J Cosmet Laser Ther 2004; 6: 27–31# J Cosmet Laser Ther. All rights reserved ISSN 1476-4172DOI: 10.1080/14764170410029022
Effective epilation of white andblond hair using combinedradiofrequency and optical energy
fluences varied from 24 to 30 J/cm2.
of Dermatology, University ofOttawa, Ottawa, Ontario, Canada
the low intensity of target melanin chromophore in hairfollicles exhibiting the aforementioned phenotypes. In this
There has been a continued evolution of photoepilatory
regard, the present study examined the long-term photo-
technology, which has improved the long-term efficacy of
epilatory effect on blond and white hair of a new technology
laser and intense pulsed light (IPL) source hair removal.
which combines an IPL source (680–980 nm), producing
These technologies vary from short wavelength ruby
optical energies as high as 30 J/cm2 with pulse durations up to
(694 nm) and alexandrite (755 nm) sources, which target
120 ms, with a bipolar radiofrequency device, which can
lighter hair/light skin phenotypes, to longer wavelength
generate radiofrequency (RF) energy as high as 20 J/cm3 with
diodes (800–900 nm), IPL sources (500–1200 nm) and
a pulse duration as long as 120 ms designed to deliver RF
1064 nm Nd:YAG technologies for darker hair/dark skin
electrical current at a depth of 4 mm, which can target deep-
lying follicles capable of producing long-term photoepilation.
However, the major refractory hair phenotype targeted by
The theory behind this technology is to deliver a relatively low
these technologies has been red, blond and white hair due to
level of optical energy that is safe for all skin types whilecompensation for the lack of high laser light intensity isachieved by utilizing an additive energy that is not optical and
Correspondence: Neil S Sadick, MD, 772 Park Avenue, New York,
does not require melanin as a target chromophore, but is
NY 10021, USA. Tel: (z1) 212 772 7242; Email: firstname.lastname@example.org
selectively absorbed by the hair structure.
erythema that lasted more than a few minutes after eachpass was completed.
Thirty-six adult women with white and blond facial hair
A baseline hair count was obtained manually by two
(aged 38–83 years; mean age 58 years) and skin phenotypes
independent observers marking terminal hairs under 66
I–V were included in the study (Table 1). Forty-one study
magnification with an apochromatic optical loupe (Nikon)
sites were selected; 36 sites were on the chin and five sites
within a well-defined 3 cm2 region. The following reference
were on the upper lip or moustache area. Twenty-one sites
landmarks were utilized: lip (mid-philtrum), chin (mid-
had blond hair while 20 exhibited white hair.7 Patients
mandibular notch/mid-lower lip vermillion border) in
were screened for endocrine disorders, recent Accutane1
order to achieve uniformity of sequential hair counts.
ingestion, recent sun exposure and scarring tendencies.
Percentage hair reduction was defined as the average
Discontinuance of any epilatory or bleaching agents for 1
number of terminal hairs present at each defined time
month was mandated prior to treatment. Patients with a
interval compared with the average number of terminal
history of previous laser, IPL or electrolysis treatment were
hairs at baseline. Hair counts were taken after each
treatment session, at months 12 (following the last treat-
Informed consent from all participants was obtained and
ment) and 18 (6 months following the last treatment).
the body site to be treated was identified and photo-
Subjective patient reports and adverse effects were also
graphed. No topical anesthetic agent was applied to treated
recorded at each follow-up visit. A patient satisfaction scale
was instituted at the last follow-up visit. The following scale
The study group of patients received four treatment
was utilized: grade I –no improvement; grade II – mild
sessions over a period of 9–12 months and results were
improvement; grade III – good improvement; grade IV –
monitored 18 months after the first treatment or 6 months
The target area was shaved prior to treatment. Sequential
digital photography using identical lighting, patient posi-tioning and camera equipment (Fujifilm FinePix S2 Pro
Digital SLR Camera, Tokyo, Japan) were obtained of alltreatment sites at baseline and 1, 3 and 6 months after the
During the first week after the treatment, no significant
last treatment. A thin layer of transparent gel was used for
hair reduction was observed. Maximum reduction in hair
cooling and skin hydration. Light pressure was applied via
counts was observed at 6–8 weeks after each treatment.
