Unwanted Body Hair
Hair is desirable on the top of the head (duh) and of course it is one of life’s ironies that so many men lose hair where they want it and gain it where they don’t. Facial hair on women can be socially debilitating. The Fonz on the television show Happy Days had a singular objection to mustaches on women (but not to women with twin sisters as I recall). Any culture that uses cell phones eschews facial and body hair on women. It’s considered unfeminine, and indeed can signal on a primitive level, an androgynous hormonal balance. In North America, hairy underarms in women is also undesirable, so much so that famous actresses sometimes find their photographs in tabloid magazines if they raise their arm and reveal body hair. At least it’s better than photographs of cellulite.
An aversion to body hair is nothing new. Renaissance paintings by the masters, contained in the vast collection at the Louvre, rarely portray body hair on women, or men.
Consequently, shaving legs and armpits is part of the maintenance ritual of being an American woman. Most women shave their legs at least twice a week and would be embarrassed revealing hairy legs. Many women pluck facial hairs daily. Countless hours are wasted in this task that has no redeeming value. Hair follicles in the beard area in men and bikini area in women may become inflamed (“folliculitis”).
Again, supermodels embody our society’s ideals, even exaggerating them (It seems legs and necks cannot be too long.) After all, supermodels have one purpose—to sell their appearance. You don’t find any body hair on supermodels. Or on Barbie for that matter. Their skin is smooth as silk and unblemished.
What about men? Men may have to shave twice daily to avoid the 5 o’clock shadow, or avoid taking off a shirt because of embarrassing body hair. Many men have told me they feel self-conscious about their body hair when they are shirtless on a beach, or at the pool with their children. The “Austin Powers” look is decidedly out, along with crooked, yellow teeth, sideburns and gold medallions. Among all the actors to play him, there has been only one hairy-chested Tarzan. None of the men on the cover of Muscle and Fitness magazine have hairy chests. George Carlin half-joked that he thinks of an ape when he sees an especially hirsute male.
Hairy groins and inner thighs are also frowned upon. Bikini waxes are part of the pre-program before tropical holidays for most women. As essential as the pre-holiday diet.
So What To Do About It?
Anyone who has seen Steve Carell’s facial reactions in the movie 40-Year-Old Virgin has some idea of the pain involved in body waxing, a sadomasochistic exercise if there ever was one.
Some women have a syndrome characterized by polycystic ovaries and body hair—polycystic ovarian syndrome. Their hair growth is similar to a man’s and they have no option but to shave daily.
Most treatments are of a temporary nature only. This includes plucking, waxing, and shaving. The use of depilatory creams is also of temporary benefit only and often irritates the skin. Plucking and waxing are especially painful and need to be repeated frequently. Why are these measures temporary? Because the hair is removed, but the follicle is left intact, ready to produce a new hair. Many women believe that shaving accelerates hair growth and causes thickening of the hair, which is an old wives tale (the hair follicle has no idea whether the hair it produced is shaved or not.) Shaving may cause skin irritation and folliculitis. Chemical applications may be complicated by dermatitis and burns.
An improved method of hair removal, making use of laser technology, was long overdue. In fact, permanent hair removal for large areas such as the back (in men) and legs (in women) was not done simply because it was not possible.
Everyone’s heard of electrolysis, the only permanent technique for hair removal available before the advent of laser hair removal in the 1990s.
Electrolysis makes use of an electric current delivered by a needle directly into individual hair follicles. Each individual hair is grasped and an electric current is sent down the hair to heat and destroy the hair follicle. Because only one follicle is treated at a time, the technique is very tedious and time-consuming. The treatment is painful. Many visits to the electrologist are needed to treat even areas the size of a postage stamp (which may include a few hundred hair follicles). Patients may attend treatments weekly over periods of over a year. And the treatment is about 50% effective, meaning about half of the hairs survive treatment.
There are complications from this technique due to the effects of electrical current. Because some skin cells are burned along with the hair follicle, scarring and ingrown hairs may result. Nodules may form. Infection is possible because of the breakdown of the skin barrier function.
The technique is practical only for small areas such as the upper lip and chin. It is completely out-of-the question for large areas such as the back or legs. Although it was introduced in the mid-20th century, the technology is from the 19th century. It is now an antiquated treatment.
Laser Hair Removal—How It Works
The hair follicles are specialized structures in the skin that produce hairs. I think of them like tulip bulbs. They are planted deep in the skin. In fact, they stick out of the underside of the skin. They are well-protected in this location. Any treatment to remove the hairs without damaging the skin must be selective. The puzzle has always been, how does one destroy the hair follicle without damaging the surrounding skin?
