Complications of laser and photoepilation

Natalya Mikhailova, dermatologist, cosmetologist, member of the American Academy of Dermatology (AAD), certified trainer of Cynosure Inc. (USA), chief physician of the aesthetic medicine clinic "Reforma", scientific director of the Martinex Medical Center, president of the All-Ukrainian public organization "Union of Mesotherapists", vice-president of the National Society of Mesotherapy (Russia)

The presence of unwanted hair is a problem for many people who are not satisfied with long-standing methods of hair removal (shaving, waxing and chemical depilation, electrolysis) due to either short-term results, severe pain, or frequent complications (for example, scarring after electrolysis). The invention of selective photothermolysis and the creation of various laser systems with different wavelength ranges have made effective and long-term hair removal possible. Currently, several types of laser and photosystems are used for hair removal: ruby laser (694 nm), alexandrite laser (755 nm), diode laser (800 nm), IPL systems (590–1200 nm), Nd:YAG laser ( 1064 nm).

Hair removal occurs due to the destruction of the hair follicle, where the main pigment is melanin, which acts as a chromophore - a substance that absorbs laser radiation with a certain wavelength. With optimal selection of energy flux density and pulse duration, the melanin of the hair follicle heats up and the hair follicle is destroyed. The surrounding tissues are not damaged.

Compared to existing types of hair removal and depilation, laser hair removal destroys the hair follicle quickly, precisely and precisely, which explains its high aesthetic result. One course of procedures is enough to get rid of unwanted hair growth in certain places for a long time (and in some cases, forever).

In addition, hair removal using lasers and photosystems allows you to quickly, practically painlessly and with minimal risk of complications treat large surfaces of the skin. It is no coincidence that it has become one of the most popular among all aesthetic procedures carried out using photo technologies.

Laser and IPL systems, according to manufacturers, help quickly, safely and effectively remove unwanted hair. But numerous studies show that these methods of hair removal are still not without side effects and complications [8, 11]. Due to the growing popularity of laser hair removal, laser therapists, dermatologists, cosmetologists, and general practitioners must know the possible complications and side effects of these procedures in order to diagnose and treat them correctly and in a timely manner.

Causes of complications

Let us list the main reasons for the development of complications characteristic of all types of procedures using lasers and IPL systems.

1. Professional errors of a doctor, which include poor quality training; diagnostic errors, especially in determining the phototype and skin condition; incorrect choice of laser type and its radiation parameters; failure to carry out test exposure; imperfection of laser technology; incomplete patient awareness of the procedure, its results and post-procedure care; lack of eye protection for the patient or doctor; lack of adequate cooling of the skin during the procedure.
2. Failure of patients to comply with doctor’s recommendations for post-procedure care.
3. The patient's health condition during the procedure. This factor affects the effectiveness of the procedure itself and the development of complications in the post-procedure period. Even with a high-quality history collection, we cannot fully take into account the presence of all aggravating factors and diseases in the patient, since he does not always know about them.

When collecting anamnesis, it is important to take into account the patient’s tendency to allergic reactions, the presence of hormonal disorders, immunodeficiency conditions, connective tissue diseases and tumor diseases, and the patient’s use of medications that affect the functional activity of melanocytes [1].

Side effects of laser hair removal

Now let's move on to the side effects of laser and IPL hair removal procedures and their complications.

Side effects of laser hair removal include pain, perifollicular swelling and erythema of the skin of the treated area. Perifollicular edema and erythema occur within a few minutes after exposure, resolve within a few hours and do not require treatment.

The severity of these reactions depends on the color, thickness and thickness of the hair, as well as on the density of the energy flow. Dark thick hair absorbs a lot of energy during the procedure and becomes very hot, which can result in perifollicular edema and erythema. When affecting fine hair, perifollicular edema is usually less pronounced. Severe swelling also occurs in patients with sensitive, reactive skin. To reduce these side effects, it is important to use effective skin cooling systems before, during and, if required, after the procedure.

It is necessary to correctly select the energy flux density and, if necessary, gradually increase it until a clinical effect is achieved. If swelling and hyperemia are pronounced, then after the procedure you can prescribe a cream with glucocorticoids or dexpanthenol. For moderate and mild symptoms of perifollicular edema, it is enough to use soothing gels and creams at home, for example, those used to relieve swelling and erythema after sunbathing.
To effectively eliminate signs of inflammation, moisturizing and restoring cream with antioxidant action Keladerm from the MedicControlPeel line (Russia - Spain) is suitable. As a means to promote regeneration, we can recommend the restorative Aloe Gel with a multivitamin complex and fireweed and chamomile extracts, as well as a hydroregulating gel with dexpanthenol and hyaluronic acid for sensitive and irritated skin.
Immediately after the laser hair removal procedure, it is not recommended to carry out thermal and physiotherapeutic procedures, massage the treated areas, and you should not sunbathe.

Laser hair removal is not a painless procedure; most patients experience pain during (or immediately after) it. To reduce pain, it is important to use an adequate method of skin cooling and, if required, local external or infiltration anesthesia [6].