the applicator to the treatment site in order to ensure good
Hair density was decreased from treatment to treatment
coupling of electrodes onto the skin surface. Contact
as noted by both patients and investigators. An average
cooling (x4‡C) was provided via incorporation of a
clearance of 48% was observed at month 18 (6 months
cooling chamber head in the treatment tip.
following the final treatment session) (Figure 1). A slightly
The level of RF energy was set at 20 J/cm3 in all study
higher photoepilatory efficiency was noted for blond hair
patients in a short pulse profile mode. The range of
(52%) versus white hair (44%) treatment sites (Table 2).
fluences used in the study protocol was 24–30 J/cm2,
Upper lip and chin sites had comparable hair removal
depending upon skin phenotype. Test pulses were carried
efficiency. Two patients had minimal response (less than
out on an area adjacent to the study site to determine thelevel of optical energy suitable for each patient. Pulses wereplaced in an adjacent minimally overlapping pattern overthe entire study site. Multiple passes were carried out to amaximum of four passes unless there was persistent
(A) Before combined intense pulsed light (IPL)/radiofrequency (RF)white hair removal; (B) after combined IPL/RF white hair removal
(four treatments; month 18 (6 months following last treatment);
Demographic profile of the IPL/RF study population (36 patients).
optical energy~26 J/cm2; RF energy~20 J/cm3).
diminution of melanocytes is associated with a lower
The results of this study indicate that combined RF and
optical energy is an effective method of photoepilation for
white and blond hair (Figure 2). It is generally acceptedthat white hair is unresponsive to light systems operating in
Mean hair removal efficiency in the IPL/RF study population (four
The thermal damage time (TDT) varies with the
diameter of the hair shaft and follicle, and the temperatureof the hair shaft or matrix.1 For medium to coarse hairs
10% mean hair reduction). These two patients were older
(50–125 microns) the TDT is 170–1000 ms.1,2 The use of
super-elongated pulses should theoretically be a more
A total of 67% of patients graded their improvement as
efficient way to produce pan-trichodestruction.25 This
good or excellent, with the majority noting good or no
mechanism of injury may be advantageous for treating
Side effect profiles noted in this study were minimal.
blond or red hair where optical coupling to lower levels ofblack-brown granules is diminished. Few such technologies
Transient hyperpigmentation requiring no therapy was
with super-long pulses are presently available for clinical
noted in 8% of patients; 14% of patients had mildpersistent erythema, which resolved within 24 hours.
usage. For white hair without pigment for optical coupling,
Results showed no significant dependence on skin color,
even a super-long pulse is likely to be effective.
as lighter and darker skin types responded similarly to
With any pulse width, optical energy targets melanin and
heating of the hair follicle occurs from the inside and
proceeds outwards. In contrast, RF energy heats the hairfollicle from the outside in and requires no chromophore. For gray or white hair where there is little or no melanin,
the optical component of the electromagnetic pulse plays aminor role. It is hypothesized that there is non-specific
Hair color is genetically determined by the presence of the
preheating of the follicle acting as a macroscopic structure
black-brown pigment melanin and the yellow-red pigment
absorbing light. The preheating reduces the impedance and
pheomelanin. There is no simple arithmetic relationship
facilitates the concentration of RF current within the outer
between eumelanin/pheomelanin ratio and hair color, but
layers of the follicle. This progression of outward to inward
the highest levels of eumelanin occurs in black hair and the
heat transfer is likely responsible for the injury ensuing to the
highest levels of pheomelanin are appreciated with red hair.
germinative area of the hair follicle which results in the hair
Eumelanin absorbs red or infrared light more than
removal efficiency that is clinically noted in this setting. This
pheomelanin and it is the black-brown pigment granules
mechanism of injury should also theoretically provide
in the matrix cells and hair shaft that provide the primary
effective epilation when the target chromophore is reduced,
target chromophores. Thus, it is not surprising that
as with blond or red hair as shown in the present study.
previously reported studies confirm that photoepilation
Other lasers being studied based on this concept include
is less effective for red, blond and white hair, where
the super-long pulsed 810 nm diode laser.36,37
Figure 2(A) After intense pulsed light (IPL) white hair removal (optical energy~20 J/cm2; no radiofrequency (RF) energy); (B) after combined IPL/RF whitehair removal (optical energy~20 J/cm2; RF energy~20 J/cm3).
