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Comparison of SHR mode IPL system with alexandrite and nd: YAG lasers for
leg hair reduction

Article in Balkan Journal of Medical Genetics · December 2012

DOI: 10.5152/balkanmedj.2012.033 · Source: PubMed

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Balkan Med J 2012; 29: 401-5 • DOI: 10.5152/balkanmedj.2012.033
© Trakya University Faculty of Medicine Original Article 401

Comparison of SHR Mode IPL System with Alexandrite and Nd:

YAG Lasers For Leg Hair Reduction
Şemsettin Karaca, Seval Doğruk Kaçar, Pınar Ozuğuz

Department of Dermatology, Faculty of Medicine, Afyon Kocatepe University, Afyonkarahisar, Turkey

ABSTRACT
Objective: Multiple lasers and light sources are currently available for hair removal and many studies comparing efficacy and safety exist. SHR mode
IPL is a technique that gives the total energy in divided doses with fewer side effects. We compared a SHR mode IPL system with alexandrite and Nd:
YAG lasers for leg hair reduction
Material and Methods: Twenty-five female participants with skin types II–IV, underwent treatment of unwanted hair on the cruris. Three selected areas
were randomly treated with the SHR mode IPL system, Alexandrite laser and Nd: YAG laser in three sessions. Hair reduction was evaluated with digital
photography by a blinded assessor every 6 weeks and 6 months after the last session. Pain severity, side effects and patient satisfaction analysis were
also investigated.
Results: Twenty-one participants completed the trial. The mean hair reductions in 6 weeks after the last treatment were 50% for the IPL system, 53% for
Alexandrite and 39% for the Nd: YAG lasers. However after 6 months; 40%, 49% and 34% hair reduction was observed, respectively. The Alexandrite laser
was the least painful system.
Conclusion: Although there is no obvious advantage of one laser system over the others in terms of treatment outcome, the Alexandrite laser is still the
most efficient and reliable way of hair removal in fair skinned individuals.
Key Words: Hair removal, Alexandrite laser, Nd: YAG laser, SHR mode IPL system
Received: 26.02.2012 Accepted: 02.05.2012

Introduction photothermolysis allows heat propagation to the surrounding

tissue including the amelanotic stem cells by using longer
Excess hair growth is a common problem for both gen- pulse durations (5). As melanin has the highest density at the
ders. Up to now, many methods such as chemical depilation, anagen phase and the hair growth center is more superficial
shaving, waxing and plucking has been used for removal of at this phase, anagen hairs are more readily affected, so that
unwanted hair. These methods can only have a short-term, multiple sessions with variable intervals are needed (3). In fact
transient effect. Although electrolysis can achieve permanent the portion of hair follicle which leads to permanent loss after
hair removal in experienced hands, it is inconvenient due to destruction is still debated.
pain and prolonged treatment sessions (1, 2). The search for Long pulse wavelength (600-1000 nm) laser systems are
an efficient, practical method with minimum side effects and preferred for epilation due to sufficient penetrance into a
long lasting efficacy has led to the development of laser hair deeply located hair root. Thus, Ruby (694 nm), Alexandrite
removal methods, in the last decade. Laser methods applied (755 nm), semi-conductor Diode (810 nm) and Nd: YAG (1064
nowadays do not yet provide permanent removal; however nm) laser systems are frequently employed for epilation from
they have gained popularity due to selective hair damage, the short to longer wavelength spectrum. In addition, Intense
decreased pain feeling, lesser time consumption, longer hair pulse light (IPL) systems are used for epilation although they
free interval and fewer side effects. are not true laser systems (1, 3).
By using appropriate wavelength, pulse duration and flu- Currently, the Ruby laser is not used in hair removal due to
ence, thermal injury can be limited to the absorbing chro- hypopigmentations observed even in skin type II (6). Melanin
mophore, melanin, which is rich in the hair bulb and shaft absorption of normal mode Alexandrite (755 nm) lasers are
(2, 3). The interrogation point of progenitor stem cell dest- very good. However, a few, postlaser pigmentation disorders
ruction, which is hypothesized to be amelanotic, should be are reported (6, 7). Due to longer wavelength, Nd: YAG (1064
the major destination to achieve permanent hair removal (4). nm) lasers partially absorb melanin but deeper penetrance is
To overcome this situation, the modified theory of selective achieved. In addition, it is safely utilized in dark-skinned pati-

