1. 1 HIRSUTISM AND HYPERTRICHOSIS: the role of photo-induced “permanent hair reduction” Dr. Tzermias Christopher GREECE

2. 2 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.

3. 3 CAUSES OF HIRSUTISM Adrenal Congenital adrenal hyperplasia 21-hydroxylase deficiency 11-hydroxylase deficiency 3b-hydroxysteroid deficiency Cushing syndrome Androgen-secreting ovarian neoplasms Ovarian Severe insulin resistance Androgen secreting ovarian neoplasms Combined adrenal and ovarian Polycystic ovary syndrome Idiopathic hirsutism Exogenous androgens Anabolic steroid Postmenopausal androgen therapy

4. 4 CAUSES OF HYPERTRICHOSIS Congenital. Hypertrichosis lanuginosa Iatrogenic Cyclosporin, streptomycin, cortisone, penicillamine Hereditary disorders Porphyria cutanea tarda, epidermolysis bullosa, Hurler’s syndrome Long standing inflammatory changes

5. 5 PHYSICAL METHODS FOR CONTROLLING HIRSUTISM AND HYPERTRICHOSIS Shaving Waxing Plucking Bleaching Chemical depilatories Electrolysis: galvanic, thermolysis

6. 6 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.

7. 7 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

8. 8 Which is the follicular target? The bulb: 2-7cm below epidermis The bulge: 1.5cm below epidermis Heating the bulge without damaging the bulb allows regrowth.

9. 9 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

10. 10 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

11. 11 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.

12. 12 Important parameters for successful hair removal Wavelength Pulse duration Fluence Spot size

13. 13 Wavelength Two factors need to be considered The depth of laser penetration The selectivity of target absorption Most appropriate wavelengths: 600-1200m

14. 14 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

15. 15 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.

16. 16 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

17. 17 NEW THEORY THE EXTENDED THEORY OF SELECTIVE PHOTOTHERMOLYSIS Longer pulse widths would be more effective

18. 18 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

19. 19 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

20. 20 Spots Greater 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

21. 21 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.

22. 22 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

23. 23 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 growth Permanent=stable for a period longer than the complete hair growth cycle. Follicular responses to laser treatment

24. 24 HISTORY For laser hair removal 1. Medications Hypertrichosis inducing(cyclosporine, minoxidil, steroids) Isotretinoin Topical retinoids, glycolic acid 2. Diseases Inflections(hepatitis, herpes, HIV) Neoplasms(androgen producing) Endocrine(polycystic ovary disease, Cushing’s) Cutaneous(psoriasis, vitiligo, keloids) 3. Other procedures Lasers, chemical peels 4. Previous treatments for hair removal 5. Pregnancy 6. Tattoos.

25. 25 Contraindications Absolute Recently suntanned skin Photosensitizing medications Photosensitivity at relevant wavelength Epilepsy triggered by light Relative Keloids, vitiligo, psoriasis Recent retinoid intake Pregnacy

26. 26 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

27. 27 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

28. 28 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

29. 29 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

30. 30 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%)

31. 31 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

32. 32 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 observation Better long term results if laser is combined with enzymes applied by iontophoresis

33. 33 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

34. 34 Safety Retinal injury Cross contamination with contact cooling devices Plume generated irritating the respiratory tract

35. 35 Comparing electrolysis to laser hair removal Advantages Permanent results Cheep Disadvantages Painful Time consuming Multiple sessions Scars Acne formation Ingrown hair

36. 36 Lasers for hair removal Long pulse ruby Long pulse Alexandrite Diode Q-Switched Nd:YAG Long pulsed Nd:YAG Non laser devices Intense pulsed light sources

37. 37 LONG PULSE RUBY (694) System namePulse Duration Fluence (J/cm 2 ) Spot size(mm) Repetition rate Epitouch Ruby (Sharplan/Esc, Needham, MA) 1.2 msec10-403-61.2Hz E-2000 (Palomar, Lexington, MA) 3 - 100msec 10-4010, 201 Hz Ruby Star (Aesculap, Irvine, CA) 2msec25-4071 Hz

