Dr Baldeep Farmah provides an introduction to how laser hair removal can be made more accessible for patients with skin of colour
The global laser hair removal industry is growing and is expected to be worth $3.4 billion by 2026, according to market experts Acumen Research and Consulting.1
Despite this buoyant growth prediction, laser hair removal has historically been a subject of avoidance for patients who have darker skin tones, specifically those identified as skin types IV, V and VI on the Fitzpatrick skin type scale.2,3 Predominantly, this can be attributed to many professional laser hair removal devices being unsuitable for use on these skin types due to the possibility of certain adverse effects. These include (but are not limited to) hyperpigmentation,4 hypopigmentation,5 blistering and scarring.6
The previous inability within the aesthetics industry to treat patients with skin types IV, V and VI has been problematic to patient and practitioners alike. This treatment exclusion meant that patients were not able to experience the same level of technology as their fair-skinned counterparts and were left having to resort to more traditional, and less sophisticated and effective methods of depilation including shaving, waxing, depilatory creams and electrolysis.
The situation is thankfully, if somewhat slowly, changing. Ongoing
technological advancements coupled with improved awareness and
education within the specialty in recent years means that laser hair
removal devices can now reliably treat patients with darker skin tones,
providing excellent outcomes.
One UK survey by the Black Skin Directory revealed that 92% of black women said it was a challenge to find a skincare professional who could meet their needs.7 In addition, 90% of respondents said the experience and knowledge of treating skin of colour (SOC) was the primary reason they chose a particular clinician.7
These statistics highlight how imperative it is that aesthetic practitioners are fully educated and informed about all skin types, and to avoid a ‘one size fits all’ approach. There are various physiological differences between dark and fair skin types that should be acknowledged, including the stratum corneum cell layers,8 ceramide levels,9,10 skin pH,11 transepidermal water loss (TEWL),12 and pigmentation.13 Specific knowledge and understanding should be applied, with particular focus on understanding melanin distribution in skin types, and how melanin reacts to laser wavelengths. It is also important to acknowledge the potential psychological impact of former treatment exclusion and how treatment disadvantage can be stressful and upsetting to explain.
The consultation itself should be structured as such so
that concerns about safety and efficacy on darker skin
types are answered before questions are even asked.
This is in addition to standard consultation discussion
points such as treatment goals and expectation, current
method of hair removal, how laser treatments work,
different types of laser technology and why certain
treatments are more effective than others, the treatment
process and any factors that may affect outcome,
medical history, pre- and post-treatment treatment care,
cost and frequency and anticipated outcome.
In addition, in my clinic, I will always perform a patch
test to observe epidermal responses, establish the
best treatment parameters for the specific skin type,
and ascertain any adverse reactions 48-72 hours
Part of the consultation process should include an analysis of skin type. The current industry standard is to use the Fitzpatrick scale that classifies skin into six broad categories (I being the fairest skin types and VI being the darkest) and is used to establish how much melanin is in the skin.14 As the population continues to diversify, there is conversation within the industry as to whether the Fitzpatrick scale is still relevant. As a result, some practitioners use a combination of different scales. One such example is the Roberts Skin Type Classification System, which observes both the Fitzpatrick and Glogau scales, and considers propensity to pigmentation, scarring and inflammation which can be useful when planning a patient’s treatment regimen.15,16
What current skin type scales do not explain and is useful to acknowledge are the physiological differences in skin types. This is important to ensure that different skin types are treated appropriately and safely, and to form an understanding of why difficulties in treating darker skin types can arise.
A key difference pertaining to laser hair removal lies in skin pigmentation. Up to 8% of the cells in the stratum basal level of the epidermis is a melanocyte.17 Melanocytes make the pigment called melanin. When laser and light energy passes through the epidermis to target its chromophore, the energy has to go through the melanocytes in the epidermis. Melanocytes in the hair bulb, epidermal melanocytes and the melanin within them can act as competing chromophores and absorb this energy, resulting in an increased risk of complications and a higher frequency of adverse events such as erythema. Longer wavelengths are considered to be more effective on darker skin types as they are absorbed less by melanin.17 In addition, longer pulse durations are also recommended to prevent overheating. Excessive overheating of melanocytes in darker skin types can result in post-inflammatory hypopigmentation which is a widely recognised adverse event of laser hair removal.17
Given the wealth of technological capabilities within the sector, it's almost unbelievable to conceive that only a decade ago, laser hair removal on darker skin was unheard of
Given the wealth of technological capabilities within the sector, it’s almost unbelievable to conceive that only a decade ago, laser hair removal on darker skin tones was unheard of. Part of the historic problems lie in the basic fundamentals of how lasers work. Many devices were simply not sophisticated enough to distinguish sufficiently between the increased amount of epidermal melanin in skin types IV-VI and melanin present in the hair follicles and shaft. It is this technological ‘confusion’ that led to a higher frequency of adverse effects. Technology is fundamental to aesthetic clinics becoming more inclusive and it’s essential for practitioners to carefully consider what a laser hair removal device can offer their clinic and patients before making an investment commitment. Different types of laser hair technology include Ruby, Alexandrite, Diode and Nd:YAG.
A Ruby laser produces pulses of red visible light at a wavelength of 694.3 nm. It is very well absorbed by the melanin pigment in the hair, making this system very effective for people of skin tones I to III on the Fitzpatrick Scale. However, due to the shorter wavelength of the Ruby laser system being absorbed more by melanocytes, is not recommended for individuals with darker skin tones due to the possibility of pigmentation issues and scarring in skin tones IV to VI.18
The Alexandrite is a red-light laser that uses an Alexandrite crystal as a
medium and operates at a shorter wavelength of 755 nm. This makes
it ideal for targeting the melanin in the hair follicles of individuals with
light to olive skin tones. Extreme caution is recommended in patients
with skin types IV to VI as the laser can destroy melanin, resulting in
A precursor to the arrival of Nd:YAG technology, Diode lasers use
semiconductor technology combined with a single narrow spectrum
light beam to target specific chromophores in the skin. The 808 nm
diode laser wavelength has a high abruption rate in melanin and uses
the principle of selective photothermolysis (SPTL) to target melanin. The
laser selectively heats the melanin and destroys the root and blood
flow to the hair follicle, which results in the disruption of hair growth and
regeneration. Suitable for use on all Fitzpatrick skin types, a diode laser
can be complemented by cooling technology, or other pain reducing
methods which improve treatment efficacy and patient comfort.21
I personally choose to use a device that combines both Nd:YAG and Alexandrite in my clinic. My device of choice is the Lumenis SPLENDOR X system, although there are many other devices available which are suitable for treating SOC. When choosing a device, I would always encourage practitioners to assess the clinical studies relating specifically to SOC for the specific device and look for a device that is customisable so you can tailor the treatment to fit the patient’s specific skin type, hair colour and thickness for the most effective treatment. You also want to consider speed for hair removal, so be sure to enquire about the spot size. This is because larger spot sizes allow the laser to penetrate deeper into the epidermis and allows the practitioner to cover larger areas more quickly.24
Technological advancements in the aesthetics industry and
specifically laser hair removal have opened a wealth of opportunities
to patients and practitioners alike. Practitioners should ensure that
they research available system technology thoroughly and choose
an option that not only allows them to treat a diverse patient base,
but that also offers them the ability to expand their expertise,
knowledge and training – all fundamental elements for procuring
trust between patient and practitioner. All decisions should involve
an element of inclusion so that all patients feel respected and
treated as an individual and their physiological and psychological
needs are considered and fulfilled simultaneously.
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