This document provides information on permanent laser hair reduction using an Nd:YAG laser system. It discusses the hair growth cycle and how lasers work to damage hair follicles. The ideal laser system is described as providing safe and effective treatment for all skin and hair types. Treatment protocols are outlined for different skin types, including recommended fluence and pulse duration settings. Expected results showing long-term hair reduction are presented. Risks are discussed and post-treatment care is described. In summary, this document serves as a guide for clinicians on best practices for laser hair removal.

1. 1
Dr. T.A. RANA
MBBS, M.D. (Skin & VD)
Dermatologist & Cosmetic Laser Surgeon
Consultant at Shri Ram Hospital & Heart Institute, •
Delhi
Vinayak Hospital, Sec-27, Noida (U.P.) •
Panchsheel Hospital, Yamuna Vihar, Delhi •

2. PERMANENT LASER HAIR
REDUCTION

3. Permanent Hair Reduction
3
Hair growth has three phases
Anagen (active)
Catagen (regression)
Telogen (resting)
Growth cycle
depends on the body part,
lasts anywhere from 4 to 12 months.
Hair reduction is considered permanent when a
significant amount of hair does not return for longer than
the complete growth cycle

4. 4
Specific Targets
Lasers generate heat in
the hair shaft, which
diffuses to the stem cell
and matrix targets to
cause desired damage

5. Damage to the Hair Shaft
5
A normal follicle Immediately after treatment

6. Depth of Penetration
6
Longer wavelengths allow laser light to penetrate
more deeply for more effective heating of the hair
shaft (typical depths are 2-6 mm)

7. How Does It Work?
7
Based on the theory of Selective
Photothermolysis:
The target chromophore is melanin
Present in the hair shaft
Also present in the upper third of the follicular
epithelium
Heat generated in the hair shaft diffuses to the
follicular epithelium to cause the damage that is
desired

8. Ideal Laser System
8
Provides Permanent Hair Reduction
Safe and effective on all skin types
Effective on a broad range of hair colors
Effective on a broad range of hair diameters

9. Ideal Laser System
9
Must combine the following parameters:
Appropriate wavelength absorption by melanin
Strong enough to allow treatment of finer and lighter hairs
Moderate enough to protect epidermis even on dark skin types
Penetration to target
Appropriate pulse widths
Short pulses for treatment of finer hairs
Long pulses for safety in darker skin types
Effective spot size and fluences
Aggressive Cooling
Compression

10. Appropriate Wavelength
10
Ideal wavelength in range 750-1200 nm
Ruby (694 nm) too well absorbed by melanin to treat
darker skin patients
Nd:YAG (1064 nm) requires 3-4 times the fluence for
similar effect

11. 11
Pulse Width Considerations
If parallel cooling is used, the longer the
pulse, the lower the epidermal temperature
rise at a particular fluence setting
There is not a pulse width that is “too long” as
far as the epidermis is concerned
Thus longer pulse widths are great for dark
skin

12. Pulse Width Considerations
12
If the pulsewidth is much longer than the
Thermal Relaxation Time (TRT) of the hair
follicle, the hair follicle will not get hot
enough to be destroyed
The TRT depends on how thick the hair is
Finer hair requires shorter pulse
Coarse hair can be treated with longer pulse

13. Fluence (J/cm2)
13
Studies have shown a fluence dependent
response with hair removal results
The higher the fluence the better the response
Risk of side-effects increases with increased
fluence
Select maximum tolerated fluence for best
efficacy

14. Cooling
14
Must protect the epidermal melanin while
treating at clinically effective fluences
Treatments with an effective cooling design
can allow 3-4 times greater fluence without
epidermal damage

15. Compression
15
Reduces competing chromophore, oxyhemoglobin
Blanches vessels and eliminates energy lost into this
target
Rotates follicle closer to surface, so laser light
penetrates deeper into the hair shaft

16. Techniques and Guidelines
1. Patient Selection
2. Laser settings
3. Patient prep
4. Follow-up

17. Fitzpatrick Skin Types
17
I Always burns, never tans
II Always burns, sometimes tans
III Sometimes burns, always tans
IV Rarely burns, always tans
V Moderately pigmented
VI Black skin

18. Patient Skin Types
18
It is critical to understand the skin type of the
patient to provide the best results
Look for the presence of tan
Tan skin does not respond the same way as natural
dark skin
Tan skin should be treated with the 100 ms option

19. Patient Skin Types
19
Nd- YAG is cleared to treat all skin types
(Fitzpatrick I-VI).
It can treat tanned skin, but avoid treating
patients with a recent severe or lengthy
exposure.