Address for Correspondence: Dr. Şemsettin Karaca, Department of Dermatology, Faculty of Medicine, Afyon Kocatepe University, Afyonkarahisar, Turkey
Phone: +90 532 226 06 10 e-mail: [email protected]
 Karaca et al. Balkan Med J
Comparison of Lasers and Light Source in Hair Removal 2012; 29: 401-5
402

ents (1, 3). Epilation via IPL (590-1200 nm) sources using diffe- 2. A 1064-nm Nd:YAG laser with a round spot size of 6 mm,
rent filters are reported to be as successful as laser systems as adjustable fluences of 30-150 J/cm2, variable pulse durati-
a result of a thermal effect, with a risk of erythema, burn and on of 45 to 60 milliseconds.
pigmentation. IPL has the advantage of lower cost and larger 3. A 650-950 nm Advanced Fluorescence Technology (AFTTM)
spot size enabling more rapid treatment, but a greater num- light based system with a rectangular spot size of 3 versus
ber of treatment sessions are required to achieve satisfying 1cm, fluence of 1-7 J/cm2, pulse frequency of 1.3 and 30
results (1, 3, 8). seconds and a contact cooling mechanism was attached.
Laser hair removal has become the most commonly used A thin layer of ultrasound gel was applied to the treatment
cosmetic procedure in the world. Multitechnology systems area as recommended by the manufacturer. For large areas
that encompass laser and light technologies in one platform such as legs operation time intervals are set as 30 seconds
are available, enabling greater versatility and flexibility in re- and at this interval the in-motion technique is used, which
gard to therapeutic choices. As new devices are being develo- requires continuous motion giving adjusted total energy
ped, treatment of all skin types and all hair color is becoming for a particular area.
possible. A super hair removal (SHR) mode for IPL system The set up and fluences used in the three systems were
exhibits the total energy applied per session, counted in ki- within the recommended range based on skin type by the
lojoules, to a precise area with the advantage of fewer side manufacturer (Table 2). All treatments were performed by the
effects than the usual IPL. Although many studies comparing same operator. The performing operator was not involved in
the efficacy and side effects exist, triple studies are few and assessment. Participants were instructed not to remove hair
we did not find a study comparing Alexandrite, Nd: YAG and 10 days before the follow up visits for accurate assessment.
IPL systems. So, we aimed to compare the short wavelength No other hair removal method other than shaving was per-
Alexandrite laser (755 nm), the long wavelength Nd: YAG la- mitted between sessions and up to the last follow up. After
ser (1064 nm) and the wide wavelength IPL (650-950 nm), all in assessment, the treatment sites were shaved before the pro-
one platform, in terms of efficacy and side effects. cedure. Ice packs were used before and after laser treatments
to reduce adverse effects and pain. Local anesthesia was not
Material and Methods applied. Standard safety measures were taken during the laser
procedure.
Participants Pretreatment and follow up photographs were taken using
This is a prospective, single centered study approved by a digital camera (Canon EOS DRXSi/EOS 450D, 12.2 megapi-
the Afyon Kocatepe University Medical Ethics committee and xel image sense digital camera) using identical lightning, pati-
conformed to the guidelines of the Declaration of Helsinki. 25
untanned volunteer Turkish women with Fitzpatrick skin types
II to IV and dark brown to black hair were recruited to the
study. The detailed procedure, expected results and comp-
lications were discussed with the participants and all of the
participants signed the informed consent. Exclusion criteria
included any previous laser or electrolysis treatment, usage of
waxing or depilation within the previous two months, history
of isotretinoin treatment or photosensitivity and hormonal
dysfunction.

