Hair removal

Primary Author(s):

Cecily Reeves, PhD, FNP-C/PA-C

Madeline B. Deutsch, MD, MPH

Jeannine Wilson Stark, LE, CPE

Introduction

The management of unwanted hair is often a challenge for transgender people, for many reasons. Barriers include access to trans-experienced aesthetic providers, transportation, affordability, and confusion regarding the options, risks and benefits.[1,2] While insurance coverage for hair removal in transgender persons is expanding, it remains inconsistent and can be a significant source of frustration and anxiety for both patient and provider.[3,4]

Transgender men, transgender women, and other gender nonconforming individuals may seek services; a care plan for each patient is best individualized according to their personal needs and transition goals. Transgender woman typically seek hair removal on the face, neck, as well as in the genital area in the case of pre-operative preparation for vaginoplasty.[5,6] Transgender men typically seek hair reduction on forearm or thigh future graft sites in preparation for phaloplasty.[5,7] While epilation (plucking, waxing, or Epi-Lady type devices) and the use of depilatories (chemicals) offer temporary measures, many seek one of several modalities that offer permanent hair reduction/removal: light amplification by stimulated emission of radiation (laser) hair removal (LHR) and electrolysis hair removal (EHR).[8,9] As with any referral for care, it is ideal to establish relationships with experienced, accessible practitioners with a positive reputation in the transgender community.

Methods: pros and cons of each

The hair growth cycle consists of three successive stages that include the anagen (growth) phase, the catagen (transitional) phase, and the telogen (resting) phase. Each strand is at its own stage of development. Time in each phase can vary by location, from an anagen phase of one to two months on the body, to two to six years on the scalp. Patterns of hair growth may also vary based on gender and ethnicity.[10] The effectiveness of both methods rely to some extent on the timing of the hair growth cycle, with the ideal response being when hairs are in the active (anagen) growth phase. Both require multiple sessions, and since effectiveness is approximately 85-90%, combined LHR and EHR may offer the best result for many. Lifelong treatment is often required for sustained effect.[10-12]

Laser Hair Removal:The use of lasers is considered a 'medical procedure' and offers the use of light to selectively target dark, coarse hairs.[13] The pigment in dark hairs absorbs the light to create heat that is transmitted down the shaft to destroy the follicle. It treats larger surface areas and is less time consuming than EHR. Treatments are typically every 4-8 weeks, depending on the treatment location, as the hair growth cycles vary by area. Safety and effectiveness may vary depending on the platform used (diode, ruby, neodymium-doped yttrium aluminum garnet; [ Nd: YAG], etc.), patient skin type and hair characteristics. LHR is generally ineffective on thin, light, red, blonde or gray hairs. A wavelength of 1064 (Nd: YAG) is the only wavelength considered safe for dark-skinned individuals (Fitzpatrick skin types 5 or 6).[9,11]

LHR is FDA-approved for permanent hair reduction. Patients are required to be evaluated by a medical provider (NP/PA/MD, etc.) prior to being treated; regulations on the qualifications and licensure of the laser operator vary by US state, with some states requiring registered nurses.[10]

As with any light-based treatment that uses selective photothermolysis, overheating can result in redness, blisters, burns, and subsequent hyper or hypo-pigmentation.[14-16] The majority of these are infrequent and temporary; however care should be taken with any patient with a history of keloids (test spot on low visibility area) and LHR is contraindicated in conditions that might flare in reaction to light exposure, such as lupus erythematous [17] It is suggested that patients with a history of herpes simplex outbreaks be aware of the potential for a light-stimulated outbreak (in treatment area) and have antivirals available for self-treatment. Treatments should be avoided when photosensitizing medications are being used (see table [18]). Do not treat areas of active infection. Flashing lights have been known to induce seizures in susceptible patients, so patients should be screened for this risk.[19] Treatments on the face require occlusion of both eyes to protect from retinal exposure and damage. Protective, wavelength specific, eye-ware is used during non-facial body treatments.[20]

Relative CONTRAINDICATIONS to laser hair removal:

• History of melanoma, raised moles, suspicious lesions, keloid scar formation, healing problems, active infections, open lesions, hives, herpetic lesions, cold sores, tattoos or permanent make-up in area of treatment, recent use of isotretinoin, tetracycline, or St. John's wort in the last year, autoimmune diseases such as lupus, scleroderma, vitiligo.[17,18]
• While not a contraindication to treatment, the following drugs may cause increased hair growth: penicillin, cyclosporins, corticosteroids, haldol, phenytoin, thyroid medications.[18]

Electrolysis involves use of an electric current with a very fine needle-shaped probe to destroy the root of individual hair follicles. There are three types of electrolysis; galvanic (direct electrical current produces a chemical reaction), thermolysis (diathermy: short-wave which produces heat) and blend (combination of galvanic and thermolysis).[21] Since electrolysis involves direct mechanical destruction of the root, it can be used on all hair colors and skin types. Treatments are typically weekly and lasting up to 1 hour, based on patient pain tolerance. Targeting individual hairs may be time consuming and costly, however is very effective when used to treat hairs that have not or will not respond to LHR. Newer technologies/epilators (27MHz frequency) offer a more comfortable treatment and may be safer than older model machines (14MHz frequency). As the frequency is increased, so is the heat produced, resulting in improved effectiveness.[22] Electrolysis is FDA-approved for permanent hair removal. In the US, electrologists are licensed in their state of practice and practice independently.

