%expand% %gdefine(pickone,'%arg(%rand(%num-args%))) %expires:(never) Cerise Richards - May 2001

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Hair: Too Much or Too Little?

On the surface, body hair appears to be the ubiquitous scourge of all TGs and TSs. If only it would adjust its appearance during transition to the areas where we want it and disappear from our faces, arms and chests. Women in Western cultures have wrestled with unwanted hair for centuries. On the other hand, long flowing scalp hair is a desired feature while balding in men and women is too frightening to contemplate. So what are we to do!

First we must understand the growth cycle of hair with the hormonal and genetic factors responsible for its growth. Then we will realize that total permanent hair removal is an illusive goal today, but that temporary hair reduction can be a reality extending its time limit with each new treatment modality. With increasing time between regrowth we have shaved, waxed, plucked, depilatorized and bleached. We have subjected ourselves to electrolysis, hormones, light waves and laser beams. Each time believing that this new treatment will be the last, but finding out that it is a continuing process. Why?

As we realize that hair on different body parts comes in different densities, thicknesses and colors, we come to realize that different areas are under different influences and therefore require different treatments. The life cycle of all hair is divided into anagen phase (active growth 1-4), catagen phase (5) lasting a few weeks, and telogen (6) phase lasting 3-4 months. The length of the anagen phase varies widely from a few months in the cheek to over 3 years in the scalp. Hair growth begins in the depth of the hair follicle and proceeds at different rates in different areas. Since the life cycle chart shows that the hair shaft is not connected to the bottom bulb in the telogen (6) and early anagen (1) phase, the electric current or laser light used will not reach the bulb and therefore hair will continue to grow. Thankfully 80% of hair is in the anagen phase at any one time, but most people cannot tell them apart. They can be visibly distinguished with experience making all methods very operator dependent.

For the most part in males the darkest and densest areas of pubic and axillary hair are under the influence of Testosterone. But the beard, arms, legs, and chest are under the influence of its metabolite Dihydrotestosterone (DHT) which acts at the skin receptors. Scalp Hair appears to be androgen independent, but may have inactive enzyme receptors. We know that the hormones Estradiol, Premarin and Cyproterone Acetate can compete for those receptors and change the hair quality in these areas, but not eliminate them. Finasteride, a medicine used to improve baldness in men can also decrease facial hair growth. It sounds contradictory but true. Hair comes in two qualities, the dark Terminal hairs and the fine non-pigmented Vellus hair seen on the male forehead and cheeks of women. Under hormonal influences they can change from one to another in both directions. The coloration of hair is caused by the pigment melanin. Eumelanin for black and brown and Pheomelanin for red and blonde. Laser treatment is dependent on the ability of Melanin to absorb the light and therefore works best on people with fair skin and dark hair. Since you have stayed with me this long I will now tell you what you can do to eliminate unwanted hair.

Electrolysis kills by one of two methods. Thermolysis using heat generation in the needle or galvanic current conduction in the hair. Both have a strong dissipation of the current in the skin and probably only have an initial kill rate of 50% with a high regrowth rate requiring continued treatments. The pain can be reduced with injectable Lidocaine or Marcaine given by your physician or you can apply a topical gel before treatment but not during, as that too dissipates the current. Many TSs have more experience than I in this area, so I will continue with Laser treatments which have developed in the last 5 years.

Lasers work by photo (light) - thermo (heat) - lysis (Destroy). The laser beam is not a magic wand but Light Amplification by Stimulated Emission of Radiation reflected into a coherent beam, where all the light travels in a straight unified line through a crystal with a wavelength specified for absorption by Melanin. Many Lasers have been marketed for hair removal as the Ruby, Infrared, Diode, ND:YAG and Alexandrite, all named for their crystals and coupled with the length of their light exposure, hence Short-Pulsed, Long Pulsed and Q-switched with a Shutter. The results coming into the Scientific Journals are not what the ads would have you believe, although they are an improvement over waxing and electrolysis. The following hair-counted result was obtained comparing the long pulsed Alexandrite and the Q-switched ND:YAG on opposite forearms for 2 treatments a month apart in women. The mean percentage reduction in hairs 2 months following completion of the alexandrite laser treatment was 55% and for the Nd:YAG laser-treated regions it was 73%. Three (3) months following the last treatment, alexandrite laser-treated patients showed a reduction of only 19%, while Nd:YAG laser-treated patients showed a 27% reduction. Patients reported average pain values of 4 to 8 on a 0 to 10 scale for the long-pulsed alexandrite and Nd:YAG laser sites. The advantages of the laser over electrolysis are many. First you can treat large areas at multiple sites at once and you can reasonably expect that approximately 20% to 30% of the hairs will not regrow after each treatment. While the machine settings are critical, the application is best done by a physician. Treatments are usually spaced 6 to 8 weeks apart. If you keep removing 25% of the 75% regrowth you will eventually have near total hair removal. You must be committed to this lengthy course of action which may be up to 2 years (10 - 12 treatments).

Time and money are the rate-limiting factors. After each treatment hair regrowth is delayed while the partially damaged bulb repairs itself. The next hair will be thinner and approach Vellus hair with time. Each year there is an improvement with topical agents such as Carbon Gels to improve the Laser’s penetration. Most new systems now have a skin cooling apparatus and use lidocaine gels for pain relief.

A non-coherent (scattered) Xenon flash lamp has arrived on the scene. This lamp will not reach groves or crevices in the skin and treats a larger rectangular area. Six months after 4 treatments most of the areas treated had a 50% hair reduction. But there is little information in the dermatology literature with scientifically controlled results. Laser and light depilation is not without complications. Since heat is the primary modality, redness, blistering of dark skin colors or tanned areas with hypo or hyperpigmentation discoloration can occur. Most studies say that these areas will heal and return to normal as with any superficial burn.

A new topical cream for use on facial hair in women is eflornithine which was approved by the FDA in July 2000. The only two studies are those quoted by the manufacturer, Bristol-Meyers Squibb for their product Vaniqa. Originally used as an intravenous cure for African Sleeping Sickness, BMS observed hair loss in these patients. When used continuously for 6 months as a light cream applied to the upper lip for 4 hours twice daily in almost 400 women, a significant reduction in hair regrowth was achieved by 8 weeks and continued to 24 weeks. Marked subjective improvement was reported by 32% of the women, but 42% reported no improvement. Hair growth returned to pretreatment levels after 8 weeks of complete withdrawal. Acne was the most common reported adverse event with temporary redness and stinging noted. This story is similar to Minoxidil, an anti-hypertensive drug, that was noted to increase peripheral hair and is now marketed as Rogaine.

Next month we will discuss scalp hair growth and loss and what we can do about it from a medical perspective.

Best Wishes for your new future.
Cerise Richards, MD

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