Abstract: Unwanted hair growth presents a significant problem for many patients and considerable resources are spent to achieve a hair-free appearance. Our aim of this study was to further evaluate the efficacy of this method in hirsutism in our region. Sixty patients with idiopathic hirsutism presenting to Dermatology Clinics of Tabriz University of Medical Sciences from September 2007 to March 2009 were classified in three groups regarding the site of hirsutism (chine, face, or mustache). All patients underwent IPL-therapy every month for six sessions. The changes in number and diameter of regional hairs were recorded at the end of each session. The patients had the mean age of 25.50±3.01 years (18-33 year). The disease was in chin in 26 cases (43.3%), face in 18 patients (30%) and mustache in 16 (26.7%). The skin type was III in 49 (81.7%) or IV in 11 (18.3%) patients. The positive therapeutic response after sixth session in total and in chin, face and mustache were 86.43, 88.66, 86.95 and 82.19%, respectively. The therapeutic response was not statistically significant in different body regions. The hair number in all treated regions was decrease significantly in each session in comparison with the first therapeutic session (p<0.05). Also, the hair diameter at the end of last session was decreased significantly in comparison with the first session in all treated regions (p<0.05). Regarding the high efficacy (86.42%) of IPL in treatment of facial hirsutism and absence of side effect, it is recommended as an effective treatment modality in hirsutism.
INTRODUCTION
Unwanted hair growth remains a significant problem for many patients and considerable resources are spent for finding an effective and safe treatment modality in order to achieve a hair-free appearance (Serrano-Grau et al., 2009; Marayiannis et al., 2003; Haedersdal and Gøtzsche, 2006; Haedersdal and Wulf, 2006). Approximately 80% of women are affected by the presence of excessive hair growth which can cause embarrassment and result in a significant emotional burden and psychological problems such as anxiety, depression and a reduced quality of life (Cameron et al., 2008; Shapiro and Lui, 2006; Dawber, 2005).
It is very important to determine the underlying causes. Although the most are ethnic or hereditary, one must rule out any signs of androgen excess, e.g., an increase in body hair, irregular menstrual cycles, acne, alopecia and seborrhea (Shapiro and Lui, 2006).
A variety of treatment methods are available, including plucking, waxing, depilatories, bleaching, shaving, electrolysis, laser, Intense Pulsed Light (IPL) and eflornithine cream (Marayiannis et al., 2003; Cameron et al., 2008; Shapiro and Lui, 2006; Dawber, 2005; Haedersdal et al., 2005). Epilation with laser devices and IPL are commonly used although the long-term effect is uncertain (Haedersdal and Gøtzsche, 2006). Different light sources were developed as the treatment of choice (Serrano-Grau et al., 2009; Toosi et al., 2006). Alexandrite laser, diode laser and IPL were clinically used for this purpose with long-term scarce comparative results (Toosi et al., 2006). Photoepilation has become a very popular procedure in aesthetic and cosmetic practice (Marayiannis et al., 2003). IPL devices are high-intensity pulsed sources, usually xenon arc lamps, emitting broad-wavelength polychromatic light between 550 and 1200 nm (Serrano-Grau et al., 2009). In recent years, the use of broad spectrum white light sources has proved to be safe and efficacious in the removal of hair with minimal short- or long-term side effects (Omi and Clement, 2006). IPL technology has revolutionized the noninvasive treatment of a whole variety of cutaneous cosmetic problems. Today’s machines are safer, more diverse, less painful and readily available. Newer, less powerful home-device IPL sources will not replace those used in a physician’s office but will augment the use of today’s more powerful medical office systems (Ciocon et al., 2009).
Studies have claimed IPL to be beneficial in the reduction of the number and/or thickness of the unwanted hair, from terminal hair to vellus (Grippaudo et al., 2009).
To date, we find only one published study about the efficacy of efficacy of IPL in unwanted hair removal in our country (Toosi et al., 2006) and also few studies evaluating the IPL effect on the multiple locations on face. Our aim of this study was to further evaluate the efficacy of this method in hirsutism on chine, face and mustache in our region.