Complications of laser hair removal

As for the complications of laser and photoepilation, they can be early, developing immediately after the procedure or during the first days after it, and late, which occur over several weeks.

Early complications

Early complications include skin burns of varying severity, folliculitis, exacerbation of acneiform rashes, exacerbation of herpes infection, allergic reactions, development of photophobia, conjunctivitis and uveitis.

Burns occur for several reasons:

• use of high energy flux density during the procedure;
• tanned skin or skin phototypes IV–VI according to Fitzpatrick;
• performing hair removal on areas with thin and sensitive skin, for example in the perianal area or labia, using inappropriate radiation parameters;
• incorrect procedure technique (impulse application, incomplete contact of the manipule with the skin);
• inadequate skin cooling system during the procedure or its absence.

Measures to prevent this complication primarily include adequate patient selection. You should not carry out the laser hair removal procedure immediately after active sun exposure; you need to wait 2–4 weeks for the tan to fade a little. This is especially important when working with ruby, alexandrite, diode lasers and IPL systems. As an alternative to these lasers, it can be proposed to use an Nd:YAG laser with a wavelength of 1,064 nm for tanned patients and patients with skin phototypes IV–VI. The point of application of the radiation of this laser is not the melanin of the hair follicle and epidermis, but oxyhemoglobin, which is located in the vessel feeding the hair follicle, so skin damage will be less likely.

When carrying out a laser hair removal procedure, it is important to avoid superimposing pulses, carefully treat areas of bony protrusions where incomplete contact of the handpiece with the skin is possible, and individually select radiation parameters for each patient. Don’t forget about test exposure to laser on an inconspicuous area: it helps determine the skin’s reaction to radiation and select its optimal parameters. The energy flux density should be increased carefully until there is a visible clinical effect and until signs of acute skin damage—blisters and bright hyperemia—appear.

During the procedure, it is important not to forget about cooling the epidermis. Melanin, contained in the epidermis, is a competing chromophore, which can also heat up and damage the integrity of the skin. Superficial cooling of the skin, performed before, during and after the procedure, reduces the temperature of the epidermis and reduces the likelihood of thermal injury to the skin. Currently, different types of cooling are used in practice. This includes applying ice to the skin, contact cooling using a sapphire window with circulating cold water (2–6 °C), and using a cryogenic spray or systems with a forced flow of cold air [6].
Treatment of skin burns depends on their severity and is carried out according to accepted standards.

Folliculitis (inflammation of the hair follicle) can develop after laser hair removal in patients suffering from hyperhidrosis. The appearance of folliculitis is also possible when, in the intervals between treatment procedures, the patient visits the pool [6].

The problem of hyperhidrosis can be solved by chemical denervation using botulinum toxins. During the course of procedures, you should limit your visits to the pool, especially in the first days after the procedure.

Acneform reactions, according to one multicenter study [4], account for an average of 6% of all complications of laser hair removal. These reactions occur more often in young patients of both sexes, mainly in individuals with skin phototypes II–V, and when using an Nd:YAG laser. The degree of their expression is insignificant. The rash resolves quickly and does not require treatment.

Exacerbation of herpetic infection occurs in patients with a history of herpes during laser hair removal in the upper and lower lip area and in the deep bikini area. To avoid this complication, it is recommended to take prophylactic antiviral drugs (Valtrex, Famvir, acyclovir) the day before the procedure or on the day of the procedure.

Allergic reactions after laser and photoepilation can clinically manifest themselves in the form of urticaria, allergic contact dermatitis, livedo, and intense itching. The reasons for their development may be related to the use of topical forms of local anesthetics used for pain relief before the procedure. There is also evidence of the development of allergic reactions to cooling gas [12]. In addition, allergic reactions are possible when using various topical skin care products after hair removal.

Treatment includes the prescription of antihistamines and topical forms of glucocorticoids. If the cause of the allergic reaction has not been established, the course of laser hair removal procedures should be discontinued.

Catarrhal conjunctivitis, photophobia, uveitis, decreased visual acuity are serious complications of the visual apparatus that occur during laser hair removal in the eyebrow area [13]. They develop in patients who did not use eye protection (glasses, metal contact lenses) during the procedure. When epilating the eyebrows, it is difficult to achieve a good treatment of the entire area if the patient is wearing glasses, so many doctors ask you to simply cover the upper eyelids with your fingers. As practice shows, this method of eye protection is ineffective and leads to serious complications. Based on the above, you should completely abandon laser hair removal of this area or use metal contact lenses, since the thin skin of the eyelids is not able to protect the eyeball from laser damage.

Late complications

If we consider the group of late complications of laser and photoepilation, we can distinguish hypo- and hyperpigmentation, scars, paradoxical hypertrichosis, leukotrichia, bromhidrosis, hyperhidrosis, malignancy or dysplasia of nevi in the area of the procedure.

Hypo- and hyperpigmentation is mainly a consequence of skin burns that occur during laser hair removal. It most often occurs in tanned patients and people with skin phototypes III–VI. It has been noted that hypopigmentation often occurs with stage I thermal damage to the skin, when the crust formed after a burn disappears. Hyperpigmentation occurs in patients who do not follow the rules of post-procedure care and begin to tan in the first two weeks after hair removal or do not use sunscreen on exposed areas of laser-treated skin. Hypo- and hyperpigmentation often appears in the area of post-burn scars.