Some of the same risks associated with LHR also apply: redness, pigment changes, and avoiding areas of active dermatitis or infection.[23] Patients with pacemakers are most safely treated with thermolysis, but should discuss with their cardiologist prior to treatment. Home laser or electrolysis devices have not demonstrated effectiveness and may cause harm.[24]

Managing pain during the procedure

At least some discomfort can be expected during either procedure.[25] Each patient is best assessed individually to determine the optimal approach for pain control. The response to each treatment can vary based on the location of treatment, level of hydration, anxiety and stress. Creating a soothing environment, the use of reassurance, deep-breathing, thoughtful orientation to the device, use of a 'test-spot,' pre-treatment with a cold compress and over-the-counter pain medication (acetaminophen) may all be helpful. It is best to avoid NSAIDS immediately prior and after treatments to minimize the risk of bruising. The use of narcotics is typically not needed, but may be appropriate in some cases.

Topical anesthetics:

Lidocaine-containing products (alone or in compounded form) should be provided to the patient initially and then as requested. Topical anesthetics reduce procedure-related pain with minimal side effects. Careful attention must be paid to the particular anatomic location, the total surface area covered, and the duration of anesthetic skin contact. Topical anesthetics can be applied 15-45 minutes prior to treatment and are typically removed during or after the procedure(s).[26-30] The use of EMLA (lidocaine 2.5% and procaine 2.5%) may have limited effect, primarily due to the prolonged onset of action and need for an occlusive barrier during the pre-treatment phase. The combination of benzocaine 20%, lidocaine 8% and tetracaine 4% (BLT) is a common and effective combination. This preparation should only be applied by a licensed medical provider or nurse, as application of excessive amounts can result in toxicity.

References

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2. Radix AE, Lelutiu-Weinberger C, Gamarel KE. Satisfaction and healthcare utilization of transgender and gender non-conforming individuals in NYC: a community-based participatory study. LGBT Health. 2014 Dec;1(4):302-8.
3. Human Rights Campaign (link is external). Finding Insurance for Transgender-Related Healthcare. Human Rights Campaign. [cited 2016 Mar 22].
4. Transgender Law Center (link is external). Recommendations for Transgender Health Care. [cited 2016 Mar 22].
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7. San Francisco Department of Public Health (SFDPH). Patient Education for Phalloplasty (link is external). Transgender Health Services [cited 2016 Mar 22].
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19. Epilepsy Foundation. Photosensitivity and Seizures (link is external). Epilepsy Foundation. [cited 2016 Mar 22].
20. Parver DL, Dreher RJ, Kohanim S, Zimmerman P, Garrett G, Devisetty L, et al. Ocular injury after laser hair reduction treatment to the eyebrow. Arch Ophthalmol Chic Ill 1960. 2012 Oct;130(10):1330-4.
21. American Electrology Association. FAQs about permanent hair removal (link is external). [cited 2016 Mar 22].
22. American Institute of Education: Electrology Program. What's Your Frequency? Electrolysis and Electrology (link is external). [cited 2016 Mar 22].
23. WebMD. Electrolysis for Removing Hair (link is external). [cited 2016 Mar 22].
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26. Chiang YZ, Al-Niaimi F, Madan V. Comparative efficacy and patient preference of topical anaesthetics in dermatological laser treatments and skin microneedling. J Cutan Aesthetic Surg. 2015 Sep;8(3):143-6.
27. Eidelman A, Weiss JM, Lau J, Carr DB. Topical anesthetics for dermal instrumentation: a systematic review of randomized, controlled trials. Ann Emerg Med. 2005 Oct;46(4):343-51.
28. Sobanko JF, Miller CJ, Alster TS. Topical anesthetics for dermatologic procedures: a review. Dermatol Surg Off Publ Am Soc Dermatol Surg Al. 2012 May;38(5):709-21.
29. Cohen JL. Pain management with a topical lidocaine and tetracaine 7%/7% cream with laser dermatologic procedures. J Drugs Dermatol JDD. 2013 Sep;12(9):986-9.

Medical Referral Disclaimer

The CoE is unable to respond to individual patient requests for medical guidance. If you need medical advice, please contact your local primary care provider. If you need clarification, seek a second opinion locally or have your provider contact us for more information.