Other techniques used to target white hair include
response noted in two elderly patients with coarse white
photodynamic therapy utilizing a photosensitizer such as 5
hair may be expected in view of the larger surface area of
amino-levulinic acid, which also leads to non-chromophore
heating required for this phenotypic population.
targeting of pilosebaceous structures.38 Melanin encapsu-lated liposomes (Meladyne) have also been studied as anexogenously introduced target for non-pigmented white,grey and light blond hair. Six-month follow-up studies
utilizing the diode laser showed 75–100% hair reductionafter three treatment sessions in 90% of treated patients.
Further comparative studies looking at the effect on hair
However, these results have never been substantiated by
RF alone versus light and RF are needed.
other investigators (Personal communication).
Integrated RF and optical energy technology represent a
The 48% hair removal efficiency observed 6 months
new effective photoepilatory technology for the long-term
following a third monthly treatment session reported in the
removal of blond and white hair phenotypes. It is
present study population suggests that combined RF and
hypothesized that this technology in this patient population
optical energy offers a favorable alternative to this
is based primarily on thermal damage induced by the RF
previously difficult to treat patient management subgroup.
component. Although results may not be quite as efficient
However, it should be noted that the epilatory efficiency of
as with chromophore-targeting primarily light-based tech-
this technology, as demonstrated in the present study, is
nologies, it does offer a new approach to this previously
not as advantageous as pure laser sources utilized for the
refractory group of photoepilatory individuals.
removal of darker hair skin phenotypes. The slightly higherphotoepilatory efficiency of 52% noted for blond hairversus 44% noted for white hair might be expected based
upon the potential synergistic effect of combined chromo-phore targeting and non-selective RF heating. The poorer
Dr Sadick is a research consultant for Syneron.
Altshuler G, Anderson R, Manstein D, et al. Extended
leg, back, and bikini region. Dermatol Surg 1999; 25:
theory of selective photothermolysis. Lasers Surg Med
Nanni CA, Alster TS. Long-pulsed alexandrite laser-
Sadick NS, Shea CR, Burchette JL, Prieto VG. High-
assisted hair removal at 5, 10, and 20 millisecond pulse
intensity flashlamp photoepilation: a clinical, histological
durations. Lasers Surg Med 1999; 24: 332–7.
and mechanistic study in human skin. Arch Dermatol
Dierickx CC, Grossman MC, Farinelli WA, et al. Hair
removal by a pulsed, infrared laser system. Lasers Surg
Anderson RR, Parrish JA. Selective photothermolysis:
precise microsurgery by selective absorption of pulsed
Dierickx CC, Grossman MC, Farinelli WA, et al.
radiation. Science 1983; 220: 524–6.
Comparison between a long-pulsed ruby laser and a
Lask G, Elman, Slatkine M, et al. Laser-assisted hair
pulsed infrared laser system for hair removal. Lasers Surg
removal by selective photothermolysis. Dermatol Surg
Grossman M, Dierickx C, Quintana A, et al. Removal of
Dierickx CC, Grossman MC, Farinelli WA, et al.
excess body hair with an 800 nm pulsed diode laser.
Permanent hair removal by normal-mode ruby laser.
Lasers Surg Med 2000; 10 (suppl): 42.
Weiss RA, Weiss MA, Marwaha S, Harrington A. Hair
Laughlin SA, Dudley DK. Long-term hair removal using
removal with a non-coherent filtered flashlamp intense
a 3-millisecond alexandrite laser. J Cut Med Surg 2000; 4:
pulsed light source. Lasers Surg Med 1999; 24: 128–32.
Nanni CA, Alster TS. A practical review of laser-assisted
Williams R, Havoonjian H, Isagholian K, et al. A clinical
hair removal using the Q-switched Nd:YAG, long-pulsed
study of hair removal using the long-pulsed ruby laser.
ruby, and long-pulsed alexandrite lasers. Dermatol Surg
Bencini P, Luci A, Galimberti M, Ferranti G. Long-term
Grossman MC, Dierickx C, Farinelli W, et al. Damage to
hair follicle by normal mode ruby laser pulses. J Am
Lorenz S, Brunnberg S, Landthaler M, Hohenleutner U.
Gold MH, Bell MW, Foster TD, Street S. Long-term
Hair removal with the long-pulsed Nd:YAG laser: a
epilation using the Epilight broadband, intense pulsed light
prospective study with one year follow-up. Lasers Surg
hair removal system. Dermatol Surg 1997; 23: 909–13.
