Advances in Laser Hair Removal in Skin of Color

Transcription

November 2011
1235
Volume 10 • Issue 1i
Copyright © 2011
ORIGINAL ARTICLES
SPECIAL TOPIC
Journal of Drugs in Dermatology
Advances in Laser Hair Removal in Skin of Color
Eliot F. Battle Jr. MD
Cultura Cosmetic Dermatology and Laser Center, Washington, DC
ABSTRACT
Laser hair removal, previously contraindicated in patients with ethnically dark (phototypes IV–VI) or sun-tanned skin, is now recognized as a safe and effective method of permanent hair reduction in all patients. Longer wavelengths, conservative fluences, longer
pulse durations and appropriate cooling methods are necessary to minimize untoward side effects and maximize efficacy. The longerwavelength Nd:YAG laser is considered safest in treating darker skin of color. An added benefit of laser epilation is that side effects
of conventional hair removal such as pseudo-folliculitis barbae and post inflammatory dyspigmentation, more commonly seen in skin
of color, may also respond favorably to the laser, thus increasing the potential for patient satisfaction.
J Drugs Dermatol. 2011;10(11):1235-1239.
INTRODUCTION
T
he removal of unwanted hair, an accepted practice in
many cultures, has been performed since ancient times. It
has evolved from temporary modes of depilation (removing hair visible above the skin) and epilation (removal of the entire
hair) such as abrasion, chemical depilatories, shaving, waxing,
tweezing, “sugaring,” and threading, to procedures which provide
more permanent hair reduction. Although permanent epilation
became possible with the advent of electrolysis, this procedure
proved to be, like some of the traditional methods noted above,
tedious and time consuming; additionally, in those with curlier
hair and darker skin phototypes (IV–VI), electrolysis was a difficult procedure, prone to result in exacerbation of inflammation,
pseudo-folliculitis barbae, post-inflammatory hyperpigmentation,
and scarring. Laser hair removal (LHR) revolutionized the field of
epilation, providing a more cosmetically scrupulous, time-saving
alternative to the hair-by-hair approach of electrolysis and the
traditional methods of hair removal. Initially contraindicated in
patients with ethnically dark or sun-tanned skin, LHR was recommended only for non-tanned, phototype I–III skin because of the
risk of untoward side effects and worsening of pre-existing conditions more often seen in phototype IV–VI skin.
permanently inhibit hair growth. In order to achieve effective
results with LHR and to assure confinement of thermal damage
to the hair follicle, the pulse duration should be less than or
equal to the thermal relaxation time of the hair shaft, estimated
to be in the range of 10–100 milliseconds.2
A “unifying” hypothesis has identified two stem cell reservoirs
in the human anagen hair follicle: a distal outer root sheath reservoir and a proximal outer root sheath reservoir containing
amelanotic stem cells, which may act as a melanocytic reservoir.3
In the mouse model, these stem cells are identified within the
bulge,4 in the human hair follicle, the bulge is thought to reside
in the lower third of the follicle of the outer root sheath.
Do Not Copy
Penalties Apply
Therefore, a modified theory of selective photothermolysis is
used to describe the mechanism of LHR because the melanocytic
chromophore target as well as the amelanotic (hair follicle and
stem cell) target must both be destroyed to accomplish permanent hair reduction. To achieve this goal, longer pulse durations
are used, allowing heat propagation to the entire hair follicle.
Mechanisms of Epilation in LHR in Skin of Color
Choice of Laser System and Optimizing Wavelength,
Pulse Duration, and Cooling
The theory of selective photothermolysis forms the foundation
of cosmetic, light-based laser therapy. This theory states that
thermal injury can be limited to the absorbing chromophore
by using the appropriate wavelength, pulse duration, and fluence (energy density expressed as J/cm2), thereby protecting
the surrounding tissue.1 In LHR, the target chromophore is the
melanin-rich hair shaft and bulb, but to ensure effective results,
thermal injury must also include the surrounding hair follicle.
Finally, destruction of progenitor stem cells is required to
To effectively treat unwanted hair in any patient, laser light must
safely pass through the epidermis to treat the dermal hair target.
The challenge in performing LHR on skin of color is that the epidermal melanin competes as a chromophore for the laser light
by absorbing the light; this light energy is converted to heat. Sufficient accumulation of heat causes thermal damage, leading to
