Pigmentation Disorders

Psychological distress from dyspigmentation in skin of color is highly prevalent. Disorders of pigmentation such as vitiligo have a significant impact on a patient’s quality of life. Similarly, in skin of color patients, melasma, acne scars, and post-inflammatory hypo- and hyperpigmentation are often hard to treat.

Skin camouflage is a great way to help patients overcome the distress of their pigmentary disorders. However, I have found in my practice that patients under use these masking products.

Once they are on board, remind patients that there is a big difference between over-the-counter corrective makeup and skin camouflage products. For instance, skin camouflage products are designed to last 8-16 hours and are significantly water resistant. They are also more durable, blend better with natural skin tone, and last longer than OTC corrective makeup.

The products are applied by blending a fine layer of camouflage cream followed by a setting powder.Standard makeup and sunscreen can then be applied over the camouflage products.

Choosing the right brand can be confusing to patients. Several lines of products can be bought at department stores and through mail order. And each brand varies in texture, durability, coverage, sun protection, and color.

In the U.S. many department stores carry skin camouflage brands. Although these products reside in the "cosmetic" section, they are not referred to as makeup, so as not to create distress for patients who do not normally wear cosmetics.

In my experience Dermablend, Covermark, and Dermacolor work well. However, there are several other brands available to experiment with.

I encourage my patients with dyspigmentation to look into these well-developed camouflage products. Often times I encourage testing of the product on their skin by an experienced company representative.

Understanding the art of skin camouflage can help many of our patients cover their skin imperfections and regain their self-confidence.

-Lily Talakoub, M.D.

Psychological distress from dyspigmentation in skin of color is highly prevalent. Disorders of pigmentation such as vitiligo have a significant impact on a patient’s quality of life. Similarly, in skin of color patients, melasma, acne scars, and post-inflammatory hypo- and hyperpigmentation are often hard to treat.

Skin camouflage is a great way to help patients overcome the distress of their pigmentary disorders. However, I have found in my practice that patients under use these masking products.

Once they are on board, remind patients that there is a big difference between over-the-counter corrective makeup and skin camouflage products. For instance, skin camouflage products are designed to last 8-16 hours and are significantly water resistant. They are also more durable, blend better with natural skin tone, and last longer than OTC corrective makeup.

The products are applied by blending a fine layer of camouflage cream followed by a setting powder.Standard makeup and sunscreen can then be applied over the camouflage products.

Choosing the right brand can be confusing to patients. Several lines of products can be bought at department stores and through mail order. And each brand varies in texture, durability, coverage, sun protection, and color.

In the U.S. many department stores carry skin camouflage brands. Although these products reside in the "cosmetic" section, they are not referred to as makeup, so as not to create distress for patients who do not normally wear cosmetics.

In my experience Dermablend, Covermark, and Dermacolor work well. However, there are several other brands available to experiment with.

I encourage my patients with dyspigmentation to look into these well-developed camouflage products. Often times I encourage testing of the product on their skin by an experienced company representative.

Understanding the art of skin camouflage can help many of our patients cover their skin imperfections and regain their self-confidence.

-Lily Talakoub, M.D.

Psychological distress from dyspigmentation in skin of color is highly prevalent. Disorders of pigmentation such as vitiligo have a significant impact on a patient’s quality of life. Similarly, in skin of color patients, melasma, acne scars, and post-inflammatory hypo- and hyperpigmentation are often hard to treat.

Skin camouflage is a great way to help patients overcome the distress of their pigmentary disorders. However, I have found in my practice that patients under use these masking products.

Once they are on board, remind patients that there is a big difference between over-the-counter corrective makeup and skin camouflage products. For instance, skin camouflage products are designed to last 8-16 hours and are significantly water resistant. They are also more durable, blend better with natural skin tone, and last longer than OTC corrective makeup.

The products are applied by blending a fine layer of camouflage cream followed by a setting powder.Standard makeup and sunscreen can then be applied over the camouflage products.

Choosing the right brand can be confusing to patients. Several lines of products can be bought at department stores and through mail order. And each brand varies in texture, durability, coverage, sun protection, and color.

In the U.S. many department stores carry skin camouflage brands. Although these products reside in the "cosmetic" section, they are not referred to as makeup, so as not to create distress for patients who do not normally wear cosmetics.