Bencini PL, Luci A, Galimberti M, Ferranti G. Long-
Herzberg J, Gusek W. Das Ergrauen Des Kopfhaares.
term epilation with long-pulsed Nd:YAG laser. Dermatol
Arch Klin Exp Dermatol 1970; 236: 368–84.
Lask G, Elman M, Noren P, et al. Hair removal with the
Nururkar V. The safety and efficacy of the long-pulsed
Epitouch ruby laser – a multicenter study. Lasers Surg
alexandrite laser for hair removal in various skin types.
Lasers Surg Med 1997; 10 (suppl): 189.
McDaniel DH, Lord J, Ash K, et al. Laser hair removal: a
Ross EV, Ladin Z, Kreindel M, Dierickx C. Theoretical
review and report on the use of the long-pulsed
considerations in laser hair removal. Dermatol Clin 1999;
alexandrite laser for hair reduction of the upper lip,
Orf RJ, Dierickx C. Laser hair removal. Semin Cutan
and long-pulsed Nd:YAG laser in hair removal in
Chinese patients. Dermatol Surg 2001; 27: 950–4.
Sadick NS. Laser and flashlamp photoepilation: a critical
Fournier N, Aghajan-Nouri N, Barneon G, et al. Hair
review of modern concepts bridging basic science and
removal with an Athos Nd:YAG 3.5 ms pulse laser: a
clinical applications. J Aesthetic Dermatol Cos Surg 1999;
3-month clinical study. J Cutan Laser Ther 2000; 2: 125–30.
Rogachefsky AS, Becker K, Weiss G, et al. Evaluation of
Goldberg DJ. Unwanted hair evaluation and treatment
a long-pulsed Nd:YAG laser at different parameters: an
with lasers and light pulse technology. Adv Dermatol
analysis of both fluence and pulse duration. Dermatol
Bencini PL, Luci A, Galimberti M, et al. Long-term
Tanzi EL, Alster TS. Long-pulsed 1064 nm Nd:YAG
laser-assisted hair removal in all skin types. Dermatol
Alster TS, Bryan H, Williams CM. Long-pulsed Nd:YAG
Anvari B, Tanenbaum BS, Milner TE, et al. Selective
laser-assisted hair removal in pigmented skin: a clinical
cooling of biological tissues: application for thermally
and histological evaluation. Arch Dermatol 2001; 137:
mediated therapeutic procedures. Phys Med Biol 1995;
Goldberg DJ, Silapunt S. Hair removal using a long-
Rogachefsky AS, Silapunt S, Goldberg DJ. Evaluation of
pulsed Nd:YAG laser: comparison at fluences of 50, 80
a super long pulse 810-nm diode hair removal in sun-
and 100 J/cm2. Dermatol Surg 2001; 27: 434–6.
tanned individuals. J Cutan Laser Ther 2001; 3: 57–62.
Ross EV, Cooke LM, Timko AL, et al. Treatment of
Rogachefsky AS, Silapunt S, Goldberg DJ. Evaluation of
pseudofolliculitis barbae in skin types IV, V and VI with
a new super-long-pulsed 810 nm diode laser for the
a long-pulsed neodymium:yttrium aluminum garnet
removal of unwanted hair: The concept of thermal
laser. J Am Acad Dermatol 2002; 47: 263–70.
damage time. Dermatol Surg 2002; 28: 410–14.
Chan HH, Ying SY, Ho WS, et al. An in vivo study
Dierickx G. Hair removal by lasers and intense pulsed
comparing the efficacy and complications of diode laser
light sources. Dermatol Clin 2002; 20: 135–46.
Servicio de Psiquiatría-CAS Vall d’HebronAgencia de Salud Pública de Barcelona (ASPB)Programa Clínico DepresiónServicio de Psiquiatría3Servicio de Psiquiatría del Parc Sanitari Sant Joan de DéuInstituto Clínico de NeurocienciasHospital Clínic de BarcelonaHospital Universitari de Bellvitge-IDIBELLCIBERSAM INTRODUCTION bupropion in the treatment of addiction in patients with coca
Diabetes Medication Guide The purpose of this guide is to provide general care information regarding management of diabetes. The guidelines are not intended to preclude more extensive evaluation and management of the patient by specialists as needed. This guideline is based on the American Diabetes Association: Standards of Medical Care in Diabetes – 2009, Diabetes Care, volume 32, Suppl