MATERIALS AND METHODS
This is an analytic study performed on patients with hirsutism presenting to Dermatology Clinics of Tabriz University of Medical Sciences from September 2007 to March 2009. Inclusion criteria were having idiopathic hirsutism in facial region. Exclusion criteria were secondary Hirsutism, having systemic disease.
A total of 60 patients were selected randomly and were classified in three groups regarding the site of hirsutism (chine, face, or mustache).
All patients underwent IPL-therapy every month for six sessions. All treatments were made by one expert dermatologist. The changes in number and diameter of regional hairs were evaluated and recorded at the end of each session.
The severity of hirsutism was determined according to the number of hairs in each region and classified as mild (5-20 hair), moderate (20-60 hair) and severe (>60 hair or involvement of all region). The skin type of patients was determined according the Fitzpatrick scale.
The study was approved by the Regional Ethics Committee. Patients signed informed consent before the operation.
The studied variables were age, site of involvement (chine, face, or mustache), severity of hirsutism, duration of disease, skin color, background disease, familial history and the results obtained in sessions 1-6 (the change in number and diameter of hairs).
The collected data were analyzed by SPSS-15 statistical software. The collected data were expressed as percentage and Mean±SD. Continuous (quantitative) variables were compared by student t-test or one-way ANOVA (Independent samples). Categorical (qualitative) variables were compared by contingency tables and chi-square test or fisher’s exact test. p-value = 0.05 was considered statistically significant.
RESULTS
All of 60 studied patients with idiopathic hirsutism were classified in three groups according the site of involvement: group C (chine involvement), group F (face involvement) and group M (mustache involvement). The demographic and basic characteristics of patients are presented in Table 1.
Table 2 shows the percent of hair removal in various sessions. In group C, the number of hairs was decreased significantly in all sessions, except for 3rd session. In group F, the hair decrease was significant in all sessions. In group M, the significant hair decrease was seen in all sessions, except for 2nd session (Table 2). In comparison with the first session, the hair removal was significant at the last session in all groups (p<0.001).
| Table 1: | Demographic and basic characteristics of studied patients |
| Table 2: | The average change of hair number in therapy sessions |
| Table 3: | The average change of hair diameter in therapy session |
| Table 4: | The average decrease of hair number in different therapy sessions |
| Table 5: | The average decrease of hair diameter in different therapy sessions |
Table 3 shows the percent of decrease in hair diameter in various sessions. As showed in this table, the hair removal in total patients was significant (p<0.05) except for second session in group C (p = 0.449) and group M (p = 0.726) in which the decrease in hair diameter was not statistically significant. Also, in comparison with first session, the hair removal in total patients was significant (p<0.001 for all sessions and p = 0.020 for the second session).
Table 4 shows the change (decrease) in the number of facial hairs in various therapeutic sessions. Comparison of change in hair number between therapeutic sessions showed that the most decrease in all groups and also in total patients was happen between the sessions 1 and 6 (p<0.001).
Table 5 shows the change (decrease) in the diameter of facial hairs in various therapeutic sessions. Comparison of change in hair diameter between therapeutic sessions showed that the most decrease in all groups and also in total patients was happen between the sessions 1 and 6 (p<0.001).
According the hairs number and diameter, the rate of response to therapy in three studied regions was not significantly different (p>0.05). The difference of hair numbers in studied groups in sixth session (p = 0.611), hair diameters in studied groups in sixth session (p = 0.176), hair numbers in first session in comparison with sixth session (p = 0.321) and hair diameters in first session in comparison with sixth session (p = 0.422) were not statistically significant (Table 4, 5).
Also, the relation between skin type (III or IV) and the rate of response to therapy was not statistically significant (p>0.05). The average decrease in hair numbers in patients with skin type of III was 87.24±14.62% in comparison with 91.82±9.03% in patients with skin type of IV (p = 0.315). The average decrease in hair diameters in patients with skin type of III was 84.39±15.73% in comparison with 86.36±9.24% in patients with skin type of IV (p = 0.691).
The difference of hair numbers in first session in comparison with sixth session was 30.31±21.42% in patients with skin type of III and 30.91±13.00% in patients with skin type of IV (p = 0.929, non-significant).
The difference of hair diameters in first session in comparison with sixth session was 27.45±19.64% in patients with skin type of III and 25.45±13.68% in patients with skin type of IV (p = 0.751, non-significant).
