Stephen Eubanks, M.D.

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1 Stephen Eubanks, M.D. The Dermatology & Laser Center at Harvard Park Denver, Colorado Assistant Clinical Professor, Dept. Dermatology University of Colorado Health Sciences Center

2 I would like to thank you for coming this morning Θα ήθελα να σας ευχαριστήσω για την παρουσία σήμερα το πρωί

3 Op]mizing Clinical Results: βελτιστοποίηση κλινικά αποτελέσματα Hair Removal αποτρίχωση Athens, Greece November 9, 2013

4 What devices have been used for hair removal Long- pulsed alexandrite laser Long- pulsed Nd:YAG laser Diode laser IPL

5 What devices have been used for hair removal I do not think IPL is an effec]ve modality for hair removal I think IPL has far more side effects than laser

6 What devices have been used for hair removal I think diode is somewhat effec]ve for hair removal There is no ques]on that 755 nm alexandrite is the gold standard for hair removal

7 For hair removal, I use the following devices GentleLase Pro GentleYAG elosplus Mo]f

8 Hair Removal Devices GentleLase Pro GentleYAG elosplus

9 We have already discussed the GentleLase Pro and the GentleYAG

10 This is the new mul]- plauorm device u]lizing elos technology There is an 810 nm diode + RF for hair removal

11 Laser Hair Removal

12 Laser Hair Removal Why is hair difficult to remove? Hair follicle biology Hair color issues Skin color issues Issues with hair in different anatomic loca]ons

13 Laser Hair Removal How does hair grow? Three phases Anagen growth Catogen transi]on Telogen res]ng

14 Laser Hair Removal How does hair grow? Anagen phase Matrix cell surround the dermal papilla These cells differen]ate into follicular structures The hair develops

15 Laser Hair Removal Where do the cells come from to regrow a hair? Most people feel the hair cells come from the hair bulge?

16

17 Laser Hair Removal Where do the cells come from to regrow a hair? The hair bulge look far away from the hair bulb area But the regenera]ng hair actually begins to grow high in the dermis

18

19 Laser Hair Removal Where do the cells come from to regrow a hair? The hair matrix is near the bulge area that has stem cells

20 Laser Hair Removal So to destroy a hair follicle with laser Destroy the hair bulb Destroy the vascular supply (dermal papilla) Destroy the bulge area

21 Laser Hair Removal Why is hair difficult to remove? Anatomic issues with the hair follicle Hair color issues Skin color issues Issues with hair in different anatomic loca]ons

22 Hair color Laser Hair Removal Only dark hair responds to laser Black hair Brown hair

23 Hair color Laser Hair Removal Only dark hair responds to laser Black hair Brown hair No response in Blond hair Red hair Grey hair

24 Laser Hair Removal Why is hair difficult to remove? Anatomic issues with the hair follicle Hair color issues Skin color issues Issues with hair in different anatomic loca]ons

25 Skin color Light Caucasian skin Minimal surface risks with laser Asian skin High risk of post- inflammatory hyperpigmenta]on Black skin Laser Hair Removal High risk of hypo- and hyperpigmenta]on

26 Laser Hair Removal Why is hair difficult to remove? Anatomic issues with the hair follicle Hair color issues Skin color issues Issues with hair in different anatomic loca]ons

27 Laser Hair Removal Anatomic loca]on in hair removal Different areas of the body have different size hairs Pa]ents will have thick and thin hair

28 Laser Hair Removal Anatomic loca]on in hair removal Laser only treats hair that is in anagen phase Different loca]ons have different percentages of anagen hairs

29 Growth Cycle Chart Body Area % Anagen % Telogen Scalp Beard Eyebrow Upper Lip Underarm Leg Bikini 30 70

30 Laser Hair Removal Anatomic loca]on in hair removal Areas with small percentages in anagen Eyebrows Axillae Bikini Legs More treatments will be needed

31 Laser Hair Removal Anatomic loca]on in hair removal Different loca]ons have different growth rates This leaves hair in the anagen phase for different amounts of ]me

32 Growth Time Body Area Anagen Telogen Scalp 2-4 yrs 3-4 mo Beard 1 yr 10 wks Eyebrow 4-8 wks 3 mo Upper Lip 16 wks 6 wks Underarm 4 mo 3 mo Leg 16 wks 24 wks Bikini 4 mo 3 mo

