Severe Urticaria After 755-nm Alexandrite Laser Surgery for Hair Reduction

Paul Wirth, Jr. and Leon Kircik, MD

Laser treatment for hair reduction is one of the most common cosmetic procedures performed in the United States. Hypertrichosis of the face is a common condition. Women predominantly seek treatment for this. Time-honored approaches for facial hair reduction include bleaching, waxing, sugaring, and electrolysis.

Lasers have been a more recent method for hair reduction. Laser treatments are advantageous because they are painless, rapid procedures that are highly successful. The efficacy of lasers for hair reduction relates to the phenomenon of selective photothermolysis. All lasers generate a single monochromatic wavelength of light. Targeted tissue or chromophores absorb light of a single wavelength.

Taking advantage of the principle of selective photothermolysis, one can match a laser to a specific target's absorption maximum for light energy and selectively destroy the target. In the case of hypertrichosis, lasers in the red or near infrared spectrum are chosen because the melanin pigment in the hair bulb absorbs these wavelengths of light. When the light energy is absorbed, the hair follicle is heated triggering anagen follicles to enter a prolonged telogen phase, resulting in the shedding of the terminal pigmented hair. In the case described here, the 755-nm alexandrite laser was chosen because of its ability to penetrate deeply into the skin and then be absorbed selectively by the hair bulb and not be absorbed by other chromophores in the skin such as water and hemoglobin. Melanin at the skin surface does compete with the hair bulb for the light energy.

To protect this pigment from thermal injury during treatment, the laser is equipped with a “dynamic cooling device.” This device emits a burst of 1,1,1,2 tetrafluoroethane, a spray cryogen that cools the surface of the skin an instant before the light energy is delivered. The “dynamic cooling device” thus protects the epidermis from unwanted thermal injury caused by melanin absorption that occurs during laser treatment. The effects of cryogen have been extensively studied.1,2

One advantage of laser treatment for the reduction of hair is that side effects are very rare. Reported here is a case of “severe urticarial” response that developed shortly after laser treatment for hair reduction of the face. Provocative testing suggests that the offending agent causing the urticarial response was 1,1,1,2 tetrafluoro-ethane, which was used to cool the epidermis.

Case

A 43-year-old Caucasian female presented with unwanted pigmented terminal hairs of the chin, upper cutaneous lip, and beard area. She had no drug allergies or history of urticaria. She was taking no medication and had no medical problems. She had no history of cold-induced urticaria or solar urticaria. Prior to laser treatment she was anesthized using 7% lidocaine/23% prilocaine topical cream applied one half hour prior to treatment. The anesthetic cream was removed with sterile saline gauge and she was treated with the long pulse alexandrite laser using 30 J/cm2, a 10-mm spot size, a 3ms pulse duration and dynamic evolving settings of 30ms spray time with a 30ms delay before delivery of the laser pulse. She tolerated the procedure well and without incident.

The evening of the treatment she developed severe facial swelling and was started on aclovate cream. She was seen the next day and was noted to have severe urticaria of the facial skin limited to the areas of facial treatment. The urticarial plaques were sharply demarcated and not evanescent. Aclovate cream was continued for three more days but the utricaria did not improve. The patient was started on systemic steroids, utilizing prednisone at a dose of 40mg each morning for one week. The urticaria gradually improved. After one week of the systemic steroids, the dose was reduced to 20mg each morning. By the end of the second week of systemic treatment, the eruption resolved and the steroids were stopped.

Four months later, the patient agreed to have provocative testing performed on her back. Topical cetaphil with 7% lidocaine/23% prilocaine as well as topical bacitracin (which was placed on the treatment site immediately after laser treatment) were placed on the back. The patient was also treated with a single pulse of 755nm light from the Alexandrite laser at a power setting of 30 J/cm2, a 10mm spot size, and a 3ms pulse duration with and without 1,1,1,2 tetrafluoro-ethane cryogen spray set at a 30ms spray time with a 30ms delay. The patient had no previous history of cold urticaria and as a control a burst of liquid nitrogen was employed and released onto the patient's back.

At 24 hours after testing, the sites of bactracin and 7% lidocaine/23% prilocaine were negative for urticaria. The sites where liquid nitrogen and 755nm light with no cryogen were used were also negative for urticaria. The sites where cryogen (1,1,1,2 tetrafluoro-ethane) alone and 755nm light and cryogen were used developed a rapid, sharply demarcated urticarial response that resolved after 10 days of topical halobetisol.

In this case, 1,1,1,2 tetrafluoro-ethane was deemed to be the offending agent causing the patient's urticarial response, based on simple provocative testing.

Discussion

The advantages of laser treatment for hair reduction include efficiency, minimal to no pain, and minimal side effects. Severe persistent urticaria following laser treatment for hair reduction has been rarely reported. Bernstein reported four laser patients who developed severe utricaria after laser treatment for hair reduction.⁴ Three of their patients were treated with the long pulse alexandrite laser and one was treated with a long pulse Nd:YAG laser system (1,064nm neodymium-doped yttrium aluminum garnet). In all four cases, the urticarial reaction was treated with topical steroids and antihistamines and resolved in one week or less. In one case, the patient required two and a half weeks for the urticaria to resolve and required the use of systemic steroids. None of the four patients treated by Bernstein had contact allergy testing and all had light energy plus 1,1,1,2 tetrafluoro- ethane cryogen for treatment.

Ishiguro et al. reported a case where a female patient developed an allergic pulmonary reaction (allergic alveolitis), which developed while performing laser surgery for hair reduction.⁵ The laser system that the patient was using employed 1,1,1,2 cryogen spray and upon rechallenge with cryogen her symptoms recurred. The investigators postulated that her allergic response was caused by the cryogen 1,1,1,2 tetrafluoro-ethane.

Severe urticaria after laser treatment for hair reduction using laser devices that use the cryogen 1,1,1,2 tetrafluoro-ethane is a rare complication. Recognition of this phenomenon is important for all physicians who treat these patients or help manage the side effects. More investigation will be necessary to further study this urticarial response after laser treatment.

Dr. Kircik has served as a researcher, consultant, or speaker for Allergan, Coria, Dermik, Galderma, Stiefel/GSK, Intendis, Medicis, Obagi, OrthoDermatologics, and Triax.

Leon Kircik, MD, FAAD is Director of Derm Research, PLLC and Physicians Skin Care, PLLC. He is Clinical Associate Professor of Dermatology at Mount Sinai Medical Center and Indiana University School of Medicine.

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2. Algermissen B, Hermes B, Henz BM Mu¨ ller U, Berlien HP. Laser-induced weal and flare reactions: clinical aspects and pharmacological modulation. Br J Dermatol. 2002; 146: 863-8.
3. Aguilar G, Wang GX, Nelson JS. Dynamic behavior of cryogen spray cooling: effects of spurt duration and spray distance. Lasers Surg Med. 2003; 32:152-9.
4. Bernstein E. Severe Urticaria After Laser Treatment for Hair Reduction. American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc. 2009.
5. 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; 46:1455-7.