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A Comparative Study of Hair Removal at an NHS Hospital: Luminette Intense Pulsed Light vs Electrolysis
Karen Harris, Janice Ferguson & Samantha Hills1
Withington Community Hospital, Manchester, UK
1Lynton Lasers Ltd, Cheshire, UK

Abstract

Twenty-five women, previously referred for NHS hair removal by electrolysis, were enrolled in a split face study to treat facial hirsutism. Each patient was treated on just six occasions, one half of the face with electrolysis, the other side with an intense pulsed light source. Patients were evaluated with respect to reduction in hair counts, side effects and discomfort during treatment. All patients treated, except one with very sparse, fair hair growth, preferred treatment with the Intense Pulsed Light and rated their average hair reduction with this method as 77% after 5 treatments. The overall patient satisfaction rates as determined by Visual Analogue Scales were 8.3 out of 10 for IPL and 5.4 out of 10 for electrolysis.

Introduction

South Manchester University Hospital NHS Trust receives in the region of 60 referrals per year for treatment of facial hirsutism. Selected patients with medically significant hirsutism are currently treated by electrolysis of individual hair follicles. The method of electrolysis was first described by Dr. Charles E. Michel, an ophthalmologist who, in 1875, reported the results of his use of electrolysis in trichiasis (ingrown eyelashes)[1]. He had been performing electrolysis since 1869. In 1924, Dr. Henri Bordier of Paris published the first article on the removal of unwanted hair growth by the method of thermolysis (also called short-wave, diathermy, high-frequency etc.) However, medical literature of the period indicates that this method was probably attempted as far back as 1910 in Germany by Dr. Eitner[2]. The thermolysis method can be used to destroy the hair by coagulation or by cauterization. Outcomes are very much operator dependant and best results are achieved by careful selection of probe size and the correct application of current intensity.
During the twentieth century, improvement has been seen with electrolysis equipment, pre-sterilized disposable needles and training, enabling the treatment to be accessible world wide. Nonetheless, treatment is uncomfortable and time-consuming – for example, a female patient with severe male pattern hair growth treated at the hospital, underwent over 180 treatment sessions of 60 minutes duration to achieve clearance of facial hair. The results depend on the anatomical site, type of hair, size of hair, hair density and the technique requires a high degree of operator skill. The side effects are relatively mild if patients are carefully selected and include a small risk of pigment changes and scarring in addition to common temporary changes including folliculitis, erythema and swelling immediately post treatment. Treatment is moderately painful and some individuals are intolerant even with the use of a topical anaesthetic cream.
Lasers and Intense Pulse Light (IPL) sources for hair removal are now in widespread use in the private sector[3, 4]. These systems work on the principle of Selective Photothermolysis[5], in which light is absorbed by the melanin contained within the hair shaft. This produces a heating effect which may be sufficient to cause permanent damage to the hair follicle which will delay or prevent future hair re-growth.
Clinical studies relating to the efficacy, clinical safety and relative effectiveness of light-assisted hair removal compared with the standard treatment of electrolysis have lagged behind clinical use. This study aims to produce an evidence base for the effectiveness or otherwise of an IPL source over electrolysis. As a secondary aim, efficacy, side effects and patient preferences will also be addressed.

Materials and Methods
Female patients referred to the hospital for removal of unwanted facial hair were invited to take part in the study. Pregnant women, or those suffering from photosensitising conditions were
Skin Laser Review Group, 2 (3) July 2005
excluded from the study along with patients with skin type VI.
Twenty-five women with facial hirsutism were enrolled for the study. Of this number, 14 had been previously diagnosed as suffering from Polycystic Ovarian Syndrome, and the remainder had idiopathic hirsutism.
Patients underwent a thorough medical consultation and patch test prior to the first full treatment. Electrolysis was performed on one side of the face for a total of 15 minutes per session, and Intense Pulse Light administered to an equivalent area on the other side. A total of 6 treatment sessions were carried out at 4-6 weekly intervals. Hair counts were determined before and after each treatment and a future paper will present the results obtained 3, 6 and 9 months after the completion of treatment. Photographs were taken before each treatment and any side effects suffered after the last treatment noted. After each treatment, patients were asked to assess the level of discomfort of both treatments using a Visual Analogue Scale, and at the end of the course of treatments, a more detailed feedback form was filled in, questioning treatment preference and patient perception of percentage hair loss.
The IPL treatment was administered using the Luminette system (Lynton Lasers, Cheshire, UK). The Luminette has two separate handpieces with different filtered outputs. The vascular and pigmented lesion handpiece has an emitted wavelength range of 550–1100 nm, whilst the hair removal handpiece (used in this study) emits 650-1100nm. These wavelengths are readily absorbed in melanin but avoid the main absorption peaks of blood, therefore avoiding the possibility of vascular damage. The pulse train delivered by the system is controlled via a skin type selection, and ranges from 95 to 200ms. Darker skin types have longer pulse train times in order to deliver the light to the skin in a safer, more gentle manner in order to minimise heating in the epidermal melanin. Treatment parameters were selected according to skin type and hair type, and ranged from 16J/cm2 to 32J/cm2. The IPL system used has interchangeable quartz light guides, which deliver light to a range of treatment areas, from 1 to 3.5cm2. The average number of shots administered in each treatment was 20 (maximum 74, minimum 4) and treatment times were typically in the region of 5 minutes.
The electrolysis method chosen for treatment was the “flash” technique, which causes destruction of the hair follicle and blood vessels by coagulation. Application of current intensity is high but can be applied in quick succession, speeding up treatment times and enabling hairs to removed quickly and reducing pain discomfort. It is expected that post treatment, skin reactions are more pronounced when using the flash method in comparison to other electrolysis techniques. The average intensity applied with the Silhouette machine was 80 μA with the exception of the more sensitive upper lip, where average currents used were 40μA. The average needle size used in the trials was 004/003. Gold needles were used on diabetic patients or those with extremely sensitive skins. The skin was cooled with ice packs before and after both treatments.

