Treatment of Pseudofolliculitis with a Pulsed Infrared Laser

STUDY Treatment of Pseudofolliculitis With a Pulsed Infrared Laser

Arielle N. B. Kauvar, MD

Background: Pseudofolliculitis barbae is a common dis- went evaluation for improvement in the pseudofollicu- order in individuals with thick, curly hairs, and treat- litis and the degree of hair reduction. ment options are limited. Main Outcome Measures: Patients were assessed at Objective: To evaluate the effectiveness of a diode la- 6- to 8-week intervals for the degree of hair-count re- ser in the treatment of pseudofolliculitis barbae. duction, improvements in papule and pustule formation, and adverse effects. Design: Observational study. Results: Complete hair-growth delays of 3 to 8 weeks’ Setting: Laser and Skin Surgery Center of New York, duration were produced, and a decrease in hair density of New York, NY. greater than 50% was noted in all subjects 6 to 8 weeks after the last laser treatment. All patients exhibited greater Patients: Ten consecutive patients with long- than 50% improvement in the signs of pseudofolliculitis. standing pseudofolliculitis barbae and skin phototypes Preexisting pigmentary changes improved with therapy. ItoIV. Conclusion: Diode laser treatment is a safe and effec- Interventions: Treatment was performed using an tive method for improving pseudofolliculitis barbae in 810-nm diode laser (20- to 30-millisecond pulse dura- patients with skin phototypes I to IV. tion) at fluences of 30 to 40 J/cm2. Three treatments were performed at 6- to 8-week intervals, and subjects under- Arch Dermatol. 2000;136:1343-1346

SEUDOFOLLICULITIS BARBAE is a shaft. In both cases, a foreign body inflam- relatively common disorder matory reaction ensues. The primary le- that occurs in glabrous skin sions of pseudofolliculitis are erythema- with coarse, curly hairs.1-4 It is tous papules and pustules. When chronic a frequent disorder of any hair- inflammation is present, hyperpigmenta- Pbearing skin with thick, curly hairs that are tion, hypopigmentation, and fibrotic scar- removed repetitively by shaving, waxing, or ring may accompany the clinical picture. Bi- plucking. Prevalence figures are only avail- opsy results show foreign body giant cells able for pseudofolliculitis barbae occur- in the dermis with microabscess forma- ring in the beard area of African Ameri- tion.5 Cultures of the pustules are sterile, and cans who shave, and range from 45% to bacteria are therefore not implicated in the 83%.1 Shaving is a predisposing factor be- pathogenesis of this disorder.6 cause it results in a sharp, pointed, short hair Treatment modalities used for pseu- that may curl over and reenter the skin. Ex- dofolliculitis barbae have been largely dis- trafollicular penetration of the hair shaft is appointing, and include topical tretinoin one cause of pseudofolliculitis barbae. cream, corticosteroids, topical and oral an- Transfollicular penetration of the hair shaft tibiotics, surgical depilation, electrolysis, and may occur as well. When the skin is held tedious shaving regimens.2,7,8 Pseudofol- taut during shaving or when a double- liculitis barbae will improve if the hairs are edged razor is used, the sharply cut hair may allowed to grow. When shaving is stopped, retract under the skin and grow directly into the ingrown hairs are released automati- From the Laser and Skin the follicular wall. Incomplete wax epila- cally by spring action within a 3- to 4-week Surgery Center of New York, tion and electrolysis can also lead to trans- period. The only definitive cure for pseu- New York, NY. follicular penetration of the growing hair dofolliculitis barbae is permanent removal