DISCUSSION
Hirsutism affects 5-10% of unselected women, depending on definition and ethnicity (Sanchez et al., 2002). Female hirsutism is an embarrassing condition that threatens both a woman’s perception of her femininity and her self-esteem (Watts, 2006). Hirsutism is defined as the excessive growth of thick dark hair in locations where hair growth in women usually is minimal or absent. Such male-pattern growth of terminal body hair usually occurs in androgen-sensitive locations, such as lips, chin, chest, areola, abdomen, back and femoral region (Stanczyk, 2006; Tekin et al., 2004). The etiology and the age of the patient when hirsutism occurs vary widely. In hirsutism of gradual onset, hyperprolactinemia, insulin-resistance syndromes, hyperthecosis, polycystic ovary syndrome and idiopathic hirsutism may be responsible (Tekin et al., 2004).
The use of light and laser for hair removal has evolved during the past decades (Sanchez et al., 2002; El-Bedewi, 2004). Lasers useful in hair removal may be grouped into three categories based on the type of laser or light source each employes: 1) red light systems (694 nm ruby), 2) infrared light systems [alexandrite laser (755 nm), semiconductor diode laser (810 nm) and neodymium: yttrium-aluminium-garnet (Nd:YAG) (1064 nm)] and 3) Intense Pulsed Light (IPL) source (590-1200 nm) (Sanchez et al., 2002; El-Bedewi, 2004). There is still an increasing demand for safer and more efficient hair removal techniques. The latest and most effective choice in the treatment of hair removal is non-coherent IPL, which is both efficient and safe method (El-Bedewi, 2004). Laser hair removal appears to be a useful adjuvant in the treatment of the hirsute patient (Sanchez et al., 2002; El-Bedewi, 2004; Randall et al., 2006). Lasers are useful for the removal of unwanted hair, using selective destruction of the hair follicle without damage to adjacent tissues (Sanchez et al., 2002; Randall et al., 2006).
The ruby laser, alexandrite laser and diode laser, as well as IPL are commonly used devices for hair laser removal. The long-pulsed Nd:YAG laser is the safest device for hair removal in dark-skinned patients because of its long wavelength, although the diode laser, alexandrite laser and IPL may be used (Wanner, 2005). Treatment with the ruby, alexandrite or diode lasers, or the use of IPL results in similar success rates, although these are somewhat lower for the nd:YAG laser (Sanchez et al., 2002).
The evidence from controlled clinical trials favors the use of lasers and light sources for removal of unwanted hair (Haedersdal and Wulf, 2006). IPL is not a real laser system because it delivers broad spectrum, non-coherent radiation with wavelength of 550-1200 nm (Sanchez et al., 2002). For the safe and effective removal of unwanted hair, the key optical parameters are wavelength, pulse duration and energy density and can vary dependent upon skin and hair color (Omi and Clement, 2006). The specific light parameters (wavelength, pulse numbers and duration and energy fluence) are individualized by computer according to the skin type and hair color. Histological examination has revealed hair follicle atrophy following IPL (Sanchez et al., 2002).
The method for laser and light assisted hair removal is based on the theory of selective photothermolysis. Selective absorption of hair chromophores from lasers and broad band light sources results in destruction of hair follicles without destroying the adjacent tissues (Sanchez et al., 2002; Lask et al., 1999). These systems are efficient and safe with proper patient selection. Multiple treatments are necessary due to the nature of the hair growth cycle (Lask et al., 1999). Selective photothermolysis relies on the absorption of a brief radiation pulse by specific pigmented targets, which generates and confines the heat to that selected target (Sanchez et al., 2002). The type of laser or IPL and their specific parameters must be adapted to the patient (hair thickness, pigment concentration, Fitzpatrick skin type) (Drosner and Adatto, 2005).