In my experience Dermablend, Covermark, and Dermacolor work well. However, there are several other brands available to experiment with.

I encourage my patients with dyspigmentation to look into these well-developed camouflage products. Often times I encourage testing of the product on their skin by an experienced company representative.

Understanding the art of skin camouflage can help many of our patients cover their skin imperfections and regain their self-confidence.

-Lily Talakoub, M.D.

For those of you who have had a busy year and haven't had the chance to regularly read the latest dermatology news on Skin and Allergy News Digital Network, we have you covered. As we ring in the new year, here's a rundown of last year's most-viewed stories:

10. Experts: Medical Dermatology Is Losing Ground, By Bruce Jancin: Experts in medical dermatology predicted the specialty will become narrower and less medically oriented by 2020. As we enter 2012, some experts said they were concerned about the emphasis on aesthetic dermatology and dermatologic surgery. 

Courtesy flickr user woodleywonderworks (Creative Commons)

9. Mohs Surgery in Medicare Patients Skyrocketing, By Sherry Boschert: Several Mohs surgery experts found that the rate of Mohs surgery per 1,000 Medicare beneficiaries increased by 236% between 1999 and 2009. Dr. Matthew Donaldson and his associates presented the data at the annual meeting of the American College of Mohs Surgery. 

8. Blog: New Isotretinoin Drug May Address Safety Concerns, By Amy Pfeiffer: This much-viewed blog post highlighted an investigational isotretinoin drug that may eliminate safety concerns associated with the drug, like IBD and depression. The gelatin capsules of CIP-iisotretinoin help reduce GI irritation and the drug is less food dependent.

7. Dosing Isotretinoin: Go Big to Avoid Second Course, By Jeffrey Eisenberg: In another isotretinoin study, investigators found that patients receiving a higher cumulative dose of the drug were no less likely to experience an acne relapse than those who received a lower cumulative dose. However, the investigators found that patients treated with a higher dose were less likely to need a second course of treatment. 

6. Knifelike Vulvar Ulcers May Signal Crohn's Disease, By Kate Johnson: Knifelike vulvar ulcers could be a sign of Crohn's disease in women, according to experts at a conference on vulvovaginal diseases. For some patients, ulcers may be the only manifestation of the disorder. 

5. Biologics Up Cardiovascular Risk, New Analysis Finds, By Sherry Boschert: Biologic therapies used to treat psoriasis have been linked to an increase in major cardiovascular events, according to researchers. One patient on placebo developed a major cardiovascular event in a study of etanercept. Five patients on ustekinumab, five on briakinumab, and one on adalimumab also developed major cardiovascular events.

4. Future Technologies Hold Promise for Hair Restoration, By Damian McNamara: At an annual meeting of dermatologic surgeons, Dr. Ricardo Mejia discussed technological advancements in hair restoration. He said the future for hair restoration could include technologies like robotic hair transfer, hair cloning, and technologies to optimize new growth. 

3. AAD: Potential Doxycycline, IBD Link Considered Worrisome, By Bruce Jancin: In more acne news, a retrospective cohort study linked tetracycline-class antibiotics with an increase in inflammatory bowel disease. The highly controversial findings were one of the hottest topics at the annual meeting of the American Academy of Dermatology and on this website.

2. Bimatoprost Repigments Vitiligo Patient Skin, By Bruce Jancin: A topical bimatoprost ophthalmic solution could serve as treatment for focal vitiligo, according to a pilot study presented at the World Congress of Dermatology. Researchers said 7 out of 10 patients exhibited pronounced repigmentation after 2 months of treatment. 

1. Marijuana Allergies "Fairly Common," Expert Says, By M. Alexander Otto: A heads up to physicians: allergy experts said marijuana allergies are more common than most people think. Patients with with a marijuana allergy exhibit symptoms including wheezing, sinusitis, throat swelling, and inhalation issues. 

Best wishes for 2012!