epidermal blistering, dyspigmentation, and scarring. In competing for laser light, epidermal melanin also decreases the amount
of light that is available to reach the intended dermal chromo-
© 2011-Journal of Drugs in Dermatology. All Rights Reserved.
This document contains proprietary information, images and marks of Journal of Drugs in Dermatology (JDD).
No reproduction or use of any portion of the contents of these materials may be made without the express written consent of JDD.
If you feel you have obtained this copy illegally, please contact JDD immediately.
JO1111
1236
November 2011 • Volume 10 • Issue 11
phore target. Thus, epidermal melanin, acting as an unintended
chromophore, decreases therapeutic efficacy and increases the
possibility of untoward side effects. Fortunately, newer generation LHR devices utilize longer wavelengths of light, allowing
the laser surgeon to effectively bypass the epidermal melanin to
penetrate more deeply. Light absorption by epidermal melanin
is decreased, permitting greater light absorption by the target
chromophore, as well as providing the safety and efficacy necessary to treat darker skin (phototypes IV–VI).
Longer pulse durations allow for more efficient cooling of the
epidermis by slowing the deposition of light energy into the
skin; the slower the pigmented epidermis absorbs light, the
slower the conversion to heat, making skin cooling more efficient. The main cause of laser-induced side effects is epidermal
thermal damage, seen when the epidermal temperature equals
or surpasses 45 oC. If heat can be efficiently removed from the
epidermis, maintaining a temperature below 45 oC, then the risk
of thermal-damage is dramatically reduced. An additional measure of safety with longer pulse durations is based on the theory
of thermokinetic selectivity, which states that smaller structures
(e.g., epidermal melanin) will lose heat more quickly than larger
structures (e.g., dermal hair follicles). The quicker dissipation of
heat from epidermal melanocytes in comparison to the larger
hair follicle serves as a protective mechanism for the epidermis.5
Inherent cooling devices are an integral part of the laser surgeon’s
armamentarium in minimizing thermal damage to all patients,
but particularly those with a richly pigmented epidermis. Cooling devices lower skin temperature by direct contact of a cooling
plate, or via emission of cooled spray, air, or gas. There is a safety
range for epidermal cooling, as seen when cryogen-induced and
cold-air cooling parameters are too aggressive, leading to coolinginduced blisters and dyspigmentation. Cryogen spray can reach
temperatures as low as minus 26.2 oC, leading to cooling-induced
hypopigmentation and hyperpigmentation. In a study evaluating
the incidence of post-inflammatory hyperpigmentation (PIH) after
Q-switched Nd:YAG laser treatment (with continuous cold air cooling) of bilateral nevus of Ota, 62 percent of patients developed PIH
on the cooled side, while only 24 percent developed PIH on the
uncooled side.6 The authors hypothesized that laser irradiated melanocytes or keratinocytes may be more reactive to stimuli such
as cold temperature, although the exact mechanism of coolinginduced dyspigmentation is unknown.
E. F. Battle Jr.
to provide the greatest efficacy and safety in treating skin phototypes IV–VI. Of these options, the longer-wavelength Nd:YAG
laser is considered the safest type to treat darker skin of color.9
To improve safety when treating darker skin types, pulse durations of 100 milliseconds or longer can be used with the
long-pulsed diode laser system. In treating very dark skin (phototype VI) with the long pulsed diode laser, Battle and Hobbs
reported that very long pulse durations (>100 ms) and appropriate adjunctive skin cooling are helpful.10
In treating darker skin types, the Nd:YAG wavelength is inherently
safer than the diode wavelength because the longer wavelength
minimizes epidermal melanin absorption and maximizes wavelength penetration to the dermal hair follicular unit.11 Therefore,
shorter, more effective pulse durations can be used more safely with the Nd:YAG lasers versus the diode lasers. When the
Nd:YAG lasers are used with aggressive skin cooling and pulse
durations >30 ms, they can safely treat phototype VI skin.12 As
with the diode laser, longer pulse durations reduce the chance for
epidermal thermal damage. Most of the FDA-approved Nd:YAG
lasers incorporate efficient epidermal cooling devices as part of
the system. With regard to overall hair reduction, however, the
longer wavelength of the Nd:YAG may be slightly less effective
because of its reduced melanin absorption.13 A study conducted by Galadari showed a 35 percent reduction in hair at twelve