In our study, 81.7% of patients had the skin type III and 18.3% had skin type IV (according the Fitzpatrick skin typing). There was no significant difference between treatment results in both groups. In general, laser hair removal is most successful in patients with lighter skin colors and dark colored hairs (Sanchez et al., 2002). The best candidates for phototermolysis are patients with lighter skin (Fitzpatrick type I- IV) and dark hairs. While successful hair removal with either laser or IPL has been reported in patients with Fitzpatrick skins type V and VI, it is clear that the incidence of complications such as burns, scarring and hypo- or hyperpigmantation increases with the degree of skin pigmentation hair (skin types II-IV). Adverse effects are minimal and transient (Drosner and Adatto, 2005; Nahavandi et al., 2008; Goh, 2003; Yaghmai et al., 2004). The successfulness of IPL in our patients with skin type of III and IV is in support of its efficacy of these types of skins especially in this region (a Middle East country).
Individuals with dark skin and especially tanned patients, are at higher risk for pigmentary changes (Drosner and Adatto, 2005; Goh, 2003; Yaghmai et al., 2004). In individuals with dark skin the high melanin concentration in the epidermis absorbs high energies that can lead to complications (Yaghmai et al., 2004). Because the skin types of IV and more are less prevalent in our region and this can explain the high success rate for IPL in our study. Another factor that causes the IPL to be the most suitable method for hair removal in our region is the high prevalence of dark hairs. Also, in our study, the dark hairs respond better to IPL hair removal.
Although long-term hair removal in hirsute women remains a challenging issue (Schroeter et al., 2004), Long-term hair removal has been claimed using IPL (Yaghmai et al., 2004). In a study of 14 subjects treated with IPL and followed for >12 months after the last treatment, a mean of 83% hair reduction was achieved after two to six treatments (Sanchez et al., 2002; Sadick et al., 2000). Average rates of long-term hair reduction are reported at between 70 and 90% at 6 months follow-up (Drosner and Adatto, 2005). However, laser or IPL hair removal should not be considered ‘permanent’ owing to the long growth/rest cycle of normal human hair follicles (Haedersdal and Gotzsche, 2006; Sanchez et al., 2002; El-Bedewi, 2004). Repeated therapies are necessary, although complete alopoecia is rarely achieved and it is unclear at what point the maximum benefit is achieved from multiple therapies (Sanchez et al., 2002; El-Bedewi, 2004). Several studies on hair removal with IPL and various laser sources have been done, but adequate data on long-term follow up are scarce (Nahavandi et al., 2008).
Applications for IPL for hair removal are gaining favor among other methods, including lasers, because of its noninvasive nature, versatility regarding different skin and hair types, safety and ease of use (Fodor et al., 2005). Toosi et al. (2006) compared the clinical efficacy, complications and long-term hair reduction of alexandrite laser, diode laser and IPL on 232 Iranian patients. The number of sessions to reach optimal result varied between 3 and 7. Six months after the last session, their findings indicated that all three light sources tested have similar effects on hair removal and in Iranian patients, using lower wavelengths minimizes the side effects (Toosi et al., 2006). Bjerring et al. (2000) conducted a clinical study on 31 patients to compare the effectiveness of an IPL and ruby laser for hair removal. The patients were treated 3 times with a new IPL on one side of the chin and neck and with ruby laser on the other side. After 6 months, IPL was found to be 3.94 times more effective than the ruby laser for hair removal (Bjerring et al., 2000).
El Bedewi treated 210 patients with skin type III-V for superfluous hair in different areas of the body (face, extremities, axillae, bikini line and back) for three to five sessions at 6-week intervals using IPL. There was a significant hair reduction of about 80% with no side effects and minimal complications. Follow-up was done 6 months after the last session (El-Bedewi, 2004). IPL is also a safe and reliable method to remove unwanted hair on skin grafts. It can be easily performed with a lower complication. Huo et al. (2008) treated 10 patients with hairy skin grafts with IPL for hair removal 3 to 5 times at intervals of 2 months. The hairs were removed completely after 3 to 5 treatments (Huo et al., 2008).
The first published report of the use of IPL for hair removal was for the treatment of terminal beard hairs in two transsexual patients. Repeated treatments appear to improve outcome, although more than three treatments do not appear to increase the success rate (Sanchez et al., 2002; Sadick et al., 2000). Recently, IPL sources have been shown to provide long-term hair removal (Lee et al., 2006; Schroeter et al., 2003). IPL is an ideal hair-removal method because of the credible effect, simple operation, rapid treatment and no serious complications (Huo et al., 2005).
