Laser hair reduction uses long-pulse lasers emitting

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1 Severe Urticaria After Laser Treatment for Hair Reduction ERIC F. BERNSTEIN, MD The author has indicated no significant interest with commercial supporters. Laser hair reduction uses long-pulse lasers emitting visible and infrared radiation in the millisecond domain to target melanin pigment contained in hair shafts, resulting in heating of the hair shafts and transfer of this heat to the hair follicle. Heating of the follicle results in an inflammatory response that triggers anagen follicles to enter a prolonged telogen phase, causing shedding of the terminal hair and its replacement by a vellous hair that is not visible to the naked eye. Lasers in the red or infrared wavelengths, specifically the 755-nm alexandrite, the 810-nm diode, and the 1,064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser are used because they penetrate deeply into the skin and are not appreciably absorbed by competing chromophores such as hemoglobin or water. 1 8 Because the bulge and bulb cells of the hair follicle are located deep within the skin, nontarget epidermal melanin pigment can be protected using surface cooling while still enabling targeting of the key structures in the follicle that cause it to enter the telogen phase. Surface-cooling strategies include forced cool air, a dynamic cooling device using cryogen spray, and contact cooling using chilled sapphire crystals or metal plates. 1 9 These devices protect the epidermis, which heats up during laser treatment because of absorption of laser energy by epidermal melanin pigment. After laser treatment, an urticarial papule develops around each treated follicle that contained a pigmented hair shaft. This urticarial response is usually confined to the immediate area surrounding the hair shaft, with a more subtle urticarial response occurring in the entire treatment site. The latter response is usually mild and most often lasts from a few minutes to 24 hours after laser treatment. This general urticarial response is seen after treatment with virtually any laser used to treat skin for a variety of conditions using wavelengths from the visible to the infrared range and is rarely clinically significant. 10 In this article, we report a severe urticarial response immediately after laser treatment for hair reduction in four subjects lasting many days after laser treatment. In three of the four cases, the subjects had received prior laser treatment for hair removal without incident. No subject had a prior history of urticaria from cold, heat, sunlight, or any other cause. Case Reports Patient 1 A 36-year-old woman with Fitzpatrick type IV skin presented for laser hair reduction on her lateral jawline. Her past medical history was noncontributory, and she was not taking any medications and had no drug allergies. She was treated using a longpulse Nd:YAG laser with 28 J/cm 2 using a 15-mm spot size, a 3-ms pulse duration, and cryogen spray cooling using a 30-second spray time and 20-ms delay (GentleYAG, Candela Corporation, Wayland, MA). The patient tolerated her first treatment well and returned 6 weeks later for her second treatment using 30 J/cm 2, with all of the other parameters the same as the first treatment. After her second treatment, she reported intense hives at the treatment site with severe pruritus and was prescribed desoximetasone cream to be applied twice a day to the treatment site. She returned for a test spot before her next treatment because of the urticaria that resulted Laser Surgery and Cosmetic Dermatology Centers, Bryn Mawr, Pennsylvania & 2009 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc. ISSN: Dermatol Surg 2010;36: DOI: /j x 147

2 SEVERE URTICARIA AFTER LASER TREATMENT after her second treatment. A test spot was performed, and she developed immediate urticaria after treatment (Figure 1). She was treated with clobetasol propionate 0.05% cream every 8 hours and diphenhydramine 25 to 50 mg every 6 hours for approximately 2 days. The urticaria resolved over the next week. Patient 2 A 41-year-old woman with Fitzpatrick type II skin presented for laser hair reduction on her arms. Her past medical history was significant for asthma and hay fever. Her only medication was an albuterol inhaler used as needed for her asthma. She had no drug allergies. She had received treatment with a laser for hair