33 Laser Hair Removal Anatomic loca]on in hair removal Areas with short anagen growth phases Eyebrows Ears Treatments should be every month

34 Laser Hair Removal Anatomic loca]on in hair removal Areas with long anagen growth phases Trunk Arms legs Treatments should be every two months

35 Laser Hair Removal How do I remove hair?

36 Laser Hair Removal You may treat dark hair in light skin In Type I IV skin, use the GentleLase Pro (755 nm)

37

38 Laser Hair Removal You may treat dark hair in dark skin In Type IV - VI skin, use the GentleYAG (1064 nm)

39

40 Laser Hair Removal Parameters The spot size is dependent on the area to treat

41 Laser Hair Removal Parameters The spot size is dependent on the area to treat Use the 8 mm spot on upper lips and ears

42 Laser Hair Removal Fluence 8 mm spot The fluence range of the 8 mm spot is J/cm 2

43 Laser Hair Removal Fluence 8 mm spot 8 mm spot Skin Type Fine Hair Medium Hair Coarse Hair I 32 J/cm 2 30 J/cm 2 28 J/cm 2 II 30 J/cm 2 28 J/cm 2 26 J/cm 2 III 24 J/cm 2 22 J/cm 2 20 J/cm 2 IV 22 J/cm 2 - -

44 Laser Hair Removal Fluence 8 mm spot Why not use the 8 mm spot size in Type IV skin with medium or coarse hair? The 8 mm spot does not penetrate as deep, leaving too much heat in the superficial epidermal layer

45 Laser Hair Removal Pulse dura]on 8 mm spot 8 mm spot Skin Type Fine Hair Medium Hair Coarse Hair I 3 msec 3 msec 3 msec II 3 msec 3 msec 5 msec III 3 msec 3 msec 5 msec IV 3 msec 3 msec 5 msec

46 Laser Hair Removal Pulse dura]on 8 mm spot Why change the pulse dura]on with coarse hair? The thermal relaxa]on ]me of thicker hairs is higher so I prefer longer pulses to more fully distribute the heat With Type I skin, there is usually not as much pigment in the coarse hairs so I do not increase the pulse dura]on

47 Laser Hair Removal Parameters Use the 8 mm spot on upper lips and ears

48 8 mm spot 3 msec 26 J/cm2 DCD 40/30 4 Tx s

49 8 mm spot 3 msec 20 J/cm 2 DCD 40/30 5 Tx s

50 Laser Hair Removal Parameters The spot size is dependent on the area to treat I seldom use the 10 mm spot

51 Laser Hair Removal Parameters The spot size is dependent on the area to treat Use the 12 mm spot on chin, neck

52 Laser Hair Removal Fluence 12 mm spot The fluence range of the 12 mm spot is J/cm 2

53 Laser Hair Removal Fluence 12 mm spot 12 mm spot Skin Type Fine Hair Medium Hair Coarse Hair I 32 J/cm 2 30 J/cm 2 28 J/cm 2 II 30 J/cm 2 28 J/cm 2 26 J/cm 2 III 22 J/cm 2 20 J/cm 2 18 J/cm 2 IV 18 J/cm 2 16 J/cm 2 14 J/cm 2

54 Pulse dura]on 12 mm spot 12 mm spot Skin Type Fine Hair Medium Hair Coarse Hair I 3 msec 3 msec 3 msec II 3 msec 3 msec 5 msec III 3 msec 3 msec 5 msec IV 3 msec 3 msec 5 msec

55 Laser Hair Removal Parameters The spot size is dependent on the area to treat Use the 12 mm spot on chin, neck

56 12 mm spot 3 msec 28 J/cm 2 DCD 40/30 4 Tx s

57 12 mm spot 3 msec 26 J/cm 2 DCD 40/30 4 Tx s

58 Laser Hair Removal Parameters The spot size is dependent on the area to treat Use the 15 mm spot on the face and underarms

59 Laser Hair Removal Fluence 15 mm spot The fluence range of the 15 mm spot is 7 30 J/cm 2

60 Laser Hair Removal Fluence 15 mm spot 15 mm spot Skin Type Fine Hair Medium Hair Coarse Hair I 26 J/cm 2 24 J/cm 2 22 J/cm 2 II 24 J/cm 2 22 J/cm 2 20 J/cm 2 III 20 J/cm 2 18 J/cm 2 16 J/cm 2 IV 14 J/cm 2 12 J/cm 2 10 J/cm 2

