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Lasers in Medical Science

https://doi.org/10.1007/s10103-018-2503-z

ORIGINAL ARTICLE

Removal of unwanted hair: efficacy, tolerability, and safety

of long-pulsed 755-nm alexandrite laser equipped
with a sapphire handpiece
Steven Paul Nistico 1 & Ester Del Duca 2 & Francesca Farnetani 3 & Stefania Guida 3 & Giovanni Pellacani 3 &
Ali Rajabi-Estarabadi 4 & Keyvan Nouri 4

Received: 30 January 2018 / Accepted: 5 April 2018

# Springer-Verlag London Ltd., part of Springer Nature 2018

Abstract
Due to the difference in refraction coefficients between air and the corneal epithelium, irradiation of the skin with a light source
can lead to reflection of the energy and its leakage to the skin causes epidermal injury. All of which decreases the efficacy of
treatment. We evaluated cooling sapphire handpieces’ efficacy in decreasing pain and epidermal injuries and enhancing the
treatment outcome in laser hair removal. A total of 49 patients with Fitzpatrick skin types of II to IV were treated for laser hair
removal on face, limbs, inguinal, and axillary areas with pulsed 755-nm alexandrite laser equipped with a sapphire handpiece and
the cooling system. Hair counts were performed by two independent observers at the baseline and 3 months after the final
treatment. A marked reduction in hair regrowth was noted 3 months after the final treatment in all body locations studied. Clinical
hair reduction was observed and fully assessed. There were no serious side effects with an average pain score of 4.6 out of 40. The
cooled sapphire cylinder tip has been shown to minimize epidermal injury and reduce the system energy leaks to the skin.

Keywords Laser . Hair removal . Alexandrite . 755 nm

Introduction aluminum garnet (Nd:YAG) laser (1064 nm), and light-

based devices for home use [2–5]. Since the American
Laser devices are considered the most efficient methods for Food and Drug Administration (FDA) approved the first
the reduction of unwanted hair [1]. The goal of these devices laser therapy for epilation in 1996, much progress has been
is to damage the bulge stem cell and the dermal papilla of the made in light-based technology and lasers.
hair follicle by targeting melanin which represents the specific Photo-epilation by alexandrite laser systems overall has
chromophore. been efficient means for hair removal, reducing hair growth
Several laser and light devices are available on the mar- by 70–80% after few laser sessions [6–8].
ket for hair removal such as ruby laser (694 nm), alexan- Nevertheless, laser hair removal has still some issues
drite laser (755 nm), diode laser (800 nm), intense pulsed that may be improved. Although effective, laser treatment
light (IPL) (590-1200 nm), neodymium-doped yttrium is associated with pain and side effects including tempo-
rary erythema, perifollicular edema, hypo- and hyperpig-
mentation, vesicle, and crusting, especially when treating
* Steven Paul Nistico dark or tanned skin [9–12].
[email protected] Also, high concentrations of sub-micron nanoparticles
have been shown to be released during laser hair removal.
1
Department of Health Sciences, University of Catanzaro BMagna The fundamental concept of laser hair removal is the
Graecia^, Viale Europa, Germaneto, 88100 Catanzaro, Italy photothermal destruction of hair follicles. Melanin, the chro-
2
University of Tor Vergata, Rome, Italy mophore contained inside the hair shaft, absorbs the light,
3
Department of Dermatology, University of Modena, Modena, Italy converting it into the heat, which then spreads to the bulge
4 and the surrounding nonpigmented areas, endothelial cells for
Department of Dermatology and Cutaneous Surgery, University of
Miami Miller School of Medicine, Miami, FL, USA instance, with the risk of damaging them. Also, laser hair
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Lasers Med Sci