Procedure
Each participant underwent a series of 3 sessions at 6 week
intervals. Follow up evaluations done at 6 weeks after each ses-
sion and 6 months after the final session. An imaginary line was
drawn from the tibial tuberosity down to the third foot finger to Figure 1. The schematic view of three treatment areas
both anterior crural regions. To the lateral side of the right tibial
tuberosity, measuring 2 cm down from the knee, a square is Table 1. The features of laser device (Harmony-XL; Alma
drawn keeping the imaginary line at one edge, another square Lasers Ltd., Caesarea, Israel)
is drawn from the inferior medial corner to the left of this line, Laser type Alexandrite Nd: YAG IPL
again keeping it at one edge. A third square is drawn to the (SHR mode)
medial side of the left tibial tuberosity (Figure 1). These 10 cm
Wavelength (nm) 755 1064 650-950
edged squares were treated in a randomized manner using
clockwise rotation with each participant. Lasers and intense Spot size 5 mm 6 mm 3x1 mm
pulsed light systems used in this study, which are on the same
Pulse width 2 ms 45-60 ms 30 sec
platform (Harmony-XL; Alma Lasers Ltd., Caesarea, Israel),
were as follows (Table 1): Fluences (J/cm2) 1-32 30-150 1-7
1. A 755-nm Alexandrite laser with a round spot size of 5 mm, Cooling none none Contact cooling
maximum fluence of 32 J/cm2, pulse frequency of 2-4Hz.
Balkan Med J Karaca et al.
2012; 29: 401-5 Comparison of Lasers and Light Source in Hair Removal
403

Table 2. The recommended fluence ranges of the three systems

Alexandrite Nd:YAG IPL
(6 mm spot size) (5 mm spot size) (3x1 cm spot size/
100 cm2 total area)
Skin type
II Fluence 25-30 J/cm2 80-100 J/cm2 7 J/cm2 (2.0-2.6 kJ)
Pulse width 2 ms 45-60 ms 30 sec
III Fluence 22-24 J/cm2 80-100 J/cm2 7 J/cm2 (2.0-2.6 kJ)
Pulse width 2 ms 45-60 ms 30 sec
IV Fluence 18-21 J/cm2 80-100 J/cm2 6 J/cm2 (2.0-2.6 kJ)
Pulse width 2 ms 45-60 ms 30 sec

Table 3. Hair reduction analysis

Wilcoxon signed ranks test
Hair reduction Alexandrite Alexandrite IPL
versus IPL versus versus
Nd:YAG Nd:YAG
6 weeks after three sessions
Alexandrite 53% NS (p=0.244) S (p<0.05) S (p<0.05)
IPL 50%
Nd:YAG 39%
6 months after three sessions
Alexandrite 49% S (p=0.002) S (p=0.001) NS (p=0.06)
IPL 40%
Nd:YAG 34%
S: significant, NS: non significant

ent positioning and camera settings by the same investigator. pregnancy, and the remaining two participants due to nonat-
Hair counts from digital photographs were performed on a tendance at follow ups. A total of 19.0% (4 subjects), 52.4%
100 cm2 area in all three sites. The investigator taking pho- (11 subjects) and 28.6% (6 subjects) of participants have skin
tographs also assessed the hair count and was blinded to the photo types II, III and IV, respectively.
treatment applications. There was no statistically significant difference in pretre-
In every session, participants marked visual analogue scale atment hair counts among the three sites; for the IPL site,
(VAS) for pain with a range from 0 (no pain) to 10 (unbearable 390±73 (mean±SEM), f Alexandrite site 384±88, Nd: YAG site
pain) and the immediate side effects were evaluated. Parti- 388±71 (p=0.172). All three systems resulted in long term hair
cipants also self assessed the procedure, measuring impro- reduction.
vement and satisfaction based on a scale ranging from 0 (no At the end of three sessions, the reduction in hair count
improvement) to 100 (total disappearance) at the end of three was 53%, 50% and 39% for Alexandrite, IPL and Nd: YAG
sessions and at the 6th month follow up. systems, respectively. The decrease in hair count for Alexand-
Data were recorded and analyzed using the SPSS statis- rite and IPL systems were statistically significantly greater than
tical analysis software version 18. A p value of 0.05 or less that observed in Nd: YAG laser (for both, p<0.05). Later, after
was considered significant. The percentage reduction in hair 6 months the reduction in hair count was decreased to 49%,
counts in all three sites compared using the Friedman test and 40% and 34% in the same order, again. This time the decline
Wilcoxon signed rank tests were used to compare the laser in hair count for Alexandrite laser was statistically significantly
systems. greater than that observed in IPL and Nd: YAG systems (for
both, p<0.05) (Table 3). The reduction in hair count was not
Results statistically related to skin type for any system.
Interpreting the mean VAS score for pain for all three ses-
Of the twenty five volunteers, twenty one participants sions, the Alexandrite laser system was the least painful with
(mean age 32.85 years, range between 25-45y) completed a mean pain score of 3.90, followed by the IPL system (5.71)
the study. Two of them were withdrawn from the study due to and Nd: YAG systems (6.95). Statistical analysis showed a sig-
 Karaca et al. Balkan Med J
Comparison of Lasers and Light Source in Hair Removal 2012; 29: 401-5
404