-- Frances Correa (FMCReporting)

For those of you who have had a busy year and haven't had the chance to regularly read the latest dermatology news on Skin and Allergy News Digital Network, we have you covered. As we ring in the new year, here's a rundown of last year's most-viewed stories:

10. Experts: Medical Dermatology Is Losing Ground, By Bruce Jancin: Experts in medical dermatology predicted the specialty will become narrower and less medically oriented by 2020. As we enter 2012, some experts said they were concerned about the emphasis on aesthetic dermatology and dermatologic surgery. 

Courtesy flickr user woodleywonderworks (Creative Commons)

9. Mohs Surgery in Medicare Patients Skyrocketing, By Sherry Boschert: Several Mohs surgery experts found that the rate of Mohs surgery per 1,000 Medicare beneficiaries increased by 236% between 1999 and 2009. Dr. Matthew Donaldson and his associates presented the data at the annual meeting of the American College of Mohs Surgery. 

8. Blog: New Isotretinoin Drug May Address Safety Concerns, By Amy Pfeiffer: This much-viewed blog post highlighted an investigational isotretinoin drug that may eliminate safety concerns associated with the drug, like IBD and depression. The gelatin capsules of CIP-iisotretinoin help reduce GI irritation and the drug is less food dependent.

7. Dosing Isotretinoin: Go Big to Avoid Second Course, By Jeffrey Eisenberg: In another isotretinoin study, investigators found that patients receiving a higher cumulative dose of the drug were no less likely to experience an acne relapse than those who received a lower cumulative dose. However, the investigators found that patients treated with a higher dose were less likely to need a second course of treatment. 

6. Knifelike Vulvar Ulcers May Signal Crohn's Disease, By Kate Johnson: Knifelike vulvar ulcers could be a sign of Crohn's disease in women, according to experts at a conference on vulvovaginal diseases. For some patients, ulcers may be the only manifestation of the disorder. 

5. Biologics Up Cardiovascular Risk, New Analysis Finds, By Sherry Boschert: Biologic therapies used to treat psoriasis have been linked to an increase in major cardiovascular events, according to researchers. One patient on placebo developed a major cardiovascular event in a study of etanercept. Five patients on ustekinumab, five on briakinumab, and one on adalimumab also developed major cardiovascular events.

4. Future Technologies Hold Promise for Hair Restoration, By Damian McNamara: At an annual meeting of dermatologic surgeons, Dr. Ricardo Mejia discussed technological advancements in hair restoration. He said the future for hair restoration could include technologies like robotic hair transfer, hair cloning, and technologies to optimize new growth. 

3. AAD: Potential Doxycycline, IBD Link Considered Worrisome, By Bruce Jancin: In more acne news, a retrospective cohort study linked tetracycline-class antibiotics with an increase in inflammatory bowel disease. The highly controversial findings were one of the hottest topics at the annual meeting of the American Academy of Dermatology and on this website.

2. Bimatoprost Repigments Vitiligo Patient Skin, By Bruce Jancin: A topical bimatoprost ophthalmic solution could serve as treatment for focal vitiligo, according to a pilot study presented at the World Congress of Dermatology. Researchers said 7 out of 10 patients exhibited pronounced repigmentation after 2 months of treatment. 

1. Marijuana Allergies "Fairly Common," Expert Says, By M. Alexander Otto: A heads up to physicians: allergy experts said marijuana allergies are more common than most people think. Patients with with a marijuana allergy exhibit symptoms including wheezing, sinusitis, throat swelling, and inhalation issues. 

Best wishes for 2012!

-- Frances Correa (FMCReporting)

For those of you who have had a busy year and haven't had the chance to regularly read the latest dermatology news on Skin and Allergy News Digital Network, we have you covered. As we ring in the new year, here's a rundown of last year's most-viewed stories:

10. Experts: Medical Dermatology Is Losing Ground, By Bruce Jancin: Experts in medical dermatology predicted the specialty will become narrower and less medically oriented by 2020. As we enter 2012, some experts said they were concerned about the emphasis on aesthetic dermatology and dermatologic surgery. 

Courtesy flickr user woodleywonderworks (Creative Commons)

9. Mohs Surgery in Medicare Patients Skyrocketing, By Sherry Boschert: Several Mohs surgery experts found that the rate of Mohs surgery per 1,000 Medicare beneficiaries increased by 236% between 1999 and 2009. Dr. Matthew Donaldson and his associates presented the data at the annual meeting of the American College of Mohs Surgery. 