months after six treatments with the Nd:YAG compared with a 40
percent reduction observed with the diode after a similar number of treatments and follow up period.14 Because of the reduced
pigment absorption with the longer Nd:YAG wavelengths, they
are best used for patients with coarse, dark hair.
Do Not Copy
Penalties Apply
Available laser and light sources for photo epilation include the
long-pulsed ruby (694 nm), long-pulsed alexandrite (755 nm),
long pulsed diode (810 nm), long-pulsed Nd:YAG (1064 nm), and
noncoherent intense pulsed light (IPL; 590-1200 nm).7 The Food
and Drug Administration (FDA) has approved two systems for
photoepilation in darker skin types: the long pulsed diode (810
nm) and the Nd:YAG (1064 nm).8 Both lasers utilize longer wavelengths, extended pulse durations and active epidermal cooling
Maximizing Safety and Efficacy: Pre-Treatment
Testing, Patient Selection, and Managing Patient
Expectations
Initiating treatment with appropriate conservative laser parameters (longer wavelengths, lower fluences, and longer pulse
durations) is crucial when treating patients with darker skin
types. Pre-treatment test spots are often necessary in determining appropriate laser parameters, particularly fluences and pulse
duration. Test spot locations should be selected deliberately,
closely matching the skin color, sun exposure, and hair density
level of the area to be treated. Test spot parameters should begin with lower fluences and longer pulse durations, and slowly
progress to higher fluences and shorter pulse durations. There
is an increased risk of thermal injury-induced side effects when
treating high hair density areas, such as those found in the upper
back and beard area. The increased risk, caused by the pooling
of heat from closely situated adjacent hairs, can be reduced by
using lower fluences. When performing test spots, it is recommended to wait a minimum of 48 hours before final evaluation to
determine the appropriate safe parameters. Patients with darker
skin can have a one-day to two-day delay in manifesting cuta-
JO1111
1237
neous side effects. A minimum of four overlapping test spots
should be performed to simulate the overlapping nature of the
actual laser treatment.
There are very few true contraindications for LHR. Gold-therapy
and St. John’s Wort are contraindications for LHR, and patients
should discontinue these for at least three months prior to initiating laser epilation. Photosensitizing drugs activated by UVA
wavelengths have often been considered contraindications;
however, hair-removal lasers are in the visible and near-infrared
wavelength spectrum, and are, therefore, generally thought to
be safe to use on patients taking these medications. While it
has long been held that taking Accutane® (isotretinoin) is a contraindication for LHR, there have been no studies showing an
increased incidence of LHR side effects in patients recently on
Accutane. Khatri reports acceptable results in a small group of
phototype III–V patients with much shorter Accutane-free intervals.15 Until more definitive evidence is available, practitioners
should exercise caution and delay LHR for a minimum of three
months after stopping Accutane.
Patients with a history of keloids or hypertrophic scarring should
be treated cautiously, using conservative laser parameters, although new research shows promising results in treating keloids
with lasers.
Prophylactic antiviral medications are indicated for patients
with chronic herpetic infections, especially if they occur in the
desired treatment area. Prophylaxis typically starts two to three
days before laser treatment commences and continues for a
total of five to seven days.
E. F. Battle Jr.
are usually performed every four to eight weeks. To maximize
the amount of pigmented hair chromophore in the skin, the patient should not wax or pluck before or in between treatments,
although waxing and plucking are not contraindications. If
needed, shaving, bleaching, and using depilatory creams are
preferable between treatment methods.
It should be explained to patients that they will experience
some level of discomfort during the procedure. This discomfort
is quite subjective and has been described as feeling like the
popping of small rubber bands, pinpricks, or pinpoint heating.
In general, it should be tolerable. Severe pain is an indicator
that the laser parameters may be too aggressive. This is particularly helpful when patients state that pain is worse than
in previous treatments. A topical anesthetic preparation (e.g.,
EMLA) and/or adjunct cooling (e.g., air cooling) will help to