Hair removal has always been made difficult by the location of the hair follicles, which are deeply situated in the skin. Lasers that nonselectively remove the top layers of the skin are therefore ineffective. Sometimes patients ask if the resurfacing lasers such as the erbium:YAG laser and the CO2 laser will get rid of their facial hair. They will vaporize surface hair, but because these wavelengths do not penetrate deeply into the dermis, the hair follicle is unaffected. A new hair grows out to replace the vaporized one.
However, lasers that produce wavelengths that penetrate more deeply into the skin are ideally suited for this purpose. All that remained was a suitable target which could absorb the laser energy and deliver it to the hair follicle.
For years, lasers have been used to treat a variety of skin conditions, such as port wine stains, benign pigment conditions and tattoos. In 1983, the concept of Aselective Photothermolysis was introduced. This described the use of medical lasers of the appropriate wavelength and energy settings to act on targets in the skin, without causing damage to the surrounding tissue.
There was no such thing as “laser hair removal” before the 1990s. Like so many important discoveries (microwaves for example), the use of a laser for hair removal was discovered by accident, while lasers were being used for tattoo removal. Doctors noticed that when they treated tattoos with a ruby laser, fewer hairs grew back in the treated area, introducing a new application of the laser to the old problem of hair removal. The laser target was the pigment in the skin. Fortunately, you don’t need to have a tattoo for the treatment to work. Pigment cells containing melanin are concentrated around hair follicles. Melanin is a naturally-occurring pigment in the skin that may be targeted by a laser using a wavelength that is well absorbed by melanin. By absorbing and then releasing the laser energy next to the hair follicle, the follicle may be disabled. The energy is concentrated in a very short pulse (milliseconds), so that heat does not build up sufficiently to cause damage to the surrounding skin cells. In this way, hair follicles may be safely deactivated, with minimal risk of scarring.
In 1991 the use of the ruby laser for hair removal was patented. Several clinical studies were performed, and in 1997, the FDA approved three types of ruby lasers for hair removal, including the EpiTouch and the EpiLaser. The FDA-approved alexandrite and diode lasers, with similar specificity for melanin, were introduced shortly afterward. Our facility has considerable experience with the long-pulsed alexandrite Apogee laser (Cynosure Inc., Westford, Mass.). The ruby (694 nm), alexandrite (755 nm), and diode (810 nm) lasers all have wavelengths that are appropriate for hair removal. Shorter wavelengths are more absorbed by melanin, but do not penetrate as deeply into the skin. The alexandrite laser provides a favorable balance of penetration and melanin absorption.
Laser Hair Removal
The Nd:YAG laser has a wavelength of 1064 nm. Consequently, it penetrates more deeply into the skin but at the price of much reduced melanin absorption. To compensate for this, a topical black carbon-mineral oil preparation was rubbed into the skin to act as a target for the laser energy. In fact, this was the first laser system marketed for hair removal (Softlight, manufactured by Thermolase). Patients needed to be waxed first to remove the hairs from the follicles and let the lotion penetrate the hair follicles. The need for waxing and a rubbed-in ointment were obvious disadvantages and it is no longer used. However, the Nd:YAG laser is sometimes used today to treat patients with dark skin types (Fitzpatrick V and VI) who cannot be treated with the newer systems, but the poor melanin absorption compromises its effectiveness.
Our center first used the ruby laser before switching to the long-pulsed alexandrite laser. The alexandrite offered advantages—a larger spot size and faster repetition rate, reducing treatment times and making them less expensive. Also, the longer “pulse duration” offered at least a theoretical advantage in delivering more energy per pulse. Although the evidence is anecdotal, our patients seemed to require fewer treatments with the long-pulsed laser. A cooling unit that blows refrigerated air over the skin provides sufficient cooling, reducing discomfort. Topical anesthetic cream such as EMLA is not required.
There are alternative Intense Pulsed Light (IPL) systems (such as Epilight) that use a flashlamp and then a filter to narrow the range of wavelengths. These light-based systems are sometimes confused with lasers. The advantage of laser treatment is specificity. All of the energy is delivered on the desired wavelength so that there is less wasted energy.
Most areas of the face and body may be treated. Women often wish to have the upper lip, chin, lower face and neck treated. These are common areas of unwanted hair, usually an inherited tendency. They are typically treated in 20 minutes or less. The bikini area and underarms are also commonly treated. The arms and legs are larger areas that may be treated and will take longer.