removal often produces combustion of hair with a malodorous of 0–40 point. (At the final visit, subjects were asked to rank
and visible plume [13]. Recently, it was demonstrated by improvement for each area on a scale from 0 (not satisfied) to
Chuang et al., by gas chromatography-mass spectrometry 5 (completely satisfied).
(GC-MS), that the hair plume contains 13 known or suspected The treated area included face, limbs, inguinal, and axillary
carcinogens and at least 20 chemical irritants that are poten- areas. Eight 3 × 2-cm areas were mapped and photographed.
tially hazardous for laser practitioners [13]. That is why the Sequential digital photographs using identical light, patient
use of smoke evacuators, good ventilation, and respiratory positioning, and camera equipment were obtained at baseline
protection are highly recommended. In the attempt to create and at three-month follow-ups. Hair counts were performed
a safe work environment and to eliminate the need for smoke manually counting and marking terminal hairs by two inde-
evacuators, custom ventilation systems, and respirators during pendent observers using digital photographs before treatment
laser hair removal, cold sapphire contact skin cooling is the and during the final evaluation 3 months after the last
best type of surface cooling [14]. Contact cooling cools the treatment.
skin with temperature-controlled sapphire glass and a topical
gel, prior to the delivery of the laser. Due to its contact with
Laser technique
skin and use of topical gel, this type of surface cooling may
have an additional benefit of plume suppression during laser
The alexandrite laser (Motus AX, DEKA, Calenzano, Italy)
hair removal.
system used in this study achieves a wavelength of 755 nm
This study evaluates the safety, tolerability, and efficacy of
with a range of fluence between 6 and 8 J/cm2, with a spot size
the long-pulsed 755-nm alexandrite laser (Motus AX, DEKA,
of 20 mm in diameter and frequency up to 10 Hz. The clinical
Calenzano, Italy), equipped with a special handpiece with a
characteristics of the patient (skin type and hair type) were
cooled sapphire cylinder tip (Moveo technology, DEKA,
used to select the ideal fluence for the procedure. No anesthet-
Calenzano, Italy) that conveys the laser beam onto the pa-
ic cream was used before the treatment. The alexandrite laser
tient’s skin.
was equipped with a special handpiece (Moveo, TM) with the
cooling system integrated. After applying a transparent gel or
oil, the Moveo handpiece was slid across the skin in a series of
Methods
continuous circular or linear movements, aiming to pass sev-
eral times over the same area. The repeated passes over small
A prospective review of the 49 patients treated for unwanted
areas caused gradual heating of the vital parts of the hair lead-
hair was made. Fitzpatrick skin types of patients ranged from
ing to its destruction in a way that is painless for the patient.
II to IV. First, a screening of secondary causes of excessive
The achievement of adequate therapeutic dose in the area of
hair growth was performed. Exclusion criteria included any
10 × 10 cm was indicated by a special alarm from the device.
previous laser treatments in the study area, hormonal dysfunc-
After every treatment, a moisturizer for skin recovery was
tion, isotretinoin use within the past year, history of photosen-
applied. Avoiding sun exposure was highly recommended,
sitivity, pregnancy, extreme tan, or a history of hypertrophic
and patients were invited to apply sunscreen during the days
scars and keloids. All patients were asked to avoid any epila-
following the session if the area was exposed.
tion techniques 4 weeks prior to laser hair removal. Shaving
was carried out immediately before the procedure, as this
allowed us to evaluate the characteristics of the follicles (fol-
licle diameter and degree of pigmentation) and to adjust the Results
treatment parameters accordingly. The participants’ eyes were
protected by suitable goggles. Participants had a mean age of 32.6 years (21–44 years), and
All 49 patients completed four treatments at 4- to 6-week 40 patients were female (82%). Twenty-one volunteers (43%)
intervals and were available for final evaluation 3 months after had skin type II, 24 (49%) had skin type III, and 4 (8%) skin
their last treatment. All laser procedures were performed dur- type IV. In total, 82 body areas were treated, 12 (15%) of
ing the periods when patients’ skin had little sun exposure. which were on the groins, 10 (12%) on the face, 42 (51%)
Subjects were also given questionnaires assessing laser toler- on the axillary region, and 18 (22%) on the limbs. The hair
ability and satisfaction. All patients signed informed consent reduction was calculated by hair counting using digital pho-
forms. tographs by the assessors at baseline and 3 months after the
During every session, the amount of pain evoked by the last treatment. Hair loss was defined as the percentage of ter-
laser treatment was expressed by the participant and recorded minal hairs absent after treatment compared with the number
on the numeric pain rating scale with a range from 0 (no pain) before treatment. We used the following hair reduction grad-
to 10 (unbearable pain). The pain scores for each treatment ing system: Zero indicated less than 25%; one, 25 to 50%;
group were cumulative for all four therapeutic sessions (range two, 51 to 75%; three, 76 to 90%; and four, greater than 90%.
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Lasers Med Sci