61 Laser Hair Removal Pulse dura]on 15 mm spot 15 mm spot Skin Type Fine Hair Medium Hair Coarse Hair I 3 msec 3 msec 3 msec II 3 msec 3 msec 5 msec III 3 msec 3 msec 5 msec IV 3 msec 3 msec 5 msec

62 15 mm spot 5 msec 10 J/cm2 DCD 40/30 6 Tx s

63 15 mm spot 3 msec 22 J/cm2 DCD 40/30 4 Tx s

64 Laser Hair Removal Parameters The spot size is dependent on the area to treat Use the 18 mm spot on legs, back

65 Laser Hair Removal Fluence 18 mm spot The fluence range of the 18 mm spot is 6 20 J/cm 2

66 Laser Hair Removal Fluence 18 mm spot 18 mm spot Skin Type Fine Hair Medium Hair Coarse Hair I 18J/cm 2 16 J/cm 2 14 J/cm 2 II 16 J/cm 2 14 J/cm 2 12 J/cm 2 III 14 J/cm 2 12 J/cm 2 10 J/cm 2 IV 12 J/cm 2 10 J/cm 2 8 J/cm 2

67 Laser Hair Removal Pulse dura]on 18 mm spot 18 mm spot Skin Type Fine Hair Medium Hair Coarse Hair I 3 msec 3 msec 3 msec II 3 msec 3 msec 5 msec III 3 msec 3 msec 5 msec IV 3 msec 3 msec 5 msec

68 18 mm spot 3 msec 12 J/cm 2 DCD 40/30 6 Tx s

69 18 mm spot 3 msec 12 J/cm 2 DCD 40/30 6 Tx s

70 I was asked about trea]ng Becker s Nevus with GentleLase Pro

71 Becker s Nevus is an acquired pigmenta]on of the upper body Aˆer some ]me, thick hairs will appear

72

73 There is an ar]cle discussing the treatment of this condi]on with long- pulsed alexandrite laser

74 15 18 mm spot 3 msec J/cm 2 DCD off 2/11 Excellent results 5/11 Good results 4/11 Fair results Hair improved in all

75 What are the poten]al issues with hair removal?

76 Paradoxical hair growth following laser treatment

77 There is one study documen]ng paradoxical hair growth aˆer laser treatment Most pa]ents had darker skin This phenomenon is more common in women

78

79

80

81 Most cases had lower than average fluences Some feel there may be slight hea]ng at the edges of the treatment area

82 The recommenda]on to avoid paradoxical hair growth is to make sure to use high enough energy It may be useful to make two passes to insure adequate hea]ng It may be useful to place cool packs over the peripheral areas

83 Laser hair removal during pregnancy

84 Pregnancy increases several hormones that can increase hair growth These hormones may also have the poten]al to increase paradoxical hair growth

85 The recommenda]on is to not perform laser hair removal during pregnancy

86 Prolonged redness from too much energy

87

88 The recommenda]on is to do a test spot and look for any blister, darkening of the skin or any unusual reac]on

89 Prolonged redness from too much cryogen

90

91 The recommenda]on is to watch as you are performing the treatment. If the cryogen is not working or misaligned, you should be able to see the reac]on

92 Can you get a Koebner phenomenon with laser hair removal?

93 The Koebner phenomenon is a worsening of a skin condi]on following trauma

94 The common condi]ons that Koebnerize include psoriasis and vi]ligo

95 Flare of psoriasis aˆer sunburn

96 Pa]ents with psoriasis can poten]ally get a Koebner phenomenon if the skin is burned in any way The solu]on would be to use adequate DCD to protect the epidermis

97 Scarring

98

99

100 Most scarring is caused by inappropriate sešngs or too much tan Talk to the pa]ent, ask about recent tanning Always look at the first few pulses, they will let you know if the sešngs are wrong

101 Most of these complica]ons may be avoided by careful a en]on to fluences, cryogen and making sure pa]ents are not tanned

102 Are there any ques]ons?

103 Thank You

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