8. Blog: New Isotretinoin Drug May Address Safety Concerns, By Amy Pfeiffer: This much-viewed blog post highlighted an investigational isotretinoin drug that may eliminate safety concerns associated with the drug, like IBD and depression. The gelatin capsules of CIP-iisotretinoin help reduce GI irritation and the drug is less food dependent.

7. Dosing Isotretinoin: Go Big to Avoid Second Course, By Jeffrey Eisenberg: In another isotretinoin study, investigators found that patients receiving a higher cumulative dose of the drug were no less likely to experience an acne relapse than those who received a lower cumulative dose. However, the investigators found that patients treated with a higher dose were less likely to need a second course of treatment. 

6. Knifelike Vulvar Ulcers May Signal Crohn's Disease, By Kate Johnson: Knifelike vulvar ulcers could be a sign of Crohn's disease in women, according to experts at a conference on vulvovaginal diseases. For some patients, ulcers may be the only manifestation of the disorder. 

5. Biologics Up Cardiovascular Risk, New Analysis Finds, By Sherry Boschert: Biologic therapies used to treat psoriasis have been linked to an increase in major cardiovascular events, according to researchers. One patient on placebo developed a major cardiovascular event in a study of etanercept. Five patients on ustekinumab, five on briakinumab, and one on adalimumab also developed major cardiovascular events.

4. Future Technologies Hold Promise for Hair Restoration, By Damian McNamara: At an annual meeting of dermatologic surgeons, Dr. Ricardo Mejia discussed technological advancements in hair restoration. He said the future for hair restoration could include technologies like robotic hair transfer, hair cloning, and technologies to optimize new growth. 

3. AAD: Potential Doxycycline, IBD Link Considered Worrisome, By Bruce Jancin: In more acne news, a retrospective cohort study linked tetracycline-class antibiotics with an increase in inflammatory bowel disease. The highly controversial findings were one of the hottest topics at the annual meeting of the American Academy of Dermatology and on this website.

2. Bimatoprost Repigments Vitiligo Patient Skin, By Bruce Jancin: A topical bimatoprost ophthalmic solution could serve as treatment for focal vitiligo, according to a pilot study presented at the World Congress of Dermatology. Researchers said 7 out of 10 patients exhibited pronounced repigmentation after 2 months of treatment. 

1. Marijuana Allergies "Fairly Common," Expert Says, By M. Alexander Otto: A heads up to physicians: allergy experts said marijuana allergies are more common than most people think. Patients with with a marijuana allergy exhibit symptoms including wheezing, sinusitis, throat swelling, and inhalation issues. 

Best wishes for 2012!

-- Frances Correa (FMCReporting)

Zain U. Syed, MD, and Iltefat H. Hamzavi, MD

Phototherapy has proven to be one of the most versatile and effective treatment options for a variety of inflammatory and pigmentary skin diseases. However, the use of these treatment modalities in patients of color requires some special considerations. The modality chosen, the dosing of the treatment and duration of treatment are all issues to be considered for patients of color treated with ultraviolet phototherapy. In addition, there are some diseases which are more commonly seen in patients of color. These diseases may have better treatment outcomes using newer phototherapeutic options such as the long pulsed Nd:YAG laser or UVA1. As our population in the United States becomes more diverse it would behoove all dermatologists to acquaint themselves with the special circumstances of treating ethnic patients with phototherapy.

*For a PDF of the full article, click on the link to the left of this introduction.

Zain U. Syed, MD, and Iltefat H. Hamzavi, MD

Phototherapy has proven to be one of the most versatile and effective treatment options for a variety of inflammatory and pigmentary skin diseases. However, the use of these treatment modalities in patients of color requires some special considerations. The modality chosen, the dosing of the treatment and duration of treatment are all issues to be considered for patients of color treated with ultraviolet phototherapy. In addition, there are some diseases which are more commonly seen in patients of color. These diseases may have better treatment outcomes using newer phototherapeutic options such as the long pulsed Nd:YAG laser or UVA1. As our population in the United States becomes more diverse it would behoove all dermatologists to acquaint themselves with the special circumstances of treating ethnic patients with phototherapy.

*For a PDF of the full article, click on the link to the left of this introduction.

