Best Practices and Evidenced-Based Use of the 800 nm Diode Laser for the Treatment of Pseudofolliculitis Barbae in Skin of Color

By Jason J. Emer MD

INTRODUCTION
Pseudofolliculitis barbae (PFB) is a common, irritating skin condition that manifests as inflammation around hair follicles after shaving and often with associated keloidal papules/nodules resulting from ingrown follicles. Patients of all skin types many present to the dermatologist with a complaint of ingrown facial hairs and/or irritation after shaving, but the problem is more commonly seen in males with darker skin types with thick, curly hair. While many treatment options exist, such as 1) allowing the beard to grow out completely; 2) shaving technique changes (direction of shave, warm compresses/steam heat to soften hair prior to shaving, single versus multiple blade razors, shaving oils); 3) treatment with topical keratolytics, antibacterials, or retinoids; 4) chemical peels; or 5) the use of oral antibiotics with anti-inflammatory affects; the most effective, permanent measure in stubborn cases is laser hair removal1 (Figure 1a-c).

Several lasers have been shown to be effective in hair reduction, such as the ruby (694 nm), alexandrite (755 nm), diode (800 nm), and long-pulsed Nd:Yag (1,064 nm).2,3 The hair removal lasers work by selective photothermolysis of follicular melanin (chromophore) located near stem cells in the bulge of the hair follicle.4 In order to be most effective, the laser energy must be absorbed primarily by the follicle, with limited influence on the surrounding tissues. Despite recent advances, post-inflammatory dyspigmentation, burns and scarring are of real concern in patients with skin of color (Fitzpatrick IV–VI), although the Nd:Yag and the diode lasers have been shown to be safe.5-7 Efficacy is higher with the diode as compared to the Nd:Yag given that the melanin in the hair follicle absorbs 3–4 times more energy at the 800 nm wavelength than at the 1,064 nm.8

The author’s experience with the diode laser with hand piece (cooled convex sapphire lens) for hair removal has shown excellent results, especially with use in patients of color. The newer hair removal lasers have pulse durations that are much longer (100–400 ms) than traditional systems (20–40 ms), allowing darker skin types to be treated with little risk of complications given the appropriate settings. Longer pulse durations transmit laser energy at slower rates, allowing a maximum temperature rise of the hair follicle with minimum energy dispersion to the surrounding tissues. Under the right parameters, a planned treatment course, sun avoidance and protection, and pretreatment with a topical skin care regimen, results are extremely satisfying to patients. Traditional settings employ high-powered, low pulse durations (25-35 J/cm2, 2 Hz, 10–30 ms) in a single-pass, although new studies have documented success with few side effects from low-powered, high pulse duration (5-15 J/cm2, 2 Hz, 100–400 ms) in single or multiple-pass pulses.9,10 Multiple-pass or “stacking” of the laser energy into the hair blub is thought to cause more destruction with less energy dispersed to surrounding tissue (given delivery is equal to or less than the thermal relaxation time of the skin or the threshold of burn). Since sensation/pain is directly related to fluence, pain may also be decreased by this new paradigm, although topical numbing creams 30–60 minutes prior to treatment and/or icepacks can limit pain during treatment.

