difficult to maneuver. When using the device, an
study treating the axillary hair of 39 women with optical coupling gel application and direct skin
skin types IV to VI. There was statistically signifi- contact with the handpiece is required, hindering
cantly greater reduction in hair counts on the laser visualization of the immediate local reaction. Fur-
side (79.4%) than on the IPL side (54.4%) at thermore, the immediate inducible perifollicular
6-month follow-up.12 Only temporary adverse edema and erythema seen with lasers is infrequently

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LASER HAIR REMOVAL: A REVIEW

encountered with the IPL, which makes it difficult to Safety concerns inherently arise because of the shift
accurately place the next pulse immediately adjacent from professional oversight to inexperienced per-
to the previous pulse and may inadvertently cause sonal use. Currently, the FDA requires compliance
patches of skin to be left untreated. Finally, IPL with certain standards and regulations for light-
devices have been shown to emit inconsistent fluence based home-use devices sold in the United States.49
and wavelengths from pulse to pulse, making clinical These devices are based on IPL and laser technolo-
results unpredictable.46 The mechanism of generat- gies but operate at lower fluences than comparable
ing light and the range of wavelengths emitted from in-office devices. The 810-nm diode Tria laser (Tria
the IPL is inherently different from that of lasers, Beauty, Inc., Dublin, CA) and 475 to 1,200 nm IPL
conferring a distinct set of advantages and disad- Silk’n device (Home Skinovations, Kfar Saba, Israel)
vantages. The low wavelengths emitted in the are the current FDA-approved hair removal systems.
spectrum of light from an IPL device can disadvan-
tageously target epidermal melanin, so IPL devices Despite these regulations, safety and prevention of
with a light range that starts in the lower wavelength accidental injury to eyes and skin of the user and
range are not recommended for darker skin. those nearby is the primary concern. Although
manufacturers may include protective eyewear with
Few studies have compared the efficacy of IPL the packaging, there is no guarantee that the
devices with that of lasers. Amin and colleagues consumer will wear the glasses during the procedure.
compared IPL with a red filter, IPL with a yellow One safety feature on most home-use devices is a
filter, a diode laser, and an alexandrite laser in 10 skin contact sensor that prevents the beam from
patients with skin types I to III. Evaluation at 1, 3, firing when not on the skin. Light is supposedly self-
and 6 months did not reveal a statistically significant contained within the device, and special protective
difference in efficacy between the four devices at goggles are not required, but if eye precautions are
each time point, although the IPL device was less breached, irreversible corneal burns, lens cataracts,
painful than the alexandrite laser.47 Another study and retinal damage may result.
compared six split-face treatments of the diode laser
with IPL in 31 hirsute women with normal testos- A few studies have assessed the ocular safety of U.S.-
terone levels. Six-month follow-up demonstrated sold devices in accordance with the FDA Center for
hair reduction of 40% for IPL and 34% for diode Devices and Radiologic Health Laser Notice No. 50,
laser, but the difference was not statistically signif- but abroad, Eadie and colleagues tested the optical
icant. There was also no difference in patient radiation hazard of the iPulse Personal IPL device
assessment of hairiness or satisfaction. Pain was (CyDen LTD, Swansea, UK) in accordance with
consistently greater with IPL than diode laser.48 International Electrotechnical Commission TR
Although IPL devices vary greatly in their efficacy, in 60825–9 and the International Committee on Non-
these studies, the IPL device used has efficiency in Ionizing Radiation Protection Guidelines on Limits
hair removal similar to that of the alexandrite and of Exposure to Broad-band Incoherent Optical
diode lasers and is typically used to treat patients Radiation. They found that this device was within
with skin types I and II. the international limits for ocular exposure.50
Another international study by Town and Ash
compared three IPL home devices, iPulse Personal,
Home-Use Devices
Silk’n/SensEpil, and Satin/Lux/Lumea (Philips,
Devices designed for home use have recently gained Netherlands), with the International Electrotechni-
in popularity because of their lower cost than a cal Commission TR 60825–9 standard. The
professional service and the convenience and luxury measured optical output varied significantly between
of depilating in the privacy of one’s own home. the three systems. At its two highest settings, the