Zain U. Syed, MD, and Iltefat H. Hamzavi, MD

Phototherapy has proven to be one of the most versatile and effective treatment options for a variety of inflammatory and pigmentary skin diseases. However, the use of these treatment modalities in patients of color requires some special considerations. The modality chosen, the dosing of the treatment and duration of treatment are all issues to be considered for patients of color treated with ultraviolet phototherapy. In addition, there are some diseases which are more commonly seen in patients of color. These diseases may have better treatment outcomes using newer phototherapeutic options such as the long pulsed Nd:YAG laser or UVA1. As our population in the United States becomes more diverse it would behoove all dermatologists to acquaint themselves with the special circumstances of treating ethnic patients with phototherapy.

*For a PDF of the full article, click on the link to the left of this introduction.

In the November issue of Journal of Drugs in Dermatology (2011;10:1235-9), Dr. Eliot F. Battle Jr., gives an excellent review of "Advances in Laser Hair Removal in Skin of Color."

Dr. Battle summarizes that "Laser hair removal, previously contraindicated in patients with ethnically dark (phototypes IV-VI) or sun-tanned skin, is now recognized as a safe and effective method of permanent hair reduction in all patients. Longer wavelengths, conservative fluences, longer pulse durations and appropriate cooling methods are necessary to minimize untoward side effects and maximize efficacy. The longer wavelength Nd:YAG laser is considered safest in treating darker skin of color. An added benefit of laser epilation is that side effects of conventional hair removal such as pseudo-folliculitis barbae and post inflammatory dyspigmentation, more commonly seen in skin of color, may also respond favorably to the laser, thus increasing the potential for patient satisfaction."

The mechanism of laser hair reduction (LHR) is based on the theory of selective photothermolysis, whereby thermal injury to a desired chromophore can be achieved with the appropriate wavelength, pulse duration, and fluence.

In LHR, the target chromophore is the pigment in the hair follicle and bulb. However, Dr. Battle notes that destruction of the non-pigmented progenitor stem cells is also required to achieve permanent hair reduction. Therefore, a modified theory of selective photothermolysis has been proposed for the mechanism of LHR where appropriate wavelengths, as well as longer pulse durations, must be used to allow heat to effectively destroy the melanocytic hair follicle and bulb, as well as the amelanotic hair follicle and stem cell. 

In darker skin types, longer wavelength lasers must be used to bypass absorption of epidermal pigment to prevent untoward side effects of dyspigmentation.

Currently the 810-nm diode and 1064-nm Nd:YAG lasers are Food and Drug Administration approved for skin types IV-VI. The Nd:YAG is inherently the safer of the two devices because of the longer wavelength; however,  long pulse durations with the diode laser with appropriate cooling have been shown to increase its safety profile.

Epidermal damage from lasers occurs when the epidermal temperature equals or exceeds 45 degrees Celsius, thus appropriate cooling mechanisms are essential for safe and effective LHR. Excessive cooling, however, can lead to dyspigmentation in darker skin.

Initiating LHR in darker skin should be done conservatively with longer wavelengths, lower fluences, and longer pulse durations. If test spots are performed, it is recommended to wait 48 hours before proceeding with therapy as patients with darker skin may manifest delayed dyspigmentation.

Patients with skin types IV-VI may also be at increased risk for paradoxical hypertrichosis. While it has been reported in most ethnic origins, those of Mediterranean and Pacific Asian descent may be particularly affected. Paradoxical hypertrichosis mainly occurs on the face and neck, and has been reported both within and outside the treatment area. While the exact cause is unknown, possible causes include the effect of inflammatory mediators and subtherapeutic thermal injury causing induction of the hair cycle. Current treatment for paradoxical hypertrichosis is laser therapy of the affected area.

The only contraindications for LHR are gold therapy and St. John’s Wort, which should be discontinued for 3 months prior to therapy. While not contraindicated, LHR is not recommended in pregnant women. 

There is no evidence supporting increased LHR side effects in patients recently receiving Accutane; however, until there is more data, it is recommended to wait 3 months after discontinuing Accutane before initiating LHR. Anti-viral prophylaxis may be taken 2-3 days prior to LHR and for 5-7 days after treatment for patients with a history of recurrent herpetic infections in the treatment area.

