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HIRSUTISM AND HYPERTRICHOSIS: the role of photo-induced “permanent hair reduction”

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

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HIRSUTISM AND HYPERTRICHOSIS: the role of photo-induced “permanent hair reduction”

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

  2. HIRSUTISMExcessive growth of coarse terminal hair in a pattern more characteristic of adult men.9-15% college aged females have severe hirsutismHYPERTRICHOSISPresence of excess hair in any body site.

  3. CAUSES OF HIRSUTISM Adrenal Congenital adrenal hyperplasia • 21-hydroxylase deficiency • 11-hydroxylase deficiency • 3b-hydroxysteroid deficiency Cushing syndrome Androgen-secreting ovarian neoplasms OvarianSevere insulin resistanceAndrogen secreting ovarian neoplasmsCombined adrenal and ovarianPolycystic ovary syndromeIdiopathic hirsutismExogenous androgensAnabolic steroidPostmenopausal androgen therapy

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

  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. 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 removalFOLLICULAR MELANINis the chromophore

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

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

  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. Fluence Higher fluences are more effective. Pulse duration Should be between the TRT of the basal layer of the epidermis and the follicle: 0.5 to 35 msec

  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. NEW THEORYTHE EXTENDED THEORY OF SELECTIVE PHOTOTHERMOLYSISLonger pulse widths would be more effective

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

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

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

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

  36. Lasers for hair removalLong pulse rubyLong pulse AlexandriteDiodeQ-Switched Nd:YAGLong pulsed Nd:YAGNon laser devicesIntense pulsed light sources

  37. LONG PULSE RUBY (694)

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

  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):135-146Persistent 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. LONG PULSED ALEXANDRITE (755)

  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. 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;25:425-430Alexandrite laser vs DiodeEquivalent clinical and histologic responses are obtained.Handrick et Alster: Derm Syrg 2001;27(7):622Eremia et al: Derm Surg 2001;27(!!):925-92

  43. DIODE LASER (800)

  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. Higher fluences and multiple treatments with the diode laser produce better long-term resultsCampos et al:J Am Acad Dermatol 2000;43:442-720 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 Surg26:428-432Tripple 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. 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 transientpigmentary disturbances.Adrian et al: j Cutan Laser Ther 2000;2:183-190

  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. Nd:YAG LASER Q-SWITCHED Nd:YAG (1064)

  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;41:165-171A 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. LONG PULSED ND:YAG (1064)

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