Researchers Review Modalities and Ethical Considerations in Pediatric Hair Removal

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A team of 3 researchers hailing from The George Washington University School of Medicine & Health Sciences; the Dermatology Branch of the National Institute of Arthritis and Musculoskeletal and Skin Diseases; and the Division of Dermatology at Children's National Hospital recently teamed up to conduct a review and analysis of hair removal modalities and ethical considerations related to the removal of unwanted hair in the pediatric population.

The review, published in Pediatric Dermatology,¹ explored the invasiveness and permanence of hair removal modalities, noting that unwanted hair is often a common concern among patients presenting to pediatric dermatology clinics. This unwanted hair, they wrote, can at times be attributed to hypertrichosis or hirsutism, or otherwise thick or dark, leading to a desire for removal.

Despite the common nature of hair removal inquiries, review authors Sanfilippo et al wrote that there is a lack of data supporting the efficacy and safety of various hair removal modalities in a population of pediatric patients, leading to gaps from a clinician's perspective.

In addition to these known gaps, review authors noted the intricate balance of ethical considerations with patient and parent desires for hair removal; this, coupled with the topic of parental consent for such procedures, can be attributed to a debate of the ethics of such hair removal.²

In addition to the ethics of hair removal, clinicians are often presented with the concern of unwanted hair's negative implications on a patient's overall well-being. Regardless of age, previous research has shown that patients tend to struggle with psychosocial challenges and significant distress as a result of the presence of unwanted hair.³

Researchers also emphasized the historical and cultural significance of hair before conducting their review, including cultural, religious, and social significance.

This recently-published review began with an examination of all articles on PubMed that had been published in the English language and involved the topic of hair removal in patients younger than 18 years of age. Relevant search terms used included, "pediatric," "adolescent," "ethic," and forms of hair removal, such as “waxing,” “epilation,” “depilat,” and “laser hair removal," among others.

Clinician Considerations

The available methods of hair removal vary from temporary to semi-permanent, according to the review.

Techniques like laser and electrolysis aim to destroy hair follicle stem cells, often requiring multiple treatments due to the cyclical nature of hair growth. While permanent reduction is possible, only excision of the follicle guarantees permanence.

Shaving, either manual or electric, is commonly used, especially during puberty.

Waxing involves applying wax to the skin and forcibly removing both the hair shaft and bulb.

Plucking and threading offer precise hair removal, often used for small areas like eyebrows.

Depilatory creams dissolve hair, and eflornithine cream reduces the length and thickness of growing hair.

Intense pulsed light and electrolysis also provide hair removal options, with lasers being the most common and