Men may experience overgrowth of hair in the beard area. The lower face and neck may be treated to reduce growth in these areas. This may also reduce ingrown hairs and folliculitis. The back of the neck, shoulders, and back are often treated. These areas are large and require a longer treatment session, usually over an hour.
While laser treatment is a huge step forward, making possible what was previously impossible, it is not perfect. Hair follicles are not all vulnerable to the laser treatment at one time, so it’s not possible to eliminate them all in one laser treatment. Hair follicles cycle, from a dormant resting stage of invulnerability (“telogen”) to the growth phase (“anagen”), a brief breakdown phase (“catagen”) and then back to their “hibernating” telogen phase again. The cycle length is different, depending on the anatomic location. For most areas of the body, it’s between 4–10 months long and about half this time is spent in the anagen phase. The scalp has a much longer anagen phase, accounting for the longer hair length of scalp hairs.
Of course, the hairs are not all in the same phase of their cycle. They only seem to be vulnerable to laser treatment in their growth phase. Perhaps this is because only during this phase there is a hair shaft present in the bottom of the follicle to absorb laser energy (the reason to avoid plucking before laser hair removal). Additionally, hair follicles that are in anagen may not be permanently deactivated with a single laser treatment. A significant percentage will survive, although the hair may be less coarse and lighter. Consequently, laser hair removal cannot effectively remove all the hair in one treatment. This is why treatments are spaced out at least a month apart, so that hairs emerging from their “hibernation” can be treated. Over the course of treatments, few hair follicles will escape exposure to the laser energy.
Procedure: Laser hair removal from chin and neck.
Before, 1 month after first treatment, 2½ years after (1 month after sixth treatment)
Procedure: Laser hair removal from back and shoulders.
Before, 15 months after (6 weeks after third treatment)
- How It Is Done
- What To Expect After Laser Hair Removal
- Care After Laser Hair Removal
The skin is typically red immediately after the procedure, like a sunburn. Hydrocortisone cream, 1%, may be applied to help reduce inflammation. Usually the redness fades over a period of hours. Hair fragments will fall out over the next week or 2. There will typically be a hair-free period of a few weeks (longer with additional treatments), followed by a less dense growth of new hair.
Patients need to know that repeated treatments will be needed. The exact number is not known and varies from patient to patient depending upon the area treated, treatment response (related to hair color, skin color, and hair density), and patient expectations.
I explain to patients that each treatment reduces the hair density by a certain percentage, say 20%. The first treatment or two may not produce a conspicuous difference, but the reduction will become more obvious with more treatments. It takes about a 50% reduction to produce a noticeable difference, so if the patient can appreciate a difference they likely have already reached this milestone. Most patients are satisfied with a reduction of about 80% and this may be reached after three to six treatments in patients with favorably dark hair and lighter skin. At this level, they may be shaving infrequently enough that their hair no longer constitutes a nuisance. Of course, they can always return in the future for additional treatments, if desired. On the other hand, there are patients who have two or three treatments, are pleased with the result, and do not return for more. This is why treatments are priced by the treatment, not for a package of treatments—we never know exactly how many treatments will be needed.
There is a small subset of patients who really want to eliminate all of the unwanted hair. These patients typically return every month and may do 10 treatments or more. Each treatment is less uncomfortable because there are fewer hairs to absorb the laser energy. You might think that they would be unhappy, returning for so many treatments, but this is not the case. They are very gratified by the improvement and simply want more of a good thing.
When we first started doing laser hair removal, we did not know whether the effects would be permanent, although early studies were encouraging. With greater experience, researchers found that the disabled hair follicles did not regain function—the effect appeared to be permanent.
Patient satisfaction is remarkably high. We were one of the first centers in our area to offer laser hair removal, in 1997, and have now successfully treated thousands of patients, mostly women, but also a large contingent of men who typically have their backs treated.
Because the laser does not produce a break in the surface of the skin, risk of infection is minimal.
Hyper- and Hypopigmentation
Hyper- and hypopigmentation can occur, particularly in patients with darker skin types. Hyperpigmentation is avoided and treated by strict avoidance of ultraviolet exposure, the use of sunblock, and a bleaching cream. It can take several months to fade. There is a risk of lightening of the skin, particularly in patients with darker complexions. This is rarely an issue for patients, who may have some increased skin pigmentation in the affected areas anyway.
This is more likely in patients with darker skin types or tanned patients because more energy is absorbed by the skin. These blisters are superficial and unlikely to leave scars.