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Patient Characteristics PATIENTS AND METHODS Patient No./ PATIENTS Age, y Skin Phototype Hair Color Location 1/18 III Black Bikini Ten consecutive patients seeking laser hair removal 2/31 III Black Axilla for the treatment of pseudofolliculitis barbae were en- 3/20 II Black Beard rolled in this study. The age of the patients ranged 4/35 IV Black Neck from 18 to 45 years. All patients had skin photo- 5/44 II Light brown Lip, chin types II to IV, with coarse curly hair ranging in color 6/22 II Brown Buttock from brown to black (Table). Each patient had a his- 7/45 II Black Lip, chin tory of pseudofolliculitis barbae in the treatment area 8/43 II Black Beard for a minimum duration of 1 year; patients 1 and 4 9/40 II Brown Bikini 10/28 II Black Bikini also had long-standing hyperpigmentation. Previ- ous treatments included topical antibiotics, oral antibiotics, and intralesional corticosteroid injections. damage or destruction has been demonstrated with a va- TREATMENT riety of laser systems, including ruby lasers,9,10 diode lasers,11 alexandrite lasers,12 Nd:YAG lasers,13,14 and a pulsed After informed consent was obtained, 35-mm pho- 15 tographs were taken of the treatment area. The area noncoherent light source. Although all of these systems was shaved with a disposable razor, and a eutectic have been shown to be effective in delaying hair re- mixture of local anesthetics (lidocaine hydrochlo- growth, recent studies have demonstrated that some pulsed ride and prilocaine hydrochloride in an emulsion base) laser and light-source hair-removal systems are capable of was applied with occlusion for 1 hour before treat- producing a permanent reduction in hair density in the ment. An 810-nm diode laser (Lighsheer; Coherent treated areas. Star, Palo Alto, Calif) was used with a 9-mm spot size The successful treatment of pseudofolliculitis bar- and a pulse width of 20 milliseconds. Treatment flu- bae in 10 women is reported herein. ences ranged from 30 to 38 J/cm2. The affected areas were treated with contiguous laser pulses, and care was taken to stretch the skin during treatment to en- RESULTS sure close contact between the sapphire cooled hand- piece and the patient’s skin. After treatment, a hy- All patients tolerated the laser treatments well and expe- drogel dressing was placed, and patients were rienced minimal discomfort. Perifollicular edema and ery- instructed to apply a combination of bacitracin zinc thema developed immediately after laser treatment and and polymixin B sulfate (Polysporin) or bacitracin lasted 2 to 3 days. Blister formation did not occur in any ointment twice daily if crusting was present. The 2 of the treatment areas. Two patients reported scattered crusts patients with hyperpigmentation were treated with after the first treatment that resolved in 2 to 3 days. Com- 4% hydroquinone cream (Lustra; Medicis, Phoenix, plete hair-growth delays of 3 to 4 weeks’ duration were re- Ariz), which they began applying 1 week after each ported for facial hair, and 4 to 6 weeks for inguinal and ax- treatment. Follow-up visits and additional treatments were illary sites. In other body sites, patients reported complete performed at 6- to 8-week intervals. Patients were in- growth delays of 4 to 6 weeks. At the last follow-up visit, a structed to shave the treatment area as needed be- decrease in hair density of greater than 50% was observed tween treatment sessions. During each visit, 35-mm in all patients. After 3 treatments, all patients reported greater photographs were obtained, and an additional treat- than 75% improvement in the papules and pustule forma- ment was performed as before. Each patient under- tion (Figure 1). Patients 1 and 4 had a history of firm hy- went 3 laser treatments. Grading was performed by perpigmented papules and nodules measuring up to 5 mm 2 independent investigators comparing pretreat- in diameter that were present for longer than 3 and 5 years, ment and posttreatment photographs. Hair counts respectively (Figure 2). Both patients underwent elec- were determined from 35-mm photographs ob- trolysis treatments in the past, which were discontinued tained before shaving the treatment area. A quartile grading system was used to rate papule and pustule after the development of pseudofolliculitis barbae in the formation, pigmentary changes, and hair density re- affected areas. Patient 1 demonstrated an improvement rat- ductions as follows: 1 indicated 0% to 25% improve- ing of 4 and patient 4 showed an improvement rating of 3 ment; 2, 26% to 50%; 3, 51% to 75%; and 4, greater in hyperpigmentation. The degree of hair reduction at the than 75%. Patients were also questioned regarding last follow-up visit was rated at least 3 in all patients their satisfaction with the treatment and their im- (Figure 3). All patients were uniformly satisfied with their pressions were recorded. treatment and noted improvement after just 1 treatment session.

COMMENT of the hair follicles. Surgical depilation carries a high morbidity. Electrolysis is a laborious procedure, and incom- Pseudofolliculitis barbae is a common disorder of gla- plete follicular destruction has resulted in keratin granu- brous skin in individuals with course, curly hair that de- lomas and pseudofolliculitis barbae. Selective follicular velops following hair removal, most commonly by shav-

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Pseudofolliculitis Improvement

4 No. of Patients

0 123 4 Improvement Rating

Figure 1. Improvement in pseudofolliculitis and degree of hair reduction in B 10 patients after 3 treatments: 1 indicates 0% to 25% improvement; 2, 26% to 50%; 3, 51% to 75%; and 4, greater than 75%.

Figure 3. Pseudofolliculitis of the chin and submental skin before (A) and 2 months after (B) treatment with the diode laser.