decrease the pain during the procedure. After treatment, there
may be immediate perifollicular edema and mild erythema
lasting from minutes to hours, but this may not be observed
because of the more conservative parameters used on darker
skin. Permanent hair reduction can still be achieved if this result
is not seen. If these reactions persist for hours, more conservative parameters should be used in the next treatment to avoid
the epidermal damage threshold.
At no point during post-treatment should there be prolonged
erythema, edema, crusting, blistering, or scab formation, irrespective of the patient’s ethnicity or skin phototype. If a previous
treatment has produced prolonged erythema, crusting, or any
other form of epidermal side effect, a thorough history should be
retaken, inquiring about recent sun exposure, new medications,
new skin products, and the post-treatment regimen. More conservative parameters should be used to ensure treatment safety.
Do Not Copy
Penalties Apply
Although there has been no evidence that pregnancy is a contraindication, it is widely practiced and recommended that patients
not undergo LHR during pregnancy.
In managing patient expectations prior to initiating LHR,
patients should understand that multiple treatments are necessary to achieve permanent hair reduction. In patients of color,
a minimum of eight laser treatments are usually required to
reach the patient’s desired hair reduction. With each treatment,
patients may expect a decrease of 10 percent to 20 percent in
the hair count, color, and diameter of the hair. Patients with
darker skin usually require more treatments than those with
lighter skin because of the need to use longer wavelengths,
lower fluences, and longer pulse durations to ensure safety.
Treatment frequency is still controversial and is based on many
factors, particularly the hair growth rate and the body region of
the treatment area. Because subsequent treatments should be
repeated before the damaged hair has a chance to fully revitalize and strengthen, it is generally agreed that more frequent
treatments are better than less frequent ones. Although there
are no studies proving ideal treatment intervals, treatments
Pre-Treatment Preparation
The treatment area must be closely shaved or clipped prior to
performing laser treatments to prevent the superficial hair from
heating and causing epidermal side effects. A gentle alcohol
cleanse should be performed to make sure there is no residual
makeup or anesthetic on the skin, followed by a final cleanse
with water to remove any residual alcohol. Appropriate goggles
must be worn by the patient, practitioner, and all observers.
Treatment can begin once the appropriate parameters are determined. Laser pulses should overlap by 10–20 percent, depending
on the type of laser system used. Fluences should be increased
cautiously, since even small increases can exceed the patient’s
epidermal damage threshold, creating thermal damage. The
practitioner should always exercise caution and perform test
spots prior to treating the full area.
In treating the upper lip and chin, the enamel of the teeth should
be protected by overlaying the teeth with gauze. Facial hair is
usually finer and lighter than the hair on the rest of the body,
JO1111
1238
making it one of the most recalcitrant areas to treat. In these cases, more than the usual number of treatments may be required.
Immediate cooling with ice packs or cool air can be used to reduce post-treatment discomfort, erythema, edema, and the risk
of epidermal side effects. A mild topical corticosteroid can also
be applied to the treatment area to reduce prolonged erythema,
edema, or irritation.
Recognizing, Minimizing, and Treating
Unwanted Side Effects
When treating patients of color with the long pulsed diode and
Nd:YAG laser system, conservative parameters will minimize
the risk of any adverse events.16,17 Epidermal thermal damage
can cause crusting, scabbing, blistering, dyspigmentation, and
scarring, but immediate, meticulous wound care will help to
minimize the risk of long-term or permanent side effects. Based
on the severity of the side effects, wound care may include topical/oral antibiotics or corticosteroids. A folliculitis-type reaction
can also be treated with antibiotics and/or corticosteroids. There
is also a small risk of herpetic outbreak in patients with a history
of recurrent herpes.
Paradoxical hypertrichosis has been reported as a rare complication of LHR, within and outside of the treatment site, and after
alexandrite lasers (755 nm) and IPL (590-1200) treatments.18-20 In
the authors’ experience, this complication can occur with any
wavelength or light source, including the diode laser (810 nm)