removal to her forearms, approximately 7 to 8 weeks before presenting to us for laser treatment, without incident using an 810-nm diode laser combined with radiofrequency (Comet Laser, Syneron Inc., Irvine, CA). She was then treated in our clinic using the long-pulse, 755-nm alexandrite laser delivering 20 J/cm 2, using an 18-mm spot size and a cryogen spray time of 50 ms with a 40-ms delay (GentleLase, Candela Corporation). Immediately after treatment, the patient reported that the treated skin felt warm, and this persisted until she left the office. That evening, she called saying that she was having an intense burning sensation on her arms and significant swelling of her arms and hands. She reported that her arms and hands became uncomfortable and that her swelling was worsening, resulting in discomfort that prevented her from sleeping thoughout the night. She was prescribed clobetasol propionate 0.05% cream every 8 hours to her arms and hands and loratadine 10 mg in the morning and diphenhydramine 25 to 50 mg at night. The patient reported for follow-up 2 days after her laser treatment and presented with urticarial plaques that were confluent on her arms and hands with tense edema (Figure 2). The following day, the patient reported that she was 75% improved and that the urticaria was resolving, and it continued to resolve over the next few days. Patient 3 A 53-year-old woman with Fitzpatrick skin type II presented for laser hair removal on her upper lip. Her past medical history was significant for coronary artery disease and her medications were olmesartan, rosuvastatin, calcium supplements, aspirin, and ezetimibe; she was allergic to lidocaine and penicillin. She had no previous history of laser hair removal. The patient was treated to her upper lip with the long-pulse alexandrite laser using 24 J/cm 2, a 15-mm spot size, a 3-ms pulse duration, and dynamic cooling device settings of a 50-ms spray time with a 40-ms delay before delivery of the laser pulse (GentleLase, Candela Corporation). The day after treatment, the patient reported redness, swelling, and irritation on her upper lip. She was prescribed clobetasol propionate 0.05% cream every 8 hours and diphenhydramine 25 to 50 mg every 6 hours. The next day, the swelling worsened, and she came into the office for examination. On physical examination, her lip was extremely indurated and erythematous with translucent papules (Figure 3). She continued the oral antihistamine and topical corticosteroid ointment and improved to baseline over the next 4 to 5 days. Figure 1. Patient 1 immediately following a test spot for laser hair reduction with the long pulse-duration Nd:YAG laser using a dynamic cooling device with cryogen spray cooling. Patient 4 A 35-year-old woman initially presented for laser hair removal on the lower extremities. She was 148 DERMATOLOGIC SURGERY

3 BERNSTEIN Figure 3. (A, B) Patient 3 seen 2 days following laser hair reduction using the long-pulse duration alexandrite laser with associated cryogen spray cooling. Figure 2. (A, B, C) Patient 2 seen 2 days following laser hair reduction treatment with the long pulse-duration alexandrite laser with cryogen spray cooling. treated using an 810-nm diode laser with contact cooling using 22 J/cm 2 with a 30-ms pulse duration (Light Sheer Laser, Lumenis Incorporated, Santa Clara, CA). She had significant hair reduction without complications and had two subsequent treatments to her lower legs, bikini area, and axillae using the same settings at 6-week intervals with significant hair reduction and no adverse complications. She then presented for the third treatment of her axillae and was treated again with the diode laser using 35 J/cm 2 and a 30-ms pulse duration. During the same visit, she was treated with the long-pulse duration alexandrite laser on her forearms using 14 J/cm 2, an 18-mm spot, and a cryogen spray setting of a 50 ms spray delivered 40 ms before the laser pulse. These treatments resulted in hair reduction and were well tolerated without side effects. After this, she was treated on her upper lip using the longpulse alexandrite laser at a fluence of 16 J/cm 2, delivered with a 15-mm spot size and a cryogen spray setting of a 50-ms spurt delivered 40 ms before the laser pulse. This treatment was well tolerated. She returned 6 weeks later for another treatment of her forearms and axilla and was again treated with the alexandrite laser using 14 J/cm 2 for the axillae and 18 J/cm 2 for the forearms, with an 18-mm spot and cryogen spray settings of a 50-ms spray 36:1:JANUARY