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Silk’nSensEpil was hazardous to the naked eye were 1-month follow-up and 72% at 3-month follow-
the skin contact safety mechanism to fail.51 Further up.55 In the most recent study, 10 adults with skin
studies are needed to assess the ocular safety of types I to IV received four to six biweekly treat-
home-devices sold within the United States. ments. Mean hair reduction was less impressive than
in the previous studies: 36% at 4 weeks and 10% at
Aside from ocular damage, unintentional misuse by 6 weeks.56 Effective hair reduction in home-use
individuals with darker skin type or a tan or devices may approach the low end of the range seen
inappropriate treatment of moles or tattoos may with in-office laser and light source treatments.
lead to thermal burns. In a study comparing 77
“appropriate” users with naturally light brown to
Complications of Photoepilation and Their
black hair and skin types I to IV to 44 “inappro-
Treatment
priate” users with naturally white, gray, red, or
blond hair and skin type V or VI, the 810-nm Tria Skin type, body location, seasonal changes, and
diode laser (SpectraGenics, Inc, Pleasanton, CA) patient history of recent sun exposure determine
induced blisters in 8% (1/12) of users with skin type complications of photoepilation. More-sun-pro-
V and 33% (10/30) of users with skin type VI. tected sites, such as the axillary and inguinal areas,
Subjects with lighter skin types did not exhibit any tend to develop complications less frequently than
blistering. Users with darker skin types described sun-exposed sites. Side effects are usually minor
more pain than those with lighter skin (mean pain and transient. The most common skin reactions
score 2.3 vs 2.0 on the first visit).52 Although the include pain, transient erythema (Figure 3), and
small sample size may overemphasize the effect, the perifollicular edema,57 although more-severe side
risk of thermal skin damage is greater in darker skin effects of thermal burns, blisters, hyperpigmenta-
types. A newer model of the Silk’n device (SensEpil) tion, persistent hypopigmentation,58 and permanent
contains a built-in sensor that prevents treatment of scarring can also occur.59 Other uncommon side
skin types V or VI. It is hoped that this added safety effects include induction or aggravation of acne,
feature will prevent the adverse outcomes seen when rosacea-like rash, premature graying of hair, tun-
treating darker-pigmented individuals. neling of hair under the skin, prolonged diffuse
redness and edema of the face, and inflammatory
Although there is not a perfect solution to these and pigmentary changes of preexisting nevi.60
safety concerns, the clinical efficacy of these home- Severe, persistent urticaria may occur in patients
use devices is promising. Wheeland’s study using the who had previously tolerated a similar procedure
Tria diode laser produced an average hair reduction
of 41% after three treatments at 6-month follow-
up.52 Multiple studies using the Silk’n IPL device
show modest hair reduction 3 and 6 months after
treatment. Mulholland treated 34 individuals three
times with a 64% average reduction 3 months after
the last treatment.53 Another study of 20 women
with skin types I to IV demonstrated hair reduction
averaging 43% across all body regions 6 months
after three treatments. Hair loss was maintained
with only a 10% to 20% increase in hair growth
between 1 and 6 months after treatment.54 Gold and
colleagues studied 22 women receiving six biweekly Figure 3. Faint erythema immediately after laser hair
treatments. Overall hair reduction was 78% at removal.