and Nd:YAG laser (1064 nm). Studies suggest that patients with
skin phototypes IV–VI may be at increased risk, particularly patients of Mediterranean or Pacific Asian descent, but patients
from most ethnic origins have been reported.21,22
E. F. Battle Jr.
post-inflammatory hyperpigmentation, but it can dramatically
improve the dyspigmentation resulting from conventional methods of epilation. Continued improvement usually occurs with
each consecutive laser treatment. Patients are often as pleased
with the improvement in skin texture and dyspigmentation as
they are with their hair reduction.
LHR not only improves PFB and
its associated post-inflammatory
hyperpigmentation, but it can dramatically
improve the dyspigmentation resulting
from conventional methods of epilation.
In treating the beard area of men, cosmetic outcome should be
considered. Permanent hair removal of the entire beard is usually not the desired outcome. The beard stubble look is often a
more natural look, and taking away the ability to grow a beard
is not always an appropriate endpoint. Treatment goals should
be to improve the cosmetic appearance of the patient and to
reduce the papular and pigmentary disorder, thus providing
the patient with a cosmetically pleasing appearance. Male patients who have beard PFB are most often affected in the upper
cheek or lower neck area. Here, the practitioner’s goal should
be to achieve permanent hair reduction in those select areas
while keeping the majority of the beard intact with a distinct,
symmetrical and appropriately neat beard line. An alternative
to pursuing permanent hair reduction, lower fluences and/or
longer pulse durations can be used to manage the condition by
delaying hair growth.
Do Not Copy
Penalties Apply
Laser Efficacy in Hair-Related Dermatologic Conditions in Skin of Color
Excessive hair growth may constitute a major cosmetic and
medical problem, whether from hirsutism or hypertrichosis. In
patients with darker skin types and tightly curled hair, there is a
high incidence of epidermal side effects with conventional hair
removal methods. LHR can provide these patients with a safe
and successful therapeutic option.
Men and women with curly, tightly coiled, coarse hair are often
plagued with ingrown hairs, producing papules and pustules
that easily lead to pigmentary disorders and scarring called
pseudo-folliculitis barbae (PFB). This condition is most frequently seen in the beard area of men or in the axillae or bikini area of
women but can also be seen on the abdomen, back, arms, and
legs. As with hirsutism, conventional approaches (e.g., waxing or
shaving) often lead to unsightly side effects. LHR temporarily or
permanently reduces the hair from the PFB lesions, dramatically
improving the condition by resolving papules and pustules and
improving skin texture and associated post-inflammatory hyperpigmentation.23,24 LHR not only improves PFB and its associated
Acne keloidalis nuchae (AKN) is most frequently seen in the occipital area of the scalp in African-Americans. It is characterized
by persistent follicular and perifollicular papules and plaques,
which often lead to hyperpigmented scarring and keloidal thickening. AKN lesions are especially recalcitrant to treatment, and
conventional methods can yield marginal, often unpredictable
results. In early lesions, where there is usually evidence of an
entrapped hair, laser-assisted hair removal is a helpful adjunctive therapy. Lower fluences and longer pulse durations should
be used initially to provide more of a hair growth delay approach, rather than opting for permanent hair reduction. For
more chronic changes associated with long-standing AKN, such
as scarring, foreign body reaction, and decreased hair growth,
more aggressive LHR parameters may be required. For best
results, this method should be combined with conventional
treatment (topical antibiotics and corticosteroids, oral antibiotics, and intralesional corticosteroid injections). The goal is to
destroy the tufted hairs that act as a foreign body, in hopes of
decreasing further scarring. In these cases, the clinical outcome
is not as satisfactory.
JO1111
1239
CONCLUSION
Everyone, regardless of skin color or ethnicity, can now be safely
and effectively treated for unwanted hair with LHR. The safest
and most effective hair-removal lasers for darker skin types are
the long pulsed diode and the long pulsed Nd:YAG laser systems. Because of the longer wavelength, the long pulsed Nd:YAG
system is considered the safest. Conservative fluences and longer pulse durations are also necessary in order to provide safe
and effective treatments to patients with darker skin types. An