nificant pain related to Nd: YAG and IPL systems but there was Interestingly, at the end of the follow up period revealing
no significant difference between two systems. the long term efficacy, the reduction with IPL system declined
Patient satisfaction analysis at the end of three sessions significantly, showing that the immediate effect was temporary
showed a mean score of 33 for IPL system, 37 for Alexandrite rather than permanent. On the other hand, a delayed increa-
laser and 27 for Nd: YAG laser, which are quite similar. Statis- sed response with Nd: YAG system is achieved that was nearly
tically the Alexandrite system showed better satisfaction rates equal to the IPL response. In a study by Goh (15), after a sing-
than Nd: YAG and IPL (for both, p<0.05). 6 months after tre- le session, long pulsed Nd: YAG lasers was found to be more
atments the scores were higher than expected, in same order effective than IPL therapy for hair removal in skin types IV–VI,
as 39, 46 and 38. Again, Alexandrite laser satisfaction scores with fewer side-effects. The author explained this with the long
were higher than IPL and Nd: YAG (p<0.05). pulse Nd: YAG laser being able to penetrate 5-7 mm depth into
There was only mild temporary erythema and perifollicular the dermis in contrast to the short wavelength IPL system used
edema after some treatment sessions. However, none of the in this study. Recently in a comparative study of Nd: YAG and
participants experienced pigmentation alterations, vesiculati- IPL systems in dark skinned individuals, the Nd: YAG system
on, burns, infection or scarring. was found most efficient after five treatments (16).
Laser parameters seem to be important in choosing the ide-
Discussion al laser for the patient. With lower fluences, temporary removal
rather than permanent is achieved. Roosen et al. (17) studied
The patient’s understanding of permanent hair removal the effect of low fluence photoepilation on hair follicles with
frequently implies lifelong sustained no hair regrowth. In fact, findings suggesting catagen transition of anagen hair follicles.
permanent reduction rather than removal is the usual outco- Long term hair removal largely depends on hair color, skin color
me (3). Detailed explanation about expectation and proper and the tolerated fluence. It is said that when optimal parame-
patient selection is crucial to achieve higher satisfaction rate. ters are used, each treatment session leads to about 15-30%
On the other hand, knowing the capability of laser systems hair loss (1, 3). In this study, six months after three sessions, only
is another critical issue. Several laser and light based devices one third of initial hair was completely lost with the Nd: YAG
are in use for laser hair removal. There are many comparative system. This result may be related to the number of sessions, as
studies on the treatment outcome and complications betwe- emphasized by Lorenz et al. (18) in their study that at least four
en different systems. Although a trial comparing Alexandrite, to five sessions are necessary for an acceptable result with the
Nd: YAG and IPL systems all together has not yet been found, Nd: YAG laser. Besides the fluences in our study as recommen-
studies comparing pair by pair I are found, usually revealing ded by the manufacturer, neither a test dose nor the maximum
Alexandrite as the most effective photoepilation method. Si- tolerated dose is aimed for. Even perifollicular edema and ery-
milarly, our study showed the Alexandrite system most effici- thema was noted in most of the patients and no adverse effects
ent so that, even six months after the last session, nearly 50% were observed. Thus, the fluences may be lower than the level
hair clearance is achieved. In a study comparing Alexandrite, that would be tolerated. On the other hand, Sadick et al. (19)
diode and Nd: YAG lasers after three treatments, the reduc- did not find a positive correlation between hair reduction and
tion in hair was 70.3%, 59.7% and 47.4% respectively (9). In number of treatments for IPL.
addition, similar to our study, Alexandrite laser was reported The effectiveness of different optical devices for hair re-
as best tolerated, whereas Nd: YAG system was the most pa- moval varies significantly among patients due to anatomical
inful application. A similar comparison trial with long pulsed location, skin type, hair color, hair thickness, duration of the
versions of Alexandrite, diode and Nd: YAG lasers systems re- hair follicle cycle and androgen status. This study is designed
vealed 65.6%, 46.9% and 42.4% mean hair reduction, respec- as within participant comparative study to eradicate these va-
tively (10). In another work, the mean hair reduction with Ale- riables. Although differences between individuals exist, about
xandrite system was 75.9% and with Nd: YAG system 73.6% 62-88% of the hair in the lower leg are in the telogen phase,
after four sessions (11). On the contrary, they have reported whereas the duration of the resting period for hair follicles is
higher pain severity in the Alexandrite group. In a split-face about 3-6 months (3). Depending on this data, we have de-
study, the decrease in hair counts was 46% in the Alexandrite cided on a 6 months follow up period after the end of three
treated site and 27% in the IPL treated site (12). The specific sessions. After six months, nearly all participants had some
wavelength and short pulse duration of laser and split pulse hair regrowth that make us consider whether a longer follow-
delivery in IPL were indicated as a probable cause. Another up for a reliable assessment of long term effects should be
study comparing short-pulse and long pulse Alexandrite lasers planned.
with IPL systems that have different cut-off filters showed no Cold packs, the least effective type of cooling, are used
superior efficacy of one to the other but the Alexandrite system in this study without any topical anesthesia, to objectively
was found to be associated with higher side effects (13). In a evaluate pain. The results were similar to literature findings,
comparison trial by Amin and Goldberg (14), which evaluated pointing to the Alexandrite laser as the most painless system,
the efficacy of an IPL device (red filter), an IPL device (yellow despite the contact cooling system attached to the IPL probe.
filter), a 810 nm diode laser, and a 755 nm Alexandrite laser, Furthermore, pain scores with IPL were nearly equal to pain
hair counts at 1, 3 and 6 months after the second treatment scores for the Nd: YAG laser. This is a conflicting result as the
showed almost 50% reduction in all devices without any supe- SHR mode IPL is thought to have the advantage of less pain
riority of one to other. and side effects.
Balkan Med J Karaca et al.
2012; 29: 401-5 Comparison of Lasers and Light Source in Hair Removal
405