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LASER HAIR REMOVAL: A REVIEW

and do not have a history of urticaria with physical A novel technology developed to alleviate pain and
stimuli. This pathogenesis is unclear but may be discomfort during laser treatments is a pneumatic
attributed to an allergic reaction to the cryogen skin flattening (PSF) device based on the “gate
cooling spray or sensitivity to specific wavelengths theory” of pain transmission in which activation
of light.61 Lastly, long-term hyperhidrosis may of non-nociceptive nerves (non-pain transmitting
result after treatment of axillary hair with the Nd: fibers) interferes with and inhibits the signal trans-
YAG laser, perhaps due to a stimulatory rather mission of pain.79 The PSF device suctions the skin
than destructive effect on eccrine sweat glands.62 into the handpiece and creates compression between
It is important for clinicians to be aware of and a contact window and the skin, stimulating tactile
communicate common and uncommon skin and pressure receptors that block transmission of
reactions to patients (Table 2). pain sensation during treatment. Moreover, the
compression mechanism temporarily expels blood
Ocular injury is another potential complication of from dermal vasculature, reducing the amount of
laser hair removal. At wavelengths in the visible competing chromophore (hemoglobin) from the
(400–720 nm) and near-infrared (720–1,400 nm) skin. Consequently, greater laser energy is trans-
range, intraocular penetration may cause retinal mitted to melanin in the hair shaft while minimizing
burns and visual damage. Special eye protection for nonselective tissue heating. The PSF system demon-
all persons near the procedure should be worn. strates hair removal efficacy equivalent to that of
Periocular (eyebrow and eyelid) laser epilation other lasers with different cooling mechanisms with
should be avoided. Cataracts, iritis, iris atrophy, less pain.80–83 It is also faster than treatment using a
pupillary distortion, uveitis, photophobia, posterior sapphire-cooled handpiece.84 In the future, devices
synechiae, and visual field defects have all been with the PSF technology may be preferred over the
reported despite use of metal protective lenses when current epidermal cooling devices because the
treating this region.63–69 former are less painful and more efficient.

Paradoxical hypertrichosis is a rare side effect seen Cooling mechanisms (forced cold air, contact cool-
in 0.6% to 10% of patients treated with IPL devices ing, or a delayed cooling device) use cold air or
and diode and alexandrite lasers.70–77 This phe- liquid nitrogen to lower the skin’s surface temper-
nomenon is more commonly seen with the alexan- ature and protect the epidermal melanin, preventing
drite and IPL devices and can affect treated and unwanted hyperpigmentation or burns. A forced
surrounding areas. Although the exact mechanism is cold air device applies a continuous stream of chilled
unknown, one theory proposes that the laser or light air 6 to 10 inches from the skin 90º to the direction
source stimulates new hair growth through syn- of movement of the laser handpiece. It has an
chronization of dormant hair follicles into terminal analgesic effect and reduces patient discomfort.85
anagen hair growth. Overall hair density appears to Because the cooled air partially protects the epider-
be greater than the previously asynchronous hair mal melanin, there are fewer side effects, including
growth.70 Another hypothesis is that suboptimal shorter-duration, less-intensive erythema and less
fluences may induce terminal hairs from vellus crusting and edema. Higher laser fluences can also
hairs.78 Risk factors for this complication include be tolerated.86 Another type of cooling device is
darker skin types (III–VI) commonly of Mediterra- contact cooling, as is often used with IPL devices.
nean, Middle Eastern, Asian, and South Asian This method has several benefits: allowing greater
descent; dark, thick hair; and underlying hormonal tolerance of high fluences; compressing and posi-
conditions. Despite initial hypertrichosis, continued tioning the follicular unit closer to the skin surface
treatment with laser therapy to the affected area will and into a region of higher fluence; imparting partial
eventually reduce the hair growth. anesthesia; and decreasing internal reflection due to

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TABLE 2. Summary of Side Effects, Prevention, and Treatment Options