added benefit of laser epilation is that some of the side effects of
conventional hair removal more commonly seen in skin of color
may also respond favorably to the laser, thus increasing the potential for patient satisfaction.
DISCLOSURES
The author has no relevant conflicts of interest to disclose.
REFERENCES
1.
Anderson RR, Parish JA. Selective thermolysis: Precise microsurgery by selective absorption of pulsed radiation. Science.
1983;220(4596):524-527.
2. Van Gemert MJC, Welch AJ. Time constants in thermal laser medicine. Lasers Surg Med. 1989;9(4):405-421.
3. Commo S, Gaillardo O, Bernard BA. The human hair follicle contains two distinct K19 positive compartments in the outer root
sheath: A unifying hypothesis for stem cell reservoir? Differentiation. 2000:66(4-5):157-164.
4. Cotsarelis G, Sun TT, Lavker RM. Label-retaining cells reside in the
bulge area of pilosebaceous unit: Implications for follicular stem
cells, hair cycle, and skin carcinogenesis. Cell. 1990;61(7):1329-1337.
5. Fuchs M. Thermokinetic selectivity—a new highly effective method for permanent hair removal: Experience with LPIR Alexandrite
laser. Derm Prakt Dermatologie. 1997;5:1.
6. Manuskiatti W, Elmpunth S, Wanitphakdeedecha R. Effect of cold
air cooling on the incidence of postinflammatory hyperpigmentation after Q-switched Nd:YAG laser treatment of acquired bilateral
nevus of Ota like macules. Arch Dermatol. 2007;143(9):1139-1143.
7. Breadon JY, Barnes CA. Comparison of adverse events of laser
and light-assisted hair removal systems in skin types IV-VI. J Drugs
Dermatol. 2007;6(1):40-46.
8. Battle E, Suthamjariya K, Alora M, et al. Very long pulses (20–200
ms) diode laser for hair removal on all skin types (abstr). Lasers
Surg Med. 2000;12(suppl):21-24.
9. Alster T, Bryan H, Williams CM. Long pulsed Nd:YAG laser assisted
hair removal in pigmented skin. Arch Dermatol. 2001;137(7):885-889.
10. Battle EF Jr, Hobbs LM. Laser-assisted hair removal for darker skin
types. Dermatol Ther. 2004;17(2):177-183.
11. Alster TS, Bryan H, Williams CM. Long-pulsed Nd:YAG laser-assisted hair removal in pigmented skin: A clinical and histological evaluation. Arch Dermatol 2001;137(7):885-889.
12. Galadari I. Comparative evaluation of different hair removal lasers
in skin types IV, V, and VI. Int J Dermatol. 2003;42(1):68-70.
E. F. Battle Jr.
13. Bouzari N, Tabatabai H, Abbasi Z, et al. LHR: Comparison of longpulsed Nd:YAG, long-pulsed alexandrite, and long-pulsed diode lasers. Dermatol Surg. 2004;30(4 Pt 1):498-502.
14. Greppi I. Diode LHR of the black patient. Lasers Surg Med.
2002;28(2):150-155.
15. Khatri KA. The safety of long-pulsed Nd:YAG laser hair removal in
skin types III–V patients during concomitant isotretinoin therapy
[Letter]. J Cosmet Laser Ther. 2009;11(1):56-60.
16. Greppi I. Diode LHR of the black patient. Lasers Surg Med.
2002;28(2):150-155.
17. Adrian RM, Shay KP. 800 nm diode LHR in African American patients:
A clinical and histologic study. J Cutan Laser Ther. 2000;2(4):183-190.
18. Alajlan A, Shapiro J, Rivers JK, et al. Paradoxical hypertrichosis after laser epilation. J Am Acad Dermatol. 2005;53(1):95-88.
19. Radmanesh M. Paradoxical hypertrichosis and terminal hair change
after intense pulsed light hair removal therapy. J Dermatol Treat.
2009;20(1):53-54.
20. Moreno-Arlas GA, Castelo-Branco C, Ferrando J. Side-effects after
IPL photodepilation. Dermatol Surg. 2002;28(12):1131-1134.
21. Moreno-Arlas GA, Castelo-Branco C, Ferrando J. Side-effects after
IPL photodepilation. Dermatol Surg. 2002;28(12):1131-1134.
22. Alajlan A, Shapiro J, Rivers JK, et al. Paradoxical hypertrichosis after laser epilation. J Am Acad Dermatol. 2005;53(1):85-88.
23. Ross EV, Cooke LM, Timko AL, Overstreet K, Graham B, Barnette
DJ. Treatment of pseudofolliculitis barbae in skin types IV, V, VI with
a long pulsed Nd:YAG. J Am Acad Dermatol. 2002;47(2):263-270.
24. Ross EV, Cooke LM, Overstreet KA, Buttolph GD, Blair MA. Treatment of folliculitis barbae in very dark skin with Nd:YAG laser.
J Natl Med Assoc. 2002;94(10):888-893.
Do Not Copy
Penalties Apply
ADDRESS FOR CORRESPONDENCE
Eliot F. Battle Jr. MD
Cultura Cosmetic Dermatology and Laser Center
5301 Wisconsin Avenue, NW
Washington, DC 20015
Phone:…………………...…......................................(202) 237-9292
E-mail:.…....……………[email protected]
JO1111

Advances in Laser Hair Removal in Skin of Color

Transcription

Similar documents

SF]ELF F1 ELP

Salon Product

here - Women`s ROGAINE

the skin care center - Pioneer Medical Group

Dry Twist Out 101

Easter 2016 Flyer-Digital-FINAL

a facial fo r yo ur h air

Girls Scrunchie

Anatomically shaped foil for hair coloring

sample pictures