Health recently wrote an article detailing laser hair removal as a treatment option for hidradenitis suppurativa (HS). What role does laser hair removal play in an HS treatment plan, and which patients make good candidates? For an expert’s perspective, I reached out to Steven Daveluy, MD, FAAD, professor and program director at Wayne State Dermatology.
In your practice, what role does laser hair removal play in an HS treatment plan?
Even though laser hair removal is a procedure, I utilize it in the same way I use medical therapies for HS. The goal is to reduce inflammation and prevent new lesions, which is the same goal when I start a new medication. Usually in HS, we have to combine multiple treatments to create a regimen that leads to disease control. I often start patients on medications, such as doxycycline, minocycline, spironolactone, finasteride, metformin or a combination, prior to laser hair removal. I can start those right away while I’m getting the prior authorization for laser hair removal. That also means that patients will be on anti-inflammatory treatments when we start laser hair removal, which reduces the risk of flares when starting. Laser hair removal can also be combined with biologic treatments.
What qualities make a good candidate for this treatment? How do skin and hair color play a role in choosing a safe and effective treatment?
Laser hair removal works best in earlier disease. The hair follicle is the site of inflammation in early disease. Once tunnels start forming in later disease, they become a source of inflammation. Plus, in later disease, the scarring and tunnels can obliterate or cover the hair follicles, so it won’t work as well in Hurley Stage 3 disease. If an area of the body has a decent amount of visible terminal hairs, laser hair removal is an option. It’s a very good option in early disease, since removing the hair follicles can effectively stop the disease. Like hair removal in general, white and gray hair won’t respond well, since the laser targets the melanin. Skin and hair color can play a role in selecting the laser, similar to cosmetic hair removal.
What should dermatology clinicians know about the two main lasers used for hair removal in HS treatment?
Here is where skin and hair color can play a role. The two lasers with the most evidence are the Nd: YAG and Alexandrite, though there is evidence for diode and intense pulsed light, just not as robust (case reports and series). The Nd:YAG works well for darker skin types, since the longer wavelength allows it to target the hair follicles with less risk of hitting melanin in the epidermis. The Alexandrite carries a greater risk of post-treatment pigmentary changes. These are important considerations in cosmetic laser hair removal. In HS, the concern is slightly less, since the disease itself can cause not only pigmentary change, but tissue damage and pain. When you weigh the risks and benefits, both lasers are appropriate for any skin type, especially since pigmentary changes after laser therapy are typically temporary. If you have both lasers available, you can use skin type to help guide treatment. If you only have one available, it’s still a valuable option for any patient.
What other lasers should a dermatology clinician consider in HS treatment, and which candidates are best for those lasers?
There is evidence for the diode laser and intense pulsed light hair removal. There is less evidence to use to make decisions, but it appears that energy-based hair removal is beneficial for HS. If you have one of these devices and are experienced using them for hair removal, those skills will apply to treating HS.
How can a dermatology clinician ensure safety when treating light and dark skin tones?
You should always follow the standard laser safety precautions, including eye protection. As mentioned above, if you have multiple lasers, you can choose the most appropriate one based on skin type.
How should a dermatology clinician counsel a patient who is undergoing laser hair removal for HS?
It’s important to counsel all patients on the risk of pigmentary changes. With appropriate laser and setting selection, the risk is low. When I discuss it with my HS patients, they often point out to me areas of post-inflammatory hyperpigmentation caused by the HS itself and tell me that dyspigmentation alone, without the pain of HS, is totally worth the risk.
Some patients experience a flare of their HS following the first or second laser treatment. This risk can be reduced by starting them on a medical therapy (antibiotic, spironolactone, etc.) before or at the same time as laser hair removal. As with all HS treatments, it’s important to let patients know that response can be unpredictable. It’s always important to be optimistic and hold on to hope that a treatment will work really well for your HS, while still remembering that if may not. If it doesn’t work well, we’ll move to the next option.
Laser hair removal is uncomfortable or even painful during the treatment. It’s important to set that expectation ahead of time. For sensitive areas, like the genital region, I will often prescribe a topical analgesic to help reduce the pain.
What else is important for dermatology clinicians to know about laser hair removal for HS?
Laser hair removal for HS is just like cosmetic laser hair removal. The only difference is that we give an extra pulse (double pulse) to the active lesions. Everything else is the same, so if you do laser hair removal, you have the skills. It typically requires a similar number of treatments, in the range of 4-8, and sometimes more. The settings are the same, based on skin type, and you increase the fluence as tolerated with each treatment. It’s a great option, especially earlier in disease. Even if a patient has Hurley Stage 3 disease in one body site, others with less scarring and tunnels may still be candidates.
Billing is a little tricky, since there isn’t currently a CPT code for laser hair removal. There are a couple of options. You may have to work with your insurance carriers to find out their preference. One option is the destruction benign codes, since they include destruction by any method, including laser (excluding vascular laser for vascular proliferations, which have their own codes). The other is the 17999, unlisted procedure of the skin. Many insurances will tell you whether or not they will authorize this code for laser hair removal for HS, but they often won’t tell you the value that they will reimburse. You have to perform the procedure and submit a claim to find out. Depending on the amount they will cover per treatment, you can determine the appropriate area to treat with each treatment. This may mean more treatment sessions to cover all the areas, but patients are usually grateful that it’s covered. The HS Foundation has prior authorization template letters on their website, including a letter for laser hair removal, that can make prior authorization much easier.
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