20. Patient Hair Types
20
• Terminal hair, not vellous hair
• Pigmented hair
– Black, brown, red, dark blonde can achieve
a long lasting result.
– Light blonde or white can experience
temporary loss for up to 3 months.
– Recommend electrolysis as a treatment for
permanent removal of discrete white hair

21. Number of Treatments
21
Temporary hair removal achieved in a single
treatment
Amount of long-term hair reduction varies
between patients
Higher fluence results in increased long-term
hair reduction
Typically 3-5 treatment are required for
nearly complete long-term hair loss
Darker skin may require more treatments

22. Treatment Intervals
22
• Wait for regrowth (harder to schedule)
• 1 month/2 months (dependent on body
location - face will be shorter time between
treatments than body)
• Take hair growth cycles into consideration…

23. How often are treatments?
23
1 treatment every 6-10 weeks depending on
body part.
Location Telogen
Months
Anagen
Months
Total
Months
Back 3-6 3-6 6-12
Thigh 3-6 3-6 6-12
Arm 3-5 1-2 4-7
Calf 3-4 4-5 7-9
Axilla 2-3 3-4 5-7
Upper Lip 1-2 3-4 4-6
Bikini 3-4 2-3 5-7

24. Setting Expectations
24
No two patients are alike, treatment outcome cannot
always be predicted: Never give promise of 100%
reduction
Clearly define permanent hair reduction
Describe need for multiple treatments:
3-5 treatments generally required
For darker skin types IV-VI, 6-10 sometimes required, since
lower fluences are used
Provide expectations in writing (e.g. patient consent)
that patients can sign, retain copy

25. Potential Patient Risks
25
Scarring: has not been reported in clinical
studies
Hypo- or Hyperpigmentation rare and transient;
usually clears in 2- 6 months; fluence and skin
type dependent
Perifollicular erythema /edema - common,
resolves in hours/days
Local blisters - high fluence/dark skin

26. Patient Contraindications
26
History of keloidal scarring
Active infections: herpetic lesions, cold sores (place on
anti-viral medication pre-tx)
Tattoos, permanent make-up, pigmented lesions (can
treat around them)
Use of photosensitizing medications such as Accutane
(isotrenoin), tetracycline
Electrolysis, waxing or plucking in last 6 weeks (target
has been removed)
Pregnancy

27. ParaFmlueetenrc eSe: leTchteio hnighest tolerable fluence will provide the
27
greatest efficacy
Pulse width: If the hair shaft is not relatively large and the
skin is not relatively dark, then the Auto Mode will provide
the highest efficacy; Optimal pulse width may change after 1
or more treatments
Optimizing fluence and pulse width safely is our goal

28. Recommended Settings - Lighter Skin Types
Skin
Type
28
Starting Fluence
(Test Spots)
Tolerated
Fluences
Pulse Duration
I 32 J/cm2
Wait 15-30 min
Increment 2-5 J/cm2
15-60J/cm2 Auto
30 ms high hair
density
II 28 J/cm2
Wait 15-30 min
Increment 2-5 J/cm2
15-60J/cm2 Auto
30 ms high hair
density
III 24 J/cm2
Wait 15-30 min
Increment 2-5 J/cm2
15-45J/cm2 Auto – finer
30 ms – coarser or
high hair density

29. Recommended Settings Darker Skin Types
29
Skin
Type
Starting Fluence
(Test Spots)
Tolerated
Fluences
Pulse Duration
IV 16-20 J/cm2
Wait 15-30 min
Increment 2-3 J/cm2
10-40J/cm2
20-70J/cm2
30 ms finer hair
100 ms coarser hair or
higher density
400 ms coarse hairs
V 12-16 J/cm2
Wait 48-72 hours
Increment 2-3 J/cm2
10-35J/cm2
20-60J/cm2
100 ms
400ms coarse hair or hair
not responding to lower
fluence
VI 8-12 J/cm2
Wait 48-72 hours
Increment 1-2 J/cm2
10-30J/cm2
20-40J/cm2
100 ms
400 ms

30. 30
Skin Type Starting Fluences (Test Spots)
Tolerated
Fluences
Pulse
Duration
All Skin
Types –
Tanned
Skin
Use low range of fluences
recommended for one skin type
darker than patient’s skin type
(e.g. treat tanned skin type III as
skin type IV).
Perform test spots on areas with
same degree of tan as area to be
treated.
n/a 100 ms
Recommended Settings Tanned Skin

31. Eye Safety
31
• Can cause severe retinal injury.
• No treatment within bony orbit of eye (outer
canthus). Treatment of eyebrows not recommended.
• Ocular Hazard Zone:
– 164 feet / 50 m
– Laser light focused by the lens of the eye onto
retina has a high fluence
• Proper eye protection MANDATORY for ALL people in
the room!

32. Pre-Treatment Steps
32
Take baseline photographs
Help patients remember density and diameter of
hair before treatment
Mark area to be treated
Never use black marker, red is best
Shave area, remove all cut hair, sanitize skin
Depilatory cream can be used, but may irritate
skin
Perform test spots

33. Local Anesthesia
33
Assess discomfort tolerance during test spots
Most often used for male backs, front necks
Other typical areas for low-threshold patients:
Upper lip, bikini lines
Frequently used local anesthesia:
Emla, Ela-max
Dental sensitivity:
Gauze, dental guards (especially with dental work)

34. Operator Techniques
34
Secure wrist strap!
Pick and place
Most effective in smaller areas
Slide and glide
Allows more rapid coverage on larger areas
Thin (< 1 mm) layer of gel enables friction-free movement
Pattern in gel enables tracking of treated areas
Keep the ChillTip flat on the skin surface and at a 90o
angle
Inspect and clean tip frequently during treatment!