SETTINGS AND METHODS
For best results in patients of color, follow this protocol for the safest and most effective treatment:
• Treat the folliculitis. Have the patient employ new shaving techniques or allow the beard to grow for 30–45 days prior to first hair removal treatment. Add topical antibacterial treatment with a benzoyl peroxide-antibiotic combination daily as well as a glycolic or salicylic acid face wash at least three times weekly.
• Avoid the sun. Sun avoidance and/or daily protection (SPF >30) will aid in preventing any melanogenesis that may interfere with selective photothermolysis of the laser energy.
• Prevent hyperpigmentation. Most notably in darker skin types, add 4% hydroquinone cream at bedtime for at least 4–6 weeks prior to treatment to help prevent post-inflammatory hyperpigmentation and/or treat the existing post-inflammatory hyperpigmentation that often exists in areas of resolved folliculitis.
• Thin the thick, curly hair. Apply a thin film of eflornithine 13.9% cream twice daily to the affected area of the beard 4–6 weeks prior to laser treatment, as hair removal results are more rapid and complete when used in combination with laser.11 It is important to warn patients of cutaneous irritation that may develop. In some patients, facial scrubs or medical devices such as the Clarisonic® Brush (Pacific Bioscience Laboratories Inc., Bellevue, WA) may also help loosen hairs and exfoliate.
• Do not forget the keloids. If possible, prior to laser treatment, keloidal papules/nodules should be lanced with a #11 blade and have the entrapped hair extracted. Larger lesions can be injected with diluted triamcinolone (2.5–5 mg/cc, <0.1 cc injected per site). Treatment of these lesions prevents “arching” of the laser beam (laser tip needs to be directed perpendicular onto a flat skin surface) and prevent vesiculation or burns that may lead to crusts with resultant scars (Figure 2). If an adverse event were to occur, treat as a superficial burn with topical antimicrobials, emollients, and/or emulsion creams.
• Plan the treatment(s) course. The motto “start low and go slow” is best followed with patients of color, given the high risk for cutaneous side effects despite adequate hair removal. Lower fluences (10–15 J/cm2) at longer pulse widths (100–400 ms) in single or multiple-pass pulses will take longer for substantial and sustained reduction in hair density, but will avoid complications. Although it is often taught that perifollicular inflammation and minimal cutaneous erythema is not the ultimate endpoint, good results can still be obtained with conservative settings with minimal irritation.
• Post-treatment skin care. Stress the importance of skin care post treatment with gentle cleansers and the use of low-potency steroid lotions/creams if cutaneous erythema or pain is substantial. Hypopigmentation that may develop is typically transitory and due to a reduced melanogenesis in “stunned” melanocytes, and not due to actual damage to the cells.

DISCLOSURES
The author has no relevant conflicts of interest to disclose.

REFERENCES
1. Bridgeman-Shah S. The medical and surgical therapy of pseudofolliculitis barbae. Dermatol Ther. 2004;17(2):158-163.
2. Liew SH. Laser hair removal: Guidelines for management. Am J Clin Dermatol. 2002;3(2):107-115.
3. Battle EF Jr, Hobbs LM. Laser-assisted hair removal for darker skin types. Dermatol Ther. 2004;17(2):177-183.
4. Choudhary S, Elsaie ML, Nouri K. Laser assisted hair-removal. G Ital Dermatol Venereol. 2009;144(5):595-602.
5. Schulze R, Meehan KJ, Lopez A, Sweeney K, Winstanley D, Apruzzese W, Victor Ross E. Low-fluence 1,064-nm laser hair reduction for pseudofolliculitis barbae in skin types IV, V, and VI. Dermatol Surg. 2009;35(1):98-107.
6. Wanner M. Laser hair removal. Dermatol Ther. 2005;18(3):209-216.
7. Kopera D. Hair reduction: 48 months of experience with 800nm diode laser. J Cosmet Laser Ther. 2003;5(3-4):146-149.
8. Tierney EP, Goldberg DJ. Laser hair removal pearls. J Cosmet Laser Ther. 2008;10(1):17-23.
9. Pai GS, Bhat PS, Mallya H, Gold M. Safety and efficacy of low-fluence, high-repetition rate versus high-fluence, low-repetition rate 810 nm diode laser for permanent hair removal–a split-face comparison study.
J Cosmet Laser Ther. 2011;13(4):134-137.
10. Braun M. Comparison of high-fluence, single-pass diode laser to low-fluence, multiple-pass diode laser for laser hair reduction with 18 months of follow up. J Drugs Dermatol. 2011;10(1):62-65.
11. Hamzavi I, Tan E, Shapiro J, Lui H. A randomized bilateral vehicle-controlled study of eflornithine cream combined with laser treatment versus laser treatment alone for facial hirsutism in women. J Am Acad Dermatol. 2007;57(1):54-59.

About the author

Jason J. Emer MD

Mount Sinai School of Medicine, Department of Dermatology, New York, NY

Comments are closed.