B be achieved.16 Several other laser systems have been developed with the same goal in mind, and include the diode laser (800-810 nm), pulsed alexandrite laser (755 nm), Nd:YAG laser (1064 nm), and a pulsed noncoherent light source. Hair follicles are logical targets for laser therapy because they are structures located relatively superfi- cially within skin, and because they contain high con- centrations of a natural chromophore, melanin. Selective laser destruction of hair follicles is achieved Figure 2. Patient with acute and chronic changes of pseudofolliculitis barbae in the inguinal skin, before (A) and after (B) 3 diode laser treatments. by using wavelengths of light that are well absorbed by melanin but poorly absorbed by other naturally occur- ring chromophores in the skin, such as hemoglobin and ing. Other hair removal methods, including wax epilation, water. The laser pulse duration is chosen to be suffi- plucking, and electrolysis, also can result in pseudofol- ciently small so that tissue heating is limited to the hair liculitis barbae. Common locations include the beard and follicle and is not conducted to the surrounding tissues. neck region in men and axillary and inguinal areas in This is accomplished by choosing a pulse duration smaller women. Traditional therapies, including topical and oral than the thermal relaxation time, or cooling time, of the antibiotics, tretinoin cream, corticosteroids, and labori- hair follicle, and has been estimated to be 40 to 100 mil- ous shaving methods, have yielded unsatisfying results. liseconds for these 200- to 300-µm-diameter structures. The most obvious treatment for this disorder is com- The wavelength of the laser determines the depth of pen- plete follicular destruction. Laser hair removal is there- etration of the laser beam in tissue as well as the degree fore a logical therapeutic approach to this common and of absorption by melanin. Melanin shows strong absorp- difficult problem. tion from approximately 400 to 1000 nm, and longer Selective destruction of hair follicles was first de- wavelengths penetrate more deeply into tissue. At the scribed with the use of a long-pulsed ruby laser (694 nm, lower end of the spectrum, melanin absorption is suffi- 270 microseconds), with hair-growth delays observed in ciently high that the risk of epidermal damage becomes all of the 13 subjects following a single treatment.9 Two greater when treating darker skin types. Relative spar- years later, 4 of these subjects showed less than 50% ter- ing of the epidermis can be achieved at the longer vis- minal hair regrowth in the treatment areas, thereby dem- ible and near infrared wavelengths, but the ability to treat onstrating that permanent reduction in hair density could lighter hairs diminishes. The best laser wavelengths for