35. Clinical End Points
35
Look for laser-tissue interaction, don’t just
depend on written parameters
End-points that indicate fluence and/or
pulsewidth must be changed:
Skin graying
Skin separation
End points listed on following slides are
normal and desirable

36. Positive Clinical End Points
36
Perifollicular erythema:
– Initial redness from ChillTip and pressure decreases
– Erythema around treated hair increases after a few
minutes

37. Positive Clinical End Points
37
Perifollicular edema
Swelling around the follicle (bumps) several
minutes after treatment

38. Positive Clinical End Points
38
Singed hair:
Hair from follicle ejected or vaporized
Can see singed hair on skin or on tip
Gel becomes brownish
Odor of singed hair present

39. Patient Results – Long Term
39
Before 46 months after last treatment
2 treatments at 30 J/cm2, 30 ms
2 treatments at 40 J/cm2, 30 ms
Chin, Female Skin Type IV

40. 40
Patient Results – Long Term
Before 24 months after last treatment
40 J/cm2
Treatments 1-3: 30 ms
Leg, Female Skin Type II

41. 41
LightSheer Results
Female, Skin type III - Chin
Pre 36 months after 5 Tx
.

42. 42
LightSheer Results
Female, Skin type IV - Chin
Pre 46 months after 4 Tx

43. 43
LightSheer Results
Male, Skin type IV - Beard
Pre 5 months after 3 Tx

44. ND YAG Results
44
Female, Skin type II - Bikini
Pre 8 months after 3 Tx

45. IPL Results
45
Female, Skin type IV - Axila
Pre 4 months after 3 Tx
Courtesy C. Dierickx, M.D.

46. Patient Results
46
Before 4 months after last treatment
22-24 J/cm2
Treatments 1-3: 30 ms
Axilla, Female Skin Type V

47. Patient Results
47
Sacral Region, Female Skin Type V
Before 3 months after last treatment
22 J/cm2
Treatments 1-4: 30 ms

48. Post-Treatment
48
Sunburned sensation is common
Suggest cool compresses or soothing cream
of gel (e.g. aloe vera)
Describe crusty spots that may occur
Clean area 2x daily with mild soap
Sunscreen for 6 weeks over area
Describe singed hair and shedding process

49. Richards-Meharg Table (Hair Growth Cycle Duration)
49
AREA OF BODY ANAGEN TELOGEN
Scalp 2-6 Years 3-4 Months
Beard/Chin 1 Year 10 Weeks
Upper Lip 16 Weeks 6 Weeks
Eyebrows 4-8 Weeks 3 Months
Ear 4-8 Weeks 3 Months
Legs 24 Weeks 16 Weeks
Arms 18 Weeks 13 Weeks
Axilla 4 Months 3 Months
Pubic 3 Months 4 Months

50. 50
Pseudofolliculitis Barbae
Commonly referred to as “razor bumps”
Not a true “folliculitis”as name implies
Inflammatory foreign body response to a sharp
hair shaft

51. ND- YAG Treatment of PFB in skin types IV-VI
51
Mean % Reduction of Lesions from Baseline
79%
86%
Study by Fran E. Cook-Bolden, MD
Ethnic Skin Specialty Group
New York, NY, USA
0.86
0.84
0.82
0.8
0.78
0.76
0.74
Male Female
Female
Male

52. Potential Risks
52
Perifollicular edema/erythema
Favorable post-treatment response
Usually resolves w/in 24 hours
Local blisters - too high fluence, dark skin
Hyper/Hypopigmentation
Transient, should clear within 2-12 months,
Fluence and skin type dependent
Scarring – Extremely rare

53. The ND-YAG laser System
The first system FDA cleared for hair
removal that was designed for hair removal
from the ground up
The clinical trials influenced the design and
parameters chosen

54. ND-YAG Clearances
54
FDA cleared to advertise “Permanent Hair
Reduction”:
For all skin types (I-VI), including tanned skin
Long-term studies have proven the efficacy
Also FDA cleared for the treatment of leg veins,
benign pigmented lesions and pseudofolliculitis
barbae

55. Neodymium:YAG
55
Melanin
absorption at 1064
nm higher then
diode laser.

56. diode Contradiction
56
The low absorption by melanin makes it potentially
safer in darker skin but it requires a thick, dark hair
to be effective
Therefore for thin and medium hair, and brown
hair, the diode has limited effectiveness
For lighter skin patients there is no advantage to
the 800 nm wavelength

57. THANK YOU
57