Side Effects Prevention Treatment Options
Pain Topical anesthetic creams, forced Application of ice packs immediately
cooled air at treatment site, local after procedure
anesthesia
Transient erythema and None; an appropriate treatment Application of ice packs immediately
perifollicular edema endpoint is to achieve transient after procedure; topical steroids, if
erythema and perifollicular edema necessary
Dyspigmentation Strict sun avoidance and protection Hyperpigmentation: sun avoidance
for a minimum of 6 weeks before and protection, topical steroids
and after each treatment; use of (early in treatment), hydroquinone,
lasers with longer wavelengths, mild chemical peels
conservative fluences, longer pulse Hypopigmentation: sun avoidance,
durations, and efficient cooling 1,550-nm nonablative fractionated
systems; selection of appropriate laser103–105
laser device, particularly in darker-
skinned individuals
Hypertrophic or keloidal Avoidance in patients with history Steroid injections and excision106,107
scars of easy scarring, hypertrophic scars, laser and intense pulsed
or keloids light,108 low-density nonablative
fractional resurfacing in early
scars,109 carbon dioxide laser
Thermal burns (blistering, Trimming hairs to prevent unintentional Supportive care: topical emollients,
ulceration) laser exposure of untrimmed hairs analgesics
and adjacent cutaneous burn that is
a particular risk with contact
cooling devices; selection of
appropriate laser device, particularly
in darker-skinned individuals; avoidance
of pigmented lesions or tattoos
Ocular damage (cataracts, Wearing wavelength-specific goggles by Referral to ophthalmology
iritis, iris atrophy, pupillary the patient and all persons in the room;
distortion, uveitis, not treating in periocular zone
photophobia, posterior
synechiae, retinal burns,
and visual field defects57–63
Reactivation of herpes Valacyclovir 500 mg by mouth twice Valacyclovir 1 g by mouth twice
simplex virus daily for 10–14 days starting day before daily for 7 days110
procedure (Beeson95)
Chrysiasis91,92 Routine screening for previous gold the Long-pulse ruby93 and pulsed dye
rapy laser94
De novo growth of thick hair Unknown Subsequent laser hair removal
or activation of hair follicles treatments
outside boundaries of area
treated
Potentiation of thin to vellus Avoidance of areas of thin or vellus Subsequent laser hair removal
hairs in treated areas hairs, although may be challenging treatments
because hairs of different thickness
often intermingled with each other in
same treatment area; seen more
commonly in skin types III–VI
Induction or aggravation of Unknown; more common in younger Traditional treatment options (local
acne individuals or systemic antibiotics) for
temporary relief; systemic
isotretinoin therapy

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LASER HAIR REMOVAL: A REVIEW

TABLE 2. Continued

Side Effects Prevention Treatment Options

De novo rosacea-like rash Unknown Unknown definitive treatment
options but reasonable to use
traditional rosacea treatments
Premature graying of hair Unknown Irreversible; unknown definitive
treatment options
Tunneling of hair under skin Unknown; more common in Early management through
submandibular area and superficial incision followed by
especially with use of high forceps extraction under adequate
fluences magnification before subsequent
laser sessions; not treatable with
further laser sessions, which can
cause fragmentation of the hair
simulating minor iatrogenic tattoo.
Prolonged diffuse redness and Unknown; typically seen in Reduction of dose and immediate
edema of face fair-skinned (types II or III) post-treatment application of cold
individuals compresses with or without
systemic nonsteroidal
anti-inflammatory medication
Inflammatory and pigmentary Unknown Biopsy may be indicated because of
changes of preexisting nevi concern regarding malignant
transformation
Persistent urticaria58 Unknown preventative measures; Trial of topical steroids; lasts for
no previous history of cold or approximately 1 week
heat urticaria
Hyperhidrosis after 1,064-nm Unknown Standard-of-care treatment for
neodymium-doped yttrium hyperhidrosis: aluminum chloride,
aluminum garnet laser botulinum toxin injection
treatment59

index matching of the sapphire plate with the skin

surface.4 Although contact cooling can be helpful,
the operator must make sure to keep the entire
handpiece flush with the skin. This is of particular
concern in areas where it is difficult to maintain
complete contact with the skin. Delayed cooling
devices impart a brief spray of liquid nitrogen onto
the skin milliseconds before the laser beam contacts
the skin. Like contact cooling, the delayed cooling
device allows for a greater tolerance of high fluences
and provides partial anesthesia. Because this type of
cooling does not compress the skin, the operator has
Figure 4. Crescent-shaped hyperpigmentation due to mis-
better visualization of the treatment area. It is also alignment of the cryogen spray in a laser using a delayed
easier to use over uneven surface areas. If the cooling device.
cryogen spray area is misaligned and does not
completely overlap with the laser treatment zone, ing device is essential in all skin types but is
distinctive sickle-shaped or crescent shaped especially critical with darker skin types to
hyperpigmentation will result87 (Figure 4). A cool- minimize adverse events.