4 SEVERE URTICARIA AFTER LASER TREATMENT delivered 40 ms before the laser pulse using the longpulse alexandrite laser, and her forearms were treated with the same settings, with the exception of the fluence, which was 18 J/cm 2. Immediately after the treatment, she reported edema and intense pruritus on her forearms and in her axillae. She was prescribed clobetasol propionate ointment twice daily and reported that the urticaria resolved slowly over the following week. She then presented to the office for another treatment of her forearms, but because of the urticaria during her previous treatment, a test spot was performed on her forearm using 20 J/cm 2, an 18-mm spot size, and a cryogen setting of 50-ms spray and 40-ms delay as before. She developed significant urticaria in the test spot treatment area that persisted for approximately 4 days, although she elected to continue with treatment in spite of her urticaria, which persisted for 1 week and was treated with clobetasol propionate ointment three times a day. Approximately 8 months later she presented for another treatment of her forearms and developed similar urticaria that was again treated with topical corticosteroids for approximately 1 week. Discussion An urticarial response is seen after most laser procedures. Urticarial papules approximately the size of the laser pulse administered with virtually any laser in the visible through infrared wavelengths result immediately after treatment. 10 This response is rarely clinically significant after most laser procedures. Although some patients may develop clinically significant urticaria or edema after some laser procedures, such as the infra-ocular edema seen after pulsed-dye laser treatment of some patients with facial telangiectasias, clinically significant edema after laser hair removal is rare. The patients reported here had dramatic, tense edema immediately after laser treatment that persisted for approximately 1 week. In three of the four patients, previous treatments at similar fluences were well tolerated. No patient had a previous history of cold or heat urticaria or urticaria from a contact allergen or any other cause. Three of the subjects were treated with an alexandrite laser, and one was treated with the Nd:YAG laser. Both of the lasers use the dynamic cooling device 11,12 to protect the epidermis during laser treatment. As with laser treatment, cryogen spray results in transient erythema and urtication but only lasting 1 to 24 hours. 9 The urticaria noted in the patients in the current report was distinct from the normal erythema and mild urticaria commonly seen after laser treatment with or without use of the dynamic cooling device. The patients reported here had severe, symptomatic urticaria with significant edema lasting approximately 1 week after laser treatment. Moreno-Arias and colleagues report a patient treated with the 810-nm diode laser using a fluence of 24 J/cm 2 with a 9-9-mm spot using contact cooling and not cryogen spray cooling who had an uneventful first treatment but developed urticaria 24 hours after her second laser treatment administered with identical settings to the first. In their patient s case, the patient developed erythema and edema at the treatment sites with intense pruritus. 13 The patient was treated with cobetasol 17-propionate 0.05% cream twice daily, with complete resolution of the urticaria by 48 hours after laser treatment, but 72 hours after treatment, ecchymoses were noted at the site of the papules that took 1 week to resolve. The patient was again treated 1 month later and immediately developed intense pruritus, erythema, and edema as before and was treated with intramuscular corticosteroids and subsequent oral corticosteroids, with resolution after 72 hours after treatment. 13 Because their patient developed purpura in the areas of urticaria, they suggested that she had urticarial vasculitis, although she refused biopsy to confirm this diagnosis. 13 Although none of the patients described in this current report developed purpura or echymoses, the remainder of their clinical picture was similar to that occurring in the patient described by Moreno-Arias and colleagues Urticaria in response to light, heat, and cold are well described, 14 and all could be the cause of the urticarial response in the patients we report here, but 150 DERMATOLOGIC SURGERY