In support of over mentioned studies, the hair removal of 86.42% achieved in our study following 6 sessions of treatment with significant loss in hair count and diameter, was an expected finding which further indicates the efficacy of IPL hair removal. Lee et al. (2006) used IPL for hair removal in 28 Korean women in the axillary area. Four treatments were carried out at intervals of 4 to 6 weeks. The unwanted hairs were wholly removed after 3-5 procedures. Follow-up for 8 months after the last treatment showed the average clearances of 52.8 to 83.4% (Lee et al., 2006). Schroeter used IPL for unwanted hair removal in 25 male-to-female transsexual patients in Netherlands. Follow-up lasted an average of 44 months. They achieved a mean hair clearance rate of 90%. The average number of treatments per patient was nine. (Schroeter et al., 2003). Fodor et al. (2005), studied the use of IPL for hair removal on 80 patients. Although permanent hair removal could not be guaranteed, based on patient satisfaction rate, they recommend using IPL for hair removal (Fodor et al., 2005).
One study evaluated the efficacy of four popular systems for laser hair removal: 1) IPL with a red filter; 2) IPL with a yellow filter; 3) iode laser and 4) alexandrite laser. Evaluation at 1, 3 and 6 months revealed a significant decrease in hair counts (approximately 50%) and hair coverage (approximately 55%). Treatment with IPL caused less pain, with efficacy similar to laser systems (Amin and Goldberg, 2006). Marayiannis et al. (2003) compared LP-Alex, SP-Alex or IPL for hair removal in 389 patients (skin types II-V), in Greece. There was not any significant difference between the LP-, SP-Alex and IPL with regard to efficacy. Transient side effects were highest with the LP-Alex and least with the IPL (Marayiannis et al., 2003).
Although laser and IPL are very popular because of their non-invasive nature and the speed at which they operate, practitioners and patients have to be cautious to avoid permanent side effects instead of permanent hair reduction (Drosner and Adatto, 2005). Schroeter et al. (2003) studied 70 female hirsute patients in the Department of Laser Therapy at the Netherlands. They were subjected to a mean of 8 treatments followed for a mean period of 27.3 months. Using the IPL, 87% hair removal was achieved. Minimal side effects occurred in 10% of the patients. They concluded that IPL is effective in achieving long-term hair removal (Schroeter et al., 2004). Paradoxical hypertrichosis and terminal hair change is a common complication of IPL photoepilation. The other more commonly seen complications were epidermal burning with blisters, erosion and crust formation followed by post-inflammatory hypo- and/or hyperpigmentation (Radmanesh, 2009). Huo et al. (2005) used IPL for unwanted hair removal in 341 Chinese patients. The treatment took 3-5 procedures, with an interval of over 2 months. There were blister in 3 cases and infection in 1 case. No pigmentation and scarring happened. Following-up of 3-6 months showed steady results with less regeneration of very thin and soft hair (Huo et al., 2005). Burning and its sequellae, leukotrichia, paradoxical hypertrichosis and folliculitis are four major side effects of IPL hair removal therapy (Radmanesh et al., 2008). However, we found not any significant side effect in our study. This may be due the especial regional distribution of women hairs. So that, the skin types of IV and X are less prevalent and the dark hairs are more prevalent in our region, as indicated in our study.
As compatible with the previous findings (Cameron et al., 2008; Schroeter et al., 2004) our study showed that the number of treatments correlated with the amount of hair lost; so that, the best results were achieved at the last (6th) session.
Lasers and IPL are now used worldwide for prolonged photoepilation (Radmanesh et al., 2008). A review of literature in 2008 showed that the patients underwent laser or IPL photoepilation, were treated every 4-6 weeks and for eight sessions or more and all patients were followed for up to 20 months (Radmanesh et al., 2008).
CONCLUSIONS
IPL is a safe and efficient modality for removing waste facial hairs of Iranian women with type 3 or 4 skin type. The fair skin with dark hairs is the best candidate for IPL-therapy for hair removal in hirsutism. We obtained the best results in end of the sixth session. Regarding the high efficacy (86.42%) of IPL in treatment of facial hirsutism and absence of side effect, it is recommended as an effective treatment modality in hirsutism.