38. 38 Advantages Greater absorption by melanin Disadvantages Low depth of penetration Non suitable for patients with skin type greater than III

39. 39 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

40. 40 LONG PULSED ALEXANDRITE (755) System namePulse duration Fluence (J/cm 2 ) Spot size(mm) Repetition rate Apogee (Cynosure Chelmsford, MA) 5, 10, 20, 40 msec 5-5010, 12.5, 15 Up to 5 Hz Gentle-Lase (Candela, Wayland,MA) 3 msec10-1008, 10, 12, 15, 18 1 Hz Epitouch ALEX (Sharplan/ESC, Needham, MA) 2 msec10-255, 101-5 Hz

41. 41 Advantages Greater depth of penetration Selective absorption of laser energy by follicular melanin Disadvantages Absorption of laser energy by the competing chromophore: oxyhemoglobin.

42. 42 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

43. 43 DIODE LASER (800) System name Pulse duration Fluence (J/cm 2 ) Spot size (mm) Repetition rate Lightsheer (Coherent) 5-1000msec10-6012X12Up to 2 Hz Apex-800 (Iriderm) 10-30msecUp to 407, 9, 11Up to 4 Hz Laserlite (Diomed) 50-250msecUp to 60W2, 4Up to 5 Hz Epistar (Niked) Up to 100msec Up to 504, 7Up to 15 Hz SLP1000 (Palomar) 200-1000 msec Up to 10010Up to 3 Hz MedioStar (Aesculap) 50msecUp to 6012X124 Hz

44. 44 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.

45. 45 Higher fluences and multiple treatments with the diode laser produce better long-term results Campos 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

46. 46 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

47. 47 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

48. 48 Nd:YAG LASER Q-SWITCHED Nd:YAG (1064) System name Pulse duration Fluence (J/cm 2 ) Spot size(mm) Repetition rate Softlight (Thermolase, San Diego, CA) 10ns2-37mm10 Hz Medlite IV (ConBio, Dublin, Ca) 5-7ns123-81,2,5,10 Hz

49. 49 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

50. 50 LONG PULSED ND:YAG (1064) System namePulse duration Fluence (J/cm 2 ) Spot size(mm) Repetition rate Gentle YAG (Candela, Wayland,MA) 3msecUp to12mm1 Hz CoolGlide (Atlus) 1-300msecUp to 3003,5,7, 10 Up to 2 Hz Lyra (Laserscope San Jose, CA) 10- 100msec Up to 601.5,3,5,10Up to 4 Hz Vasculight (ESC,Needham, MA) 1-14msecUp to 656

51. 51 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

52. 52 At 1 year follow up after 3 treatments delivered on monthly basis with the long-pulsed Nd:YAG laser at fluences 40-50 J/cm 2 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

53. 53 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

54. 54 Different fluences with long-pulsed Nd-YAG laser (50,80 or 100 J/cm 2 ) 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

55. 55 INTENSE PULSED LIGHT SOURSES (IPLS) System name Pulse duration Fluence (J/cm 2 ) Spot Size(mm)Repetition rate 590-1200 Epilight (ESC, Needham, MA) 15-100Up to 4510X45,8X350.5 Hz 600-950 Ellipse (Danish Dermatologic development, Hoersholm, Denmark) 0.2-50msecUp to 2110X480.25 Hz 500-1200 Esteloux (Palomar, Lexington, MA) 10-100msecUp to 1216X46Up to 1 Hz 400-1200 Spatouch (Radiancy, Orandeburge, NY) 35msecUp to 722X550.25 Hz

56. 56 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.

57. 57 NEWER DEVICES A 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

58. 58 MICROWAVE TECHNOLOGY Wavelength System name Pulse duration Fluence (J/cm 2 ) Spot size 2.2X 10(-1) MDS (MW, Medical Scottsdale, AZ) 25-30msec 20-286X4 This system delivers pulses of microwave energy in conjunction with a spray of coolant to the skin.

59. 59 Photo Assisted Epilation: Practical Tips Dr. Tzermias Christopher GREECE

60. 60 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.

61. 61 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.

62. 62 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.

63. 63 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.

64. 64 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