A marked reduction in hair regrowth was noted 3 months When choosing treatment parameters, several factors must be
after the final treatment in all body locations studied (Figs. 1 considered, individually selected, and adjusted to the clinical
and 2). Clinical hair reduction scores on the face and inguinal situation before starting treatment sessions. The spot size which
area averaged 3.9 (Fig. 3). Hair on the legs was slightly more we used in all patients was set at 20 mm. A large spot size
responsive with clinical hair reduction scores of 4.1. Axillary provides great penetration capacity for the radiation and can
hair demonstrated the most impressive hair reduction scores, also allow for the more rapid treatment of large areas. The
averaging 4.3. fluence (J/cm2) determines the temperature achieved within
the follicular stem cells in the bulge while the pulse duration
Side effects corresponds to the time length of that reached temperature.
Fitzpatrick skin type and hair type are the main clinical charac-
The only side effect recorded during the treatment was light teristics to consider when selecting the form of treatment. The
discomfort in some patients. This discomfort was managed by larger the size of the follicle and the higher its degree of pig-
parameters adjustment, decreasing the fluence and/or increas- mentation, the lower the fluence required for photothermolysis.
ing the pulse duration. Immediate side effects of the laser Meanwhile, finer or less pigmented hairs will require higher
treatments included only perifollicular erythema. This side fluences. We reconsidered fluence parameters at each treatment
effect was transient and resolved within 2 days of onset in session. The progressive reduction in size of the follicles over
all patients. There were no incidences of blistering, successive sessions means that the initial treatment parameters
dyspigmentation, scarring, cutaneous infection, and paradox- will not be applicable in subsequent treatment sessions [16–18].
ical hypertrichosis. The long pulse 755 nm Alexandrite laser allows for deep
penetration into the dermis permitting it to act on fair and
Subject tolerability and satisfaction black hair, but because of the competition with melanin, it is
particularly indicated in patients with low skin types (up to 3–
Based on subject questionnaires, the long-pulse alexandrite 4) due to the risk of burning which results in hyper- or
laser with special handpiece was rated as almost not painful hypopigmentations. In order to counteract this problem, we
with mean pain scores of 4.6 out of 40. The bikini line and the used a specific handpiece with a cooled sapphire cylinder tip
face were the more sensitive areas with pain scores slightly that conveys the laser beam into the patient’s skin. First, se-
higher than limb and axilla regions. At the final visit, accord- lective cooling of the epidermis has been shown to minimize
ing to the five-point satisfaction scale, alexandrite laser was epidermal injury [19]. Second, the use of this sapphire guide
found to be comparable with mean scores of 4.0. drastically reduces the system energy leaks to the skin. When
we irradiate the skin with a light source, because of the differ-
ence in refraction coefficients between air and the corneal
Discussion epithelium, some of the radiation is reflected. This is a signif-
icant portion of energy lost during the treatment, which cannot
Since 1997, the long pulse 755 nm alexandrite laser has been be used for therapeutic purposes. Using the special handpiece,
utilized with efficacy in laser hair removal [15]. The physical the laser-skin coupling is optimized by doubling the transmis-
parameters within the specific devices vary considerably in sion of energy. The sapphire tip that comes in contact with the
terms of wavelength, pulse duration, spot size, and fluence. skin decreases the variation in the reflection index by reducing

Fig. 1 The results of hair RESULTS 3 MONTHS AFTER THE FINAL TREATMENT
reduction in all studied body
locations 3 months after the final
treatment with 755-nm Axillary zone
alexandrite laser Motus AX,
D.E.K.A., Calenzano, Italy
Limbs
Hair reducon score: 0 indicates
less than 25%; 1, from 25% to 50%;
2, from 51% to 75%; 3, from 76% to
Inguinal zone 90%; 4, more than 90%.

Face

0 1 2 3 4 5
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Lasers Med Sci

Fig. 2 Fig. 1 in detail RESULTS 3 MONTHS AFTER THE FINAL TREATMENT -DETAIL

Axillary zone

Limbs
Hair reducon score: 0 indicates
less than 25%; 1, from 25% to 50%;
2, from 51% to 75%; 3, from 76% to
Inguinal zone 90%; 4, more than 90%.

Face

3.7 3.8 3.9 4 4.1 4.2 4.3 4.4

the reflected energy loss. Working at low fluences (6–8 J/cm2) 2Light absorption by melanin causes epidermal damage,
makes the treatment painless. Some discomfort during treat- which limits the maximum fluence that can be used in
ment was the only side effect to be reported in patients receiv- epilation procedures. Skin cooling is used to protect the
ing treatments to reasonably large areas on the limbs. The epidermis during the laser treatment and to avoid the
repeated passages over the same area make the treatment itself postinflammation hyperpigmentation. Air and contact
uniform without leaving untreated areas. If well performed, cooling are the most popular methods. Contact cooling
the repeat-pass technique with the Moveo handpiece reduces produces more effective and precise cooling of the skin
application times and makes it possible to treat particularly thanks to an optimal sapphire-skin contact that is achieved
demanding skin areas quickly. Lowering the energy level by pressing the device firmly against the skin and by using
not only results in less painful treatment but also reduces po- a thin layer of high-thermal-conductivity liquid to fill in
tential side effects. As we observed in our study, no serious the skin microroughness.
side effects occurred during the treatment period. Also, with this handpiece, a stable cooling during all the
Taking into consideration the outcomes of other papers treatment is achieved. The epidermal temperature is signifi-
where similar laser settings for hair removal were used cantly but harmlessly decreased by this method, while the
with and without application of the cooled sapphire matrix cells of the hair follicle temperature remain unchanged.
handpiece, we can confirm that laser hair removal with There are several limitations of this study: absence of con-
contact cooling produces significantly less nanoparticle trol group, evaluation only the short term results of the hair
plume when compared to treatments performed with removal treatment, and the method of assessment of hair
cryogen-spray cooling and refrigerated air [14]. The use counts. Hair counting by means of digital photographs could
of gel, absence of dynamic air movement, and the close make possible that thin hairs after laser treatment were not
contact of the laser handpiece to skin all contribute to trap- noticed by assessors on the digital photographs, and thus,
ping and reducing free-floating nanoparticles. the percentage of hair reduction was higher.

Fig. 3 A 29-year-old woman with

Fitzpatrick skin type III who
underwent treatment of unwanted
hair in the face at a baseline and b
3-month follow-up after four
treatments with 755-nm
alexandrite laser Motus AX and
Moveo technology, DEKA.,
Calenzano, Italy
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Lasers Med Sci

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Surg 39(6):823–838
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