Laser-assisted hair removal, photorejuvenation and laser treatment of acne and atrophic scars can now be offered to patients with skin of color. However, it is still important to proceed with caution because all risks are not eliminated with newer technologies.
Chicago - Advances in technology have allowed popular cutaneous laser surgery procedures to be performed safely and effectively in persons with skin of color, according to Teresa Soriano, M.D.
"Unwanted absorption of laser energy by epidermal melanin in darker skin types increases risks of thermal injury, postinflammatory pigmentatary alterations and scarring," she says.
"However, the advent of longer wavelength devices with longer pulse durations has made laser-assisted hair removal safe and effective in persons with darker skin.
Laser-assisted hair removal in skin of color is performed using an 800 nm diode laser with a 100 ms pulse duration or long-pulsed 1064 nm Nd:YAG laser.
Patients are counseled that multiple treatments will be necessary, but no specifics on the number of sessions or interval between them should be provided.
"These variables differ among individuals, and so we tell patients simply to return for the next session when there is enough hair growth to retreat," Dr. Soriano tells Dermatology Times.
In preparation for laser-assisted hair removal, patients are advised to avoid the sun, use sunscreens and refrain from plucking or waxing for four weeks.
In addition, a bleaching cream regimen is started if the patient has pseudofolliculitis-associated postinflammatory hyperpigmentation (PIH).
The laser treatment itself can be especially painful in persons with darker, thicker and coarser hair. To improve comfort, Dr. Soriano applies a compounded topical anesthetic cream containing 7 percent lidocaine and 7 percent tetracaine 30 to 60 minutes prior to the procedure. An epidermal cooling device is also used during the procedure.
Post-treatment care includes immediate application of a topical corticosteroid cream to control erythema, followed by continuation as needed. Cool compresses also help to reduce erythema, and sun avoidance must be continued.
Although post-treatment erythema typically resolves within 48 hours, patients are counseled that it may be longer-lasting and that they may also develop some vesiculation, PIH or hypopigmentation.
"All of these adverse events are seen more frequently in patients with darker skin; a tan; dense, thick, black hair; or when treating with higher fluences," Dr. Soriano says.
While technological advances have improved the safety profile of laser-assisted hair removal in skin of color, Dr. Soriano says that she is aware of a relatively high number of malpractice cases in this population, including patients treated in physician offices.
The leading complaint in these cases is that pigment alteration lasts longer than expected.
"Fortunately, the pigmentary problems usually clear within six months, and so have resolved before the case ever reaches court," Dr. Soriano says.
While scarring is now rare with the advances in laser technology, it can occur and must be mentioned in the informed consent for patients undergoing laser-assisted hair removal.
Lack of response should also be included as an outcome in the informed consent.
Dr. Soriano says there are also reports of paradoxical hypertrichosis at both the site of treatment and involving adjacent skin.
This adverse event is much more common in darker skin types, particularly with treatment of the face, and it may raise a 'red flag' of an underlying hormonal disorder, she explains.
"Patients who develop increased hair growth should be considered for testing for underlying hyperandrogenism," Dr. Soriano says.
Fractional photothermolysis with a CO2 laser is still risky in patients with darker skin, but erbium nonablative fractional photothermolysis can be used to treat periorbital wrinkles, pigmented lesions (such as age spots and sunspots) and dyschromias.