832 DERMATOLOGIC SURGERY

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GAN AND GRABER

Complications in Darker Skin Types using the alexandrite laser, with complications
developing in 15 of 550 (2.7%) treatment sites. The
Patients with darker skin types are more at risk of
most common side effect was blistering, with a
side effects such as dyspigmentation and scarring
smaller incidence of folliculitis, transient hyperpig-
because of their greater epidermal melanin content.
mentation, and excoriation. Scarring was not
Using longer wavelengths, longer pulse durations,
observed. The authors attributed the low incidence
conservative fluences, and more-efficient cooling
of adverse effects to preventative measures. Patients
systems can minimize these complications in indi-
were instructed to practice rigorous sun protection
viduals with darker skin. Epidermal melanin absorbs
before and after treatment, were pretreated with
longer wavelengths lasers such as the Nd:YAG less
hydroquinone and glycolic acid, and were given
efficiently, which makes them less damaging. The
postlaser topical corticosteroids. During treatments,
Nd:YAG is the best laser system to use for pig-
direct thermal tissue damage was minimized through
mented skin. Small structures such as epidermal
determination of the minimal fluence parameter that
melanin also cool faster than large structures such as
would provoke mild perifollicular erythema, appro-
hair follicles. Longer pulse durations can effectively
priate selection of an epidermal cooling device, and
heat hair follicles while epidermal melanin has
avoidance of overlapping pulses.93 Such an intensive
cooled and is thermally protected.
regimen may hinder adherence and be impractical
for the average patient. The long-pulse Nd:YAG is
Effective cooling is important for all skin photo-
the best laser system to use for darker-pigmented
types, as mentioned previously, but is especially
individuals, but the Nd:YAG and diode lasers
critical in those with more epidermal melanin
both have few transient side effects without such
(darker phototypes), but excess epidermal cooling
stringent preventative measures before, during, and
without sufficient offsetting energy from the laser
after treatment than are necessary when using the
can increase the risk of postinflammatory hyperpig-
alexandrite laser in this select population.
mentation in darker-skinned individuals88,89
(Figure 4). Its mechanism is not well understood,
but laser-induced inflammation may stimulate Laser Treatment
the melanocytes to become more hypersensitive to
Patient Selection
the cold temperature of the cryogen spray.
Pretreatment evaluation should include a thorough
A low complication rate in darker-skinned individ- medical history. A history of endocrine abnormali-
uals is seen after treatment with the Nd:YAG and ties or menstrual dysfunction should prompt a
diode laser and, with rigorous preventative mea- thorough examination to unveil a systemic and
sures, the Alexandrite laser. A survey of 50 subjects treatable cause of hirsutism. Likewise, a patient with
with skin type VI treated using the long-pulse Nd: sudden onset of lanugo-type hypertrichosis should
YAG indicated high patient satisfaction in terms of be evaluated for a paraneoplastic syndrome.94
hair reduction. The majority would recommend it to Recurrent infections with herpes simplex virus
other patients. Minimal complications were experi- (HSV) at or around the mouth or genital area
enced, with most cases reporting transient erythema. warrants appropriate prophylactic treatment with
Only three cases had transient hyperpigmentation.90 valacyclovir 500 mg twice daily for 10 to 14 days
The diode laser could be safely used in individuals starting the day before the procedure.95 A history of
with skin types V and VI, with reported postoper- keloids or hypertrophic scars should be investigated
ative side effects being mild crusting and transient to avoid overly aggressive treatment. Hairs should
hypo- and hyperpigmentation.91,92 In another study, be trimmed or shaved to minimize the smoke plume
150 individuals with skin types IV to VI were treated during treatment and prevent hair from becoming