The low number of participants and the treatment sessions 8. Haedersdal M, Wulf HC. Evidence-based review of hair removal
can be accepted as our limitations as well as not determining using lasers and light sources. JEADV 2006;20:9-20. [CrossRef]
the maximum tolerated dose. The usage of a device with three 9. Khoury JG, Saluja R, Goldman MP. Comparative evaluation of
long-pulse alexandrite and long-pulse Nd: YAG laser systems
systems in one platform can also be regarded as a limitation. used individually and in combination for axillary hair removal.
Dermatol Surg 2008;34:665-7. [CrossRef]
Conclusion 10. Bouzari N, Tabatabai H, Abbasi Z, Firooz A, Dowlati Y. Laser
hair removal: comparison of long-pulsed Nd: YAG, long-pulsed
Although there is no obvious advantage of the SHR mode alexandrite, and long-pulsed diode lasers. Dermatol Surg
IPL system over the others in terms of treatment outcome, 2004;30:498-502. [CrossRef]
11. Davoudi SM, Behnia F, Gorouhi F, Keshavarz S, Nassiri Kashani M,
the Alexandrate laser is still the most efficient and painless
Rashighi Firoozabadi M, et al. Comparison of long-pulsed alex-
light source in comparison with the Nd: YAG and IPL of the andrite and Nd:YAG lasers, individually and in combination, for
SHR mode. Despite the continuous efforts for the develop- leg hair reduction: an assessor-blinded, randomized trial with 18
ment of new laser systems in permanent hair removal with a months of follow-up. Arch Dermatol 2008;144:1323-7. [CrossRef]
minimal number of session, we can state that there is as yet 12. McGill DJ, Hutchison C, McKenzie E, McSherry E, Mackay IR. A
no developed safe and efficient light source that meets the randomised, split-face comparison of facial hair removal with the
alexandrite laser and intense pulsed light system. Lasers Surg
expectations.
Med 2007;39:767-72. [CrossRef]
13. Marayiannis KB, Vlachos SP, Savva MP, Kontoes PP. Efficacy of
Conflict of Interest long- and short pulse alexandrite lasers compared with an in-
This study was supported by Afyon Kocatepe University, tense pulsed light source for epilation: a study on 532 sites in
scientific fund (09.TIP.01) 389 patients. J Cosmet Laser Ther 2003;5:140-5. [CrossRef]
14. Amin SP, Goldberg DJ. Clinical comparison of four hair remov-
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