Results and Discussion
After six treatments, every woman treated, regardless of hair colour or texture, saw some degree of improvement with both techniques. The photographs and hair counts clearly show that for women with more than approximately 100 hairs in the area to be treated, Intense Pulsed Light is by far the quickest method of hair removal. Of the 25 women who started the study, four dropped out partway through treatment, one woman due to pregnancy, one woman because she found both treatments too uncomfortable and the remaining two were unable to attend clinics at the required frequency. Of the 21 women who completed the six treatments, only two preferred treatment with electrolysis, one of whom changed her mind at the follow-up sessions. Both these women had light hair and very sparse hair growth (initial hair counts of 24 in one woman, and 60 on the other).

Patient Assessment
After each treatment, patients were asked to complete a visual analogue scale, indicating discomfort levels for both treatments. The discomfort ratings for the Intense Pulsed Light treatments decreased as the treatment progressed, from 4.5 out of 10 after the first treatment to 2.9 out of 10 after the sixth treatment (average 3.8). This is to be expected as the density of hair follicles present reduces. There was no statistically significant difference in discomfort levels throughout the electrolysis treatments (4.5 after the first treatment and 4.7 after the final 2
Skin Laser Review Group, 2 (3) July 2005
treatment, average discomfort rating 4.6 out of 10).
Immediately after the sixth and final treatment, the patients filled in a form which monitored overall patient discomfort levels and perception of hair loss for both treatments. The average electrolysis discomfort level when measured at this point was 5.3 ± 2.7 out of 10, and the average discomfort rating for IPL was 3.8 ± 1.8 out of 10. These values show a statistical correspondence to the averages obtained immediately after each treatment.

Side Effect Profile
The incidence of side effects with both treatments was low. Seventeen patients were questioned as to both positive and negative side effects and the results can be seen in figure 7. Negative side effects were particularly unusual with the IPL, with only 8 people seeing some immediate erythema, and only 2 experiencing redness that lasted for more than 24 hours. No burning, blistering, pigmentation changes or scarring were experienced. As expected, the incidence of side effects was higher with the flash electrolysis method, with most people experiencing initial erythema, crusting and swelling. No scarring was reported but one person noted some a small area of hyperpigmentation.
Positive side effects were also noted with both treatments. Finer and lighter hair was commonly seen with the IPL treatments, (10 and 7 reports respectively from the 17 patients questioned). Thirteen people reported an increase in self-confidence after IPL treatment, compared to 8 after electrolysis. 15 people also reported a decrease in the time spent on hair removal on the IPL treated side (8 on electrolysis). Interestingly, six people also reported an improvement in skin texture after IPL and two people commented on an improvement of existing acne. There were no reports of this type of improvement on the electrolysis side, nor were the patients told that this type of benefit can occur after IPL, so we can perhaps assume that the light treatment also resulted in a photo-rejuvenating effect in some patients.

Conclusion
Both electrolysis and Intense Pulsed Light treatments have been shown to be efficacious in the treatment of women with facial hirsutism. As expected, electrolysis performed better on fairer hair, and is particularly useful for treatment of women with very sparse hair growth. Nonetheless, in women with hair counts of more than approximately 100, intense pulsed light treatments were vastly superior. The fast treatment times, reduced discomfort and rapid results meant that both operator and 20 out of 21 patients preferred IPL treatment over electrolysis. Patient perception of hair loss with IPL was 78% after only 6 treatments, compared to 50% for electrolysis, with a corresponding satisfaction rating of 85% for IPL treatment and 50% for electrolysis. Most patients experienced some skin reaction after electrolysis treatment, including skin redness, crusting and swelling. The only negative side effect seen after IPL treatment was transient skin redness, and out of 17 patients questioned, all but two reported a decrease in the time spent on hair removal on the IPL treated areas and 13 reported an improvement in self-confidence.

References
1. CE Michel, St. Louis Clinical Record, October, 1875, 2:145-148
2. R.N. Richards M.D,G.E. Meharg R.N.A: History of Electrolysis “Practice Manual and Reference Guide and Temporary Hair Removal Cosmetic and Medical Electrolysis. American Electrology Association 2002-2004
3. P. Lor, B. Lennartz, R. Ruedlinger ‘Patient satisfaction study of unwanted facial and body hair: 5 Years experience with intense pulsed light.’ Journal of Cosmetic & Laser Therapy. 4, 3-4, 73, 2002
4. Robert Weiss, Margaret Weiss, Sangeeta Marwaha, Allan Harrington ‘Hair Removal with a Non-Coherent Filtered Flashlamp IPL Source’ Lasers Surg. Med, 24, 128, 1999
5. R. Anderson, J. A. Parrish, “Microvasculature can be Selectively Damaged using Dye Lasers: A Basic Theory and Experimental Evidence in Human Skin”. Lasers in Surgery and Medicine 1: 263 – 276 (1981).

**Medical study taken from http://www.beautyandmedical.com.au/files/laserstudy.pdf, accessed on 11/04/09**