With each treatment, patients may expect a 10%-20% decrease in hair count, color, and diameter of the hair. In patients of darker color, a minimum of eight treatments may be required to achieve results, with treatments typically scheduled 4-8 weeks apart. 

Dr. Battle also noted that LHR not only treats unwanted hair, but also effectively diminishes inflammation and dyspigmentation from pseudofolliculitis barbae and acne keloidalis nuchae, as these conditions are due to ingrown and/or tufted coarse curled hairs in darker skin types.

In the November issue of Journal of Drugs in Dermatology (2011;10:1235-9), Dr. Eliot F. Battle Jr., gives an excellent review of "Advances in Laser Hair Removal in Skin of Color."

Dr. Battle summarizes that "Laser hair removal, previously contraindicated in patients with ethnically dark (phototypes IV-VI) or sun-tanned skin, is now recognized as a safe and effective method of permanent hair reduction in all patients. Longer wavelengths, conservative fluences, longer pulse durations and appropriate cooling methods are necessary to minimize untoward side effects and maximize efficacy. The longer wavelength Nd:YAG laser is considered safest in treating darker skin of color. An added benefit of laser epilation is that side effects of conventional hair removal such as pseudo-folliculitis barbae and post inflammatory dyspigmentation, more commonly seen in skin of color, may also respond favorably to the laser, thus increasing the potential for patient satisfaction."

The mechanism of laser hair reduction (LHR) is based on the theory of selective photothermolysis, whereby thermal injury to a desired chromophore can be achieved with the appropriate wavelength, pulse duration, and fluence.

In LHR, the target chromophore is the pigment in the hair follicle and bulb. However, Dr. Battle notes that destruction of the non-pigmented progenitor stem cells is also required to achieve permanent hair reduction. Therefore, a modified theory of selective photothermolysis has been proposed for the mechanism of LHR where appropriate wavelengths, as well as longer pulse durations, must be used to allow heat to effectively destroy the melanocytic hair follicle and bulb, as well as the amelanotic hair follicle and stem cell. 

In darker skin types, longer wavelength lasers must be used to bypass absorption of epidermal pigment to prevent untoward side effects of dyspigmentation.

Currently the 810-nm diode and 1064-nm Nd:YAG lasers are Food and Drug Administration approved for skin types IV-VI. The Nd:YAG is inherently the safer of the two devices because of the longer wavelength; however,  long pulse durations with the diode laser with appropriate cooling have been shown to increase its safety profile.

Epidermal damage from lasers occurs when the epidermal temperature equals or exceeds 45 degrees Celsius, thus appropriate cooling mechanisms are essential for safe and effective LHR. Excessive cooling, however, can lead to dyspigmentation in darker skin.

Initiating LHR in darker skin should be done conservatively with longer wavelengths, lower fluences, and longer pulse durations. If test spots are performed, it is recommended to wait 48 hours before proceeding with therapy as patients with darker skin may manifest delayed dyspigmentation.

Patients with skin types IV-VI may also be at increased risk for paradoxical hypertrichosis. While it has been reported in most ethnic origins, those of Mediterranean and Pacific Asian descent may be particularly affected. Paradoxical hypertrichosis mainly occurs on the face and neck, and has been reported both within and outside the treatment area. While the exact cause is unknown, possible causes include the effect of inflammatory mediators and subtherapeutic thermal injury causing induction of the hair cycle. Current treatment for paradoxical hypertrichosis is laser therapy of the affected area.

The only contraindications for LHR are gold therapy and St. John’s Wort, which should be discontinued for 3 months prior to therapy. While not contraindicated, LHR is not recommended in pregnant women. 

There is no evidence supporting increased LHR side effects in patients recently receiving Accutane; however, until there is more data, it is recommended to wait 3 months after discontinuing Accutane before initiating LHR. Anti-viral prophylaxis may be taken 2-3 days prior to LHR and for 5-7 days after treatment for patients with a history of recurrent herpetic infections in the treatment area.

With each treatment, patients may expect a 10%-20% decrease in hair count, color, and diameter of the hair. In patients of darker color, a minimum of eight treatments may be required to achieve results, with treatments typically scheduled 4-8 weeks apart. 

