Consultation
When you meet with your patient to discuss hair removal, there are several factors to take into consideration: skin type, skin condition, area of hair removal, method and desired results. While some patients might come to you requesting a specific technique, their Fitzpatrick type as well as the location for the procedure might not lend themselves to their request. This is the time to educate your patient as to what is best for their individual skin needs in order to avoid potential complications that could lead to a worsened skin condition.
Caring for the skin within and around the hair removal area is also important when developing pre- and post-procedure regimens. Several hair removal treatments induce heat, such as electrology and Light Amplification by Stimulated Emission of Radiation, better known as LASER, traumatizing the hair follicle and the surrounding skin in the process. For patients with darker, Fitzpatrick V to VI skin types, this heat can lead to PIH. Understanding what stimulates melanogenesis is essential to determining which hair removal methods are most appropriate for which patients. Failing to take all factors into consideration could lead to unnecessary complications.

Methods and Precautions
There is a wide variety of hair removal systems available today, everything from over-the-counter lotions and creams to procedures that must be performed by a trained professional. Here are just a few:
Dermaplaning: Surface-level hair removal methods include shaving and dermaplaning. Similar to shaving with a razor, dermaplaning involves a trained clinician using a surgical blade to scrape away hair from a given area on the body. During this procedure, the outermost skin layer is exfoliated along with the hair. Without the heat and friction of alternative hair removal methods, dermaplaning is a sound choice for patients with sensitive skin and rosacea, as well as all Fitzpatrick types. Dermaplaning can be coupled with gentle chemical peels following treatment, which will also address any underlying
skin conditions.
Chemical depilatories: If your patient inquires about using a chemical depilatory cream, inform them of the potential for skin irritation using such lotions, especially higher Fitzpatrick's or those with sensitive skin conditions. The ingredients used to instigate a chemical reaction that breaks down the keratin in the hair – making it possible to simply wipe it away – can lead to undue irritation and inflammation, leading to negative outcomes.
Tweezing: Another common epilation method is tweezing. Sometimes painful and only truly useful on small areas in need of hair removal, such as the eyebrows and other areas of the face, tweezing can be performed by professionals as well as by the patient at home. The surrounding skin will usually appear red and irritated directly after tweezing, but the inflammation tends to disappear relatively quickly, making this method a possibility for all skin types and conditions.
Epilation: Similar to tweezers, there are also mechanical epilators, which are used to grab the hairs and pull them out with limited effort from the patient or professional utilizing the device. Mechanical epilators are available for home use, as well as by clinicians, with efficacy depending on the manufacturer of the device, the mechanism of action and the ability of the user to wield it properly.
Threading: Recently, threading has become popular in Western countries; however it is actually an ancient form of hair removal originating in the Middle East. Threading is a process of grabbing the hair in a twisted thread being rolled over the skin, plucking the hair out in the process. Akin to tweezing, this is another procedure that would be best for smaller areas of hair removal, like the eyebrows. Patients with sensitive or compromised skin conditions could experience some irritation from this procedure.
Waxing: Some patients may have experience with waxing, both at home and performed by a professional for a variety of hair removal needs. Hot or cold, hard or soft wax can be used, depending on the needs of the patient. When wax is applied to the area in need of epilation, it is left to harden, in the case of hard wax, and then removed quickly. Most soft waxes are warmed before application and then removed with a strip of muslin. While areas of the face can typically be handled at home by the patient with wax, it is still recommended for patients prone to PIH or sensitive skin to see a professional for this service to avoid complications. Larger areas like the legs, chest or back are most often treated by a professional. Depending on the area of the body and the amount of hair in need of removal, this method can be quite painful. The heat and trauma caused by pulling out the hair rapidly makes this a contraindicated procedure for those with sensitive skin, rosacea and impaired barrier function. Patients with dry skin conditions should increase the hydration to their skin with serums, masks or other professional treatments several weeks prior to waxing to avoid trauma to surrounding skin. Those prone to PIH should use pigment-inhibiting daily care products for two to three weeks prior to waxing.
While chemical peels can be added to less aggressive hair removal procedures, such as dermaplaning, they should be avoided in the same appointment when waxing is performed to minimize the risk of irritation and exacerbating any existing skin conditions.

Advanced Procedures
Today, the most popular permanent hair removal methods include laser or intense pulsed light (IPL) and electrology. Patients should be made aware of the heat that is induced with both of these procedures, as Fitzpatrick types V to VI will be at a higher risk for PIH. If a darker skinned patient is adamant about one of these methods, pigment-inhibiting daily care and professional treatments are a must, both pre- and post-hair removal.
Both laser and IPL treatments use light that is directed at the hair follicle; dark pigmented hair absorbs the light, resulting in the elimination of hair growth. These methods tend to be expensive and require multiple sessions for permanent hair removal to be achieved. These methods are ineffective on patients with lighter pigmented hair, as they only work through the absorption of the light through the aforementioned dark pigment of the hair.
Electrology treatments work by inserting a probe into the hair follicle in order to destroy the cells responsible for hair growth. Similar to laser and IPL, electrology is costly and also requires multiple sessions for desired results, since each hair follicle must be targeted individually by the device. Electrology is a good choice for patients with lighter hair who are unable to use laser or IPL.

Enhancing Hair Removal Procedures to Promote Overall Skin Health
Patients who have dry or compromised skin should use hydrating daily care products containing urea, hyaluronic acid, sodium PCA and glycerin at home. These are all biocompatible ingredients that will assist with barrier repair and increase inter- and intracellular hydration. Skin that is properly hydrated facilitates hair removal and the further irritation of the skin will be minimized.
Patients prone to PIH should use daily care products with pigment-inhibiting ingredients for about two weeks prior to their hair removal procedure. Having a chemical peel or some other type of professional melanogenesis-inhibiting treatment is beneficial prior to their hair removal appointments. Continue daily care and professional treatments throughout their hair removal process.
For all methods of hair removal, ingrown hairs (also called pseudofolliculitis barbae) can be a concern. Ingrown hairs occur when a hair follicle is infected or irritated as the hair grows back. Patients with curly or coarse hair are more prone to ingrown hairs than those with fine hair. Recommending daily care products and professional treatments that are formulated with ingredients such as salicylic acid, lactic acid and resorcinol will help keep follicles clear and limit bacterial proliferation and potential infection.
Regardless of which hair removal process is employed, post-procedure care should always be discussed with the patient. Anti-inflammatory ingredients, such as low percentages of hydrocortisone, bisabolol and aloe, will help with any potential redness or irritation. Reducing inflammation will also help to diminish the potential of PIH.
There are now several prescription drugs available for patients who want an option for preventing hair from growing back. These work by suppressing and inhibiting hair growth, but be sure those who inquire about such drugs are aware that once they stop taking such medications, hair growth will occur once again.
In order to maximize the outcomes of hair removal treatments, consider a "bundle" option, offering products and professional treatments in conjunction with the hair removal procedures. This will not only encourage patient compliance, but it will also develop long-lasting patient relationships and a continued revenue stream for your practice. Once the patient sees how their overall skin health has improved, they will continue to return for more products and treatments well beyond those just for hair removal.

Michelle Goldsmith, a licensed aesthetician, joined PCA SKIN in 2003. Goldsmith has excelled as a Physicians Consultant, Editorial Liaison and Educator, teaching Chemical Peel trainings to students and licensed professionals throughout the United States. She also speaks at medical and aesthetic meetings throughout the country, and mentors and trains physicians, skin care clinicians and students around the world.