5 BERNSTEIN none of our patients had a history of urticaria in response to cold. Neither did they have a history of urticaria in response to heat or light. However, urticaria in response to specific wavelengths of light has been described 15 and thus may not be elicited by sunlight if patients were sensitive to specific wavelengths in the visible red and infrared spectrum. Thus, the patients described in our current report could have been sensitive to the specific wavelengths emitted by the lasers used here: 755 and 1,064 nm. In addition, an urticarial reaction to the cryogen itself, 1,1,1,2,tetrafluoroethane, used in the dynamic cooling device, is also possible. Ishiguro and colleagues describe a patient who developed allergic alveolitis with eosinophil infiltration and who worked performing laser hair removal using a laser that employed cryogen spray cooling with 1,1,1,2,tetrafluoroethane as the cryogen. Upon rechallenge with the cryogen, her symptoms recurred, and thus the authors concluded that her pulmonary allergic reaction was from the cryogen. 16 It is possible that the patients presented here developed a cutaneous allergic reaction to the cryogen spray. Unfortunately, none of the patients described here chose to pursue testing for contact allergy to the cryogen spray; testing to heat, cold, or light; or use of a laser that does not employ the dynamic cooling device, so the causative factor of their severe urticarial response could not be determined. Severe urticaria after laser treatment for hair reduction using a laser equipped with cryogen spray cooling appears to be a rare reaction that occurs immediately after treatment. Although cryogen spray cooling and laser hair reduction have been used for many years, this urticarial reaction appears to be newly described. Clinicians should be alert to this condition and may in retrospect identify patients who discontinued treatment due to urticaria. 2. Campos VB, Dierickx CC, Farinelli WA, et al. Hair removal with an 800-nm pulsed diode laser. J Am Acad Dermatol 2000;43: Lou WW, Quintana AT, Geronemus RG, Grossman MC. Prospective study of hair reduction by diode laser (800 nm) with long-term follow-up. Dermatol Surg 2000;26: Grossman MC, Dierickx CC, Farinelli W, et al. Damage to hair follicles by normal mode Ruby lasers. J Am Acad Dermatol 1996;35: Dierickx CC, Grossman MC, Farinelli WA, Anderson RR. Permanent hair removal by normal-mode ruby laser. Arch Dermatol 1998;134: Görgü M, Aslan G, Aköz T, Erdogan B. Comparison of Alexandrite laser and electrolysis for hair removal. Dermatol Surg 2000;26: Bouzari N, Tabatabai H, Abbasi Z, et al. Laser hair removal: YAG, long-pulsed Alexandrite, and long-pulsed diode lasers. Dermatol Surg 2004;30(4 Pt 1): Handrick C, Alster TS. Comparison of long-pulsed diode and long-pulsed Alexandrite lasers for hair removal: a long-term clinical and histologic study. Dermatol Surg 2001; 27: Datrice N, Ramirez-San-Juan J, Zhang R, et al. Cutaneous effects of cryogen spray cooling on in vivo human skin. Dermatol Surg 2006;32: Algermissen B, Hermes B, Henz BM Müller U, Berlien HP. Laser-induced weal and flare reactions: clinical aspects and pharmacological modulation. Br J Dermatol 2002;146: Aguilar G, Wang GX, Nelson JS. Dynamic behavior of cryogen spray cooling: effects of spurt duration and spray distance. Lasers Surg Med 2003;32: Waldorf HA, Alster TS, McMillan K, et al. Effect of dynamic cooling on 585-nm pulsed dye laser treatment of port-wine stain birthmarks. Dermatol Surg 1997;23: Moreno-Arias GA, Tiffon T, Marti T, Camps-Fresneda A. Urticaria vasculitis induced by diode laser photo-epilation. Dermatol Surg 2000;26: Dice JP. Physical urticaria. Immunol Allergy Clin North Am 2004;24: Alora MB, Taylor CR. Solar urticaria: case report and phototesting with lasers. J Am Acad Dermtol 1998;38: Ishiguro T, Yasui M, Nakade Y, et al. Extrinsic allergic alveolitis with eosinophil infiltration induced by 1,1,1,2-tetrafluoroethane (HFC-134a): a case report. Intern Med 2007;46: References 1. Campos VB, Dierickx CC, Farinelli WA, et al. Ruby laser hair removal: evaluation of long-term efficacy and side effects. Laser Surg Med 2000;26: Address correspondence and reprint requests to: Eric F. Bernstein, MD, Main Line Center for Laser Surgery, 32 Parking Plaza, Suite 200, Ardmore, PA 19003, or dermguy@dermguy.com 36:1:JANUARY