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LASER HAIR REMOVAL: A REVIEW

trapped underneath a contact cooling device. If hairs may regrow some years later. A single laser
hair is present on the skin surface, the laser will treatment typically yields a 2- to 6-month growth
target the exposed hair and induce a thermal delay. Hair regrowth is generally more sparse, with
cutaneous burn (Figure 5). individual hairs being thinner and paler.102 Patients
should also be aware that hairs do not fall out
Individuals should be screened for previous gold or immediately after treatment but are shed over a
isotretinoin therapy. A history of taking gold salts, period of days to weeks. Sun avoidance should be
historically used for treatment of diseases such as strictly enforced before the procedure, because
rheumatoid arthritis, is a contraindication to laser patients cannot be treated if at all tan. Epidermal
therapy. The combination of laser treatment and melanin competes for absorption of light energy and
gold intake can induce chrysiasis, a type of cutane- confers a risk of side effects such as hypo- or
ous hyperpigmentation.96,97 Treatment of chrysiasis hyperpigmentation (Figure 6), blistering, ulceration,
is limited, with only a few case reports documenting and scarring. Because melanin in the hair shaft is
improvement using the long-pulsed ruby 98 and essential for effective laser removal, individuals with
pulsed dye 99 lasers. Laser hair removal while taking white, blonde, or red hair, histologically correlating
isotretinoin is controversial. Although recent studies to a lack of melanin, paucity of melanin, or presence
suggest that it may be safe,100,101 there may be a risk of eumelanin, are not good candidates for laser hair
of phototoxicity, skin fragility, and impaired tissue removal. Waxing, plucking, threading, or any epi-
repair, with a delay in reepithelialization and scar lation method that pulls out the entire hair shaft
formation. We recommend a washout period of at should be avoided between treatments or for at least
least 6 to 12 months before laser exposure. 4 weeks before a treatment.

An important part of the consultation visit is to Treatment Considerations

establish realistic patient expectations, detail poten-
Pretreatment with topical anesthetics varies between
tially adverse outcomes, and discuss the cost of the
patients and specific anatomic sites. More-sensitive
procedure. Patients should understand that multiple
areas such as the upper lip and inguinal region may
(approximately 4–6) treatments will be necessary for
require a 30-minute to 1-hour incubation with a
long-term hair removal, although this does not
topical anesthetic cream such as lidocaine, prilo-
guarantee a permanent solution, because treated
caine, Betacaine, or tetracaine. Other less commonly
used anesthetic methods include application of

Figure 5. A burn sustained after laser hair removal using a

contact cooling handpiece. The unshaven hair on the skin’s
surface absorbs light and creates a burn. Courtesy of Dr. Figure 6. Persistent hypopigmentation after laser hair
Thomas Rohrer. removal in a suntanned patient.

834 DERMATOLOGIC SURGERY

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GAN AND GRABER

forced cooled air to the treatment site, local removal. Possessing a detailed understanding of each
infiltration of anesthesia, regional nerve block, or a laser’s properties is critical for the clinician to
combination thereof. accurately customize individual treatments to the
unique patient. Laser technology within the scope of
Most importantly, before starting the procedure, hair removal continues to evolve from its beginnings
proper eye protection is critical for the patient, in the mid-1990s. Current research is directed
proceduralist, and any observers in the treatment toward optimizing safety, efficacy, and comfort for
room. Each device requires the use of specific goggles patients of all skin types. In the future, these
unique to that machine’s particular wavelength. improvements will probably have longer-lasting
Therefore, goggles are not interchangeable between treatment results while minimizing untoward
laser or IPL devices of other wavelengths. Addition- side effects.
ally, because of the risk of ocular damage, treatments
should not be performed in the periocular zone.
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