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 hair removal are therefore somewhere in the range of 700 An added benefit of laser treatment was the induc- to 1000 nm. tion of hair-growth delays in all body areas treated, in- One of the greatest challenges in laser hair removal cluding the beard, axillary, and inguinal regions. All sub- is targeting follicular melanin while sparing epidermal jects exhibited a decrease in hair density of greater than melanin. Epidermal damage is limited by selecting pulse 50% at the last visit. Because of the short follow-up pe- durations longer than the thermal relaxation time of skin, riod after the last laser treatment (6 to 8 weeks), it was which has been estimated to be approximately 3 to 10 not possible to assess the degree of long-term hair re- milliseconds. Longer heating times allow the basal layer duction in these patients. However, based on other clini- to cool as it is slowly heated. Therefore, the theoreti- cal studies using the same treatment variables, it is likely cally ideal pulse duration for hair-removal lasers should that these patients also will have achieved a permanent lie between 10 and 100 milliseconds. Damage to the epi- reduction in hair growth. dermis can also be limited by cooling the skin’s surface Pseudofolliculitis is a common problem typically during laser treatment. A variety of novel skin-cooling affecting men in the beard area and women in the axil- methods are now being used for this purpose. The diode lary and inguinal regions. Traditional treatment options laser has a water-cooled sapphire tip that is applied di- are limited and yield unsatisfactory results. This report rectly to the skin during treatment and serves to lower the demonstrates that treatment of pseudofolliculitis barbae temperature of the epidermis by extracting heat away. Other with a pulsed diode laser results in dramatic clinical methods of skin cooling include water-chilled quartz plates, improvement in as few as 3 treatment sessions, with the cryogen spray cooling, and the application of cold gel to induction of significant hair-growth delays. This is a the skin surface during treatment. By selectively cooling practical therapeutic approach, enabling treatment of the epidermis, high peak temperature can be generated large body-surface areas quickly with minimal morbidity within the hair follicle while minimizing accumulation of to the patient. heat energy near the skin surface and resultant epidermal damage. Accepted for publication May 22, 2000. Permanent removal of hair requires irreversible dam- Reprints: Arielle N. B. Kauvar, MD, Laser and Skin age to the follicular stem cells. The location of follicular Surgery Center of New York, 317 E 34th St, Suite 11N, New germinative cells remains somewhat of a controversy; it is York, NY 10016. unclear whether the stem cells reside in the bulb or within a specialized area of the outer root sheath located at the REFERENCES point of insertion at the arrector pili muscle, which has been termed the bulge. The bulge is located at an approximate 1. Alexander AM, Delph WI. Pseudofolliculitis barbae in the military: a medical ad- depth of 1.5 mm, whereas the bulb resides at an approxi- ministrative and social problem. J Natl Med Assoc. 1974;66:459-464. mate depth of 2 to 3 mm. Damage to these potential stem 2. Brown LA Jr. Pathogenesis and treatment of pseudofolliculitis barbae. Cutis. 1983; cell sites may occur by means of direct heat conduction to 32:373-375. these areas, and/or generation of photoacoustic shock waves 3. Halder RM. Pseudofolliculitis barbae and related disorders. Dermatol Clin. 1988; from the shaft and matrix, which have a high concentra- 6:407-411. 4. Brauner G, Flandermeyer KL. Pseudofolliculitis barbae. Int J Dermatol. 1977;16: tion of melanin. Longer visible-light and near-infrared wave- 520-525. lengths provide the necessary combination of sufficient tis- 5. Strauss JS, Kliginan AM. Pseudofolliculitis of the beard. Arch Dermatol. 1956; sue penetration and adequate melanin absorption for this 74:533-542. purpose. The 810-nm emission wavelength of the diode la- 6. Greenbaum SS. Folliculitis barbae traumatica. Arch Dermatol. 1935;32:237- 241. ser used in this study provides sufficient tissue penetra- 7. Coquilla BH, Lewis CW. Management of pseudofolliculitis barbae. Mil Med. 1995; tion needed for follicular damage. At a pulse duration of 160:263-269. 20 milliseconds, hair-follicle injury is achieved primarily 8. Crutchfield CE. The causes and treatment of pseudofolliculitis barbae. Cutis. 1998; by means of direct heat conduction from melanin-dense 61:351-354. areas of the follicle. 9. Grossman MC, Dierickx C, Farinelli W, Flotte T, Anderson RR. Damage to hair follicles by normal-mode ruby laser pulses. J Am Acad Dermatol. 1996;35:889- This study has demonstrated that treatment with the 894. diode laser improves the acute and chronic changes of 10. Kauvar ANB. Hair removal with Q-switched lasers. Paper presented at: Annual pseudofolliculitis barbae. All patients exhibited a de- Meeting of the American Society for Dermatologic Surgery; May 17, 1996; Palm crease in the numbers of papules and pustules. Two of Desert, Calif. the patients who demonstrated more chronic changes, 11. Lou W, Quintana A, Geronemus R, Grossman M. Prospective study of hair reduction by diode laser (800 nm) with long-term follow-up. Dermatol Surg. 2000; including long-standing hyperpigmentation and fi- 26:428-432. brotic papules, showed global improvement. There was 12. McDaniel DH, Lord JL, Ash KA, Newman J, Zukowski M. Laser hair removal: a a reduction in the fibrotic papules, hyperpigmentation, review and report on the use of the long-pulsed alexandrite laser for hair reduc- and inflammatory lesions. This study shows that treat- tion of the upper lip, leg, back, and bikini region. Dermatol Surg. 1999;25:425- 430. ment with the diode laser improves pseudofolliculitis for 13. Bencini PL, Luci A, Galimberti M, Ferranti G. Long-term epilation with long- 2 months. With the induction of long-term reductions pulsed neodimium:YAG laser. Dermatol Surg. 1999;25:175-178. in hair growth, we anticipate that disease remission will 14. Goldberg DJ, Littler CM, Wheeland RG. Topical suspension-assisted Q-switched last even longer. Further studies with longer-term fol- Nd:YAG laser hair removal. Dermatol Surg. 1997;23:741-745. low-up are needed to establish the duration of the ther- 15. Gold MH, Bell MW, Foster TD, Street S. Long-term epilation using the EpiLight 2 broad band, intense pulsed light hair removal system. Dermatol Surg. 1997;23: apuetic benefit. Remarkably, high fluence (30-38 J/cm ) 909-913. did not produce epidermal damage or pigmentary alter- 16. Dierckx CC, Grossman MC, Farinelli WA, Anderson RR. Permanent hair removal ation, even in the patient with phototype IV skin. by normal-mode ruby laser. Arch Dermatol. 1998;134:837-842.

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