Dr. Battle also noted that LHR not only treats unwanted hair, but also effectively diminishes inflammation and dyspigmentation from pseudofolliculitis barbae and acne keloidalis nuchae, as these conditions are due to ingrown and/or tufted coarse curled hairs in darker skin types.

In the November issue of Journal of Drugs in Dermatology (2011;10:1235-9), Dr. Eliot F. Battle Jr., gives an excellent review of "Advances in Laser Hair Removal in Skin of Color."

Dr. Battle summarizes that "Laser hair removal, previously contraindicated in patients with ethnically dark (phototypes IV-VI) or sun-tanned skin, is now recognized as a safe and effective method of permanent hair reduction in all patients. Longer wavelengths, conservative fluences, longer pulse durations and appropriate cooling methods are necessary to minimize untoward side effects and maximize efficacy. The longer wavelength Nd:YAG laser is considered safest in treating darker skin of color. An added benefit of laser epilation is that side effects of conventional hair removal such as pseudo-folliculitis barbae and post inflammatory dyspigmentation, more commonly seen in skin of color, may also respond favorably to the laser, thus increasing the potential for patient satisfaction."

The mechanism of laser hair reduction (LHR) is based on the theory of selective photothermolysis, whereby thermal injury to a desired chromophore can be achieved with the appropriate wavelength, pulse duration, and fluence.

In LHR, the target chromophore is the pigment in the hair follicle and bulb. However, Dr. Battle notes that destruction of the non-pigmented progenitor stem cells is also required to achieve permanent hair reduction. Therefore, a modified theory of selective photothermolysis has been proposed for the mechanism of LHR where appropriate wavelengths, as well as longer pulse durations, must be used to allow heat to effectively destroy the melanocytic hair follicle and bulb, as well as the amelanotic hair follicle and stem cell. 

In darker skin types, longer wavelength lasers must be used to bypass absorption of epidermal pigment to prevent untoward side effects of dyspigmentation.

Currently the 810-nm diode and 1064-nm Nd:YAG lasers are Food and Drug Administration approved for skin types IV-VI. The Nd:YAG is inherently the safer of the two devices because of the longer wavelength; however,  long pulse durations with the diode laser with appropriate cooling have been shown to increase its safety profile.

Epidermal damage from lasers occurs when the epidermal temperature equals or exceeds 45 degrees Celsius, thus appropriate cooling mechanisms are essential for safe and effective LHR. Excessive cooling, however, can lead to dyspigmentation in darker skin.

Initiating LHR in darker skin should be done conservatively with longer wavelengths, lower fluences, and longer pulse durations. If test spots are performed, it is recommended to wait 48 hours before proceeding with therapy as patients with darker skin may manifest delayed dyspigmentation.

Patients with skin types IV-VI may also be at increased risk for paradoxical hypertrichosis. While it has been reported in most ethnic origins, those of Mediterranean and Pacific Asian descent may be particularly affected. Paradoxical hypertrichosis mainly occurs on the face and neck, and has been reported both within and outside the treatment area. While the exact cause is unknown, possible causes include the effect of inflammatory mediators and subtherapeutic thermal injury causing induction of the hair cycle. Current treatment for paradoxical hypertrichosis is laser therapy of the affected area.

The only contraindications for LHR are gold therapy and St. John’s Wort, which should be discontinued for 3 months prior to therapy. While not contraindicated, LHR is not recommended in pregnant women. 

There is no evidence supporting increased LHR side effects in patients recently receiving Accutane; however, until there is more data, it is recommended to wait 3 months after discontinuing Accutane before initiating LHR. Anti-viral prophylaxis may be taken 2-3 days prior to LHR and for 5-7 days after treatment for patients with a history of recurrent herpetic infections in the treatment area.

With each treatment, patients may expect a 10%-20% decrease in hair count, color, and diameter of the hair. In patients of darker color, a minimum of eight treatments may be required to achieve results, with treatments typically scheduled 4-8 weeks apart. 

Dr. Battle also noted that LHR not only treats unwanted hair, but also effectively diminishes inflammation and dyspigmentation from pseudofolliculitis barbae and acne keloidalis nuchae, as these conditions are due to ingrown and/or tufted coarse curled hairs in darker skin types.