To prevent these complications, it is recommended to perform laser hair removal in patients with skin phototypes III–VI using long-pulse Nd:YAG lasers. In addition, these patients can use whitening creams two weeks before the procedure.

During the procedure, it is important to choose the right radiation parameters and use reliable and effective methods of cooling the epidermis to prevent thermal injury.

In most cases, hypo- and hyperpigmentation is a reversible phenomenon, but if it persists for a long time, medications are used. To correct hyperpigmentation, whitening agents containing hydroquinone, azelaic acid, alpha-hydroxy acids, and glucocorticoids are prescribed [5]. To correct hypopigmentation, copper-based preparations are used, but if they do not have the desired effect, you can resort to cosmetic tattooing.

Scars are the result of thermal damage to the skin below the basement membrane. If a burn wound becomes infected during the rehabilitation process, then in almost 100% of cases gross hypertrophic scar changes occur. It has been noted that post-burn scars most often form on the neck and mandibular region [7].

Depending on the anatomical location and genetic predisposition, atrophic, normotrophic, hypertrophic and keloid scars can occur.

Thus, Kluger et al [10] reported a case of the development of a keloid scar in the tattoo area in a 41-year-old patient with skin phototype III after laser hair removal in the chest area. He had a history of keloid scars, which were successfully treated with triamcinolone injections. When analyzing this case, it turned out that the tattoo pigments acted as a chromophore that competed with the melanin of the hair follicle. As a result of absorption of laser energy, the tattoo pigment heated up, which led to skin burns and then the formation of a keloid scar [10].

Today, atrophic and normotrophic scars are treated with conservative methods, but with rather low effectiveness; their surgical treatment is possible. Laser ablative and non-ablative fractional photothermolysis is used quite actively and with a high degree of efficiency to smooth the skin surface in the scar area.

Pathological scars, which include hypertrophic and keloid scars, are treated with intradermal injections of prolonged forms of glucocorticoids (Kenalog, Diprospan) into the scar area. Russian scientists have recently proposed a new and quite effective method for treating pathological scars - the use of a copper vapor laser [1].

Paradoxical hypertrichosis - increased hair growth after laser and photoepilation procedures.

According to data from various sources, stimulation of hair growth occurs in women with skin phototypes III–VI, mainly on the face and neck, at the border between the treated and untreated zones [3]. The following mechanisms may be involved in the development of this complication:

• treatment using low (subthreshold) density energy flow, which does not destroy the hair follicle, but has a stimulating effect on hair growth;
• thermal-inflammatory effect – activation of “dormant” follicles and stimulation of telogen phase hair growth in areas bordering the epilation zone [2].

Prevention of this complication is to use an energy flux density sufficient to remove hair. To correct paradoxical hypertrichosis, long-pulse Nd:YAG lasers are used [3].

Leukotrichia, bromhidrosis, hyperhidrosis. One interesting retrospective study was conducted in 2009 [9]. According to the data obtained, with laser hair removal in the armpit area, complications such as hyperhidrosis, bromhidrosis and leukotrichia may develop. Hyperhidrosis was observed in 11% of patients, mainly with skin phototypes II and V, when a combination of two lasers was used during the procedure - diode and alexandrite. The development of bromhidrosis (4% of cases) and leukotrichia (2%) did not have any significant correlation with age, skin phototype and type of laser radiation.

Dysplasia and malignancy of nevi in the area of laser hair removal. Do not forget about the possibility of degeneration of melanocytic nevi in the hair removal area. Nevus melanin is a competing chromophore and absorbs laser radiation along with hair follicle melanin. As a result of repeated exposure to laser radiation or pulsed light (IPL system), thermal damage to melanocytic formations occurs, their growth is activated, and atypical cells appear, which can ultimately lead to the development of melanoma.

Prevention of this complication is not to subject skin areas with any neoplasms to laser hair removal. If there are nevi in the affected area, and hair removal is still carried out, then the nevi must be covered with special protective devices.

***

So, as an analysis of the clinical experience of colleagues and publications in professional journals shows, laser hair removal, which seems like such a simple procedure, can lead to serious complications if it is performed incorrectly. Avoiding complications and minimizing side effects is one of the main tasks of an aesthetic medicine doctor. To do this, you should be thoughtful about the purpose of procedures, carefully collect anamnesis, and take into account the individual characteristics of the patient when choosing the type and parameters of exposure. And of course, it is very important to have professional knowledge of the equipment, to know the specifics of each laser and each photosystem. When performing laser hair removal, there is not only the risk of choosing high radiation parameters, leading to the above-mentioned complications, but also the risk of playing it safe - choosing parameters that are insufficient to solve the problem of a given patient and, as a result, ineffective, which can lead not only to the absence of the desired effect, but to the appearance of the exact opposite - to increased hair growth!

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KOSMETIK international journal, No. 2/2012, pp. 78-82