The risk of scarring is minimized by the use of appropriate energy settings.
A moisturizer may be used after treatment. For persistent redness or a prickly, sunburn sensation, a mild steroid cream, such as Hydrocortisone 1% may be applied to the affected areas. This is an over-the-counter medication. It is probably wise to avoid sun exposure for at least a few days after treatment, or longer if another treatment is contemplated.
Q: Is there any cream that works to remove hair?
A: There is a product called Vaniqa which is marketed for hair removal. I have prescribed it, on occasion, to patients that request it. Tellingly, no one has asked for a renewal of the prescription. It appears to have minimal effectiveness.
Q: Are there any restrictions after the laser treatment?
A: Avoidance of ultraviolet light (i.e. sun exposure) for several days (in some cases, longer) after treatment is strongly advised in order to avoid hyperpigmentation (darkening of the skin) due to temporary melanocyte hypersensitivity.
Avoid sun and tanning before treatments to reduce the amount of melanin in the skin that would otherwise absorb the laser energy, causing more discomfort and making it necessary to reduce the energy setting on the laser.
Q: Is the hair removal permanent?
A: Studies show that the hair follicles that are damaged by the laser treatment do not tend to recover, so that the effect is permanent. But, of course, not all hairs are removed with each treatment. Each treatment reduces the hair count (“density”).
Q: What should I expect after my first treatment?
A: I use the analogy of cutting trees in a forest. If an enthusiastic woodsman were to cut down every fifth tree in a forest, the forest would still look pretty much like a forest. It may take three or more such tree-cutting sessions, cutting down 20% each time, before the forest starts to look thinned out. Once about half the trees are eliminated, the results are noticeable. So you should not expect too much from just one or two treatments. Be patient and after your third or fourth treatment you should be noticing a difference. For my more mathematically-inclined patients, an exponential curve is a useful reference. In the mid-portion of the curve, there is a rapid decline, but then the curve flattens out, approaching but never actually reaching zero hairs.
Q: Is it painful?
A: There is some discomfort. The analogy is a rubber band snapping on the skin. After awhile it does not seem to hurt as much. However, there are areas of the face and body, such as the upper lip and flanks that seem to be more sensitive. The cooling unit is very helpful in making it less uncomfortable. The treatment should be a little uncomfortable, but it should not be too painful either. The energy setting is adjusted to strike the right balance. Another clue is the redness of the skin. A little redness is desirable but a lot of redness may indicate the power setting is a little too high. Almost everyone can tolerate it. We’ve even treated 12-year-old girls on occasion.
Q: How many treatments will I need?
A: This depends on your skin type, hair color and density, area of the body, and your expectation level. If you have dark hair and light skin, you have the ideal combination and should have a good result. If your hair is very dense, you are going to need more treatments. Most patients are satisfied with a hair reduction of about 80%. This may reduce the need for shaving from a daily ritual to perhaps weekly or less often. Some patients wish to eliminate the hairs completely. I have patients who have had 10 treatments or more. Notably, they are not dissatisfied patients. On the contrary, they are happy to have a safe, effective treatment that has helped them tremendously with a problem that causes them social embarrassment. The male beard area is notoriously dense. Men having this area treated should expect to have more treatments.
Q: I have a big problem with ingrown hairs. Will this help?
A: Yes. Ingrown hairs can be a nuisance, causing chronic inflammation. The hair is difficult to extract because it is buried by the skin. Laser hair removal can help reduce the hair density, and therefore the problem, because it works on hair follicles that are located under the surface of the skin.
Q: Should I let the hair grow out before my laser treatment?
A: Yes. It can be helpful to have just the slightest amount of hair growth at the time of treatment, just enough to show the affected area. But any more than this is unnecessary. So you can stop shaving the day before your treatment or perhaps the morning of your treatment if your hair comes in quickly.
Q: I heard that shaving is to be avoided because this makes the hair come in worse. Is this true?
A: No. This is an old wives tale. Shaving is to be encouraged. Women can shave too. This is much faster and less painful than plucking or tweezing. The new hairs that erupt from the surface of the skin do seem to be coarser but this is simply because it is short. It simply has not grown out enough to be flexible. If anything, shaving can be healthy for skin, providing a little exfoliation. Women should not regard it as unfeminine. With laser hair removal treatments, it is not necessary to shave as often.
Q: Do the hairs just fall out?
A: Yes. You may see hair fragments that get pushed out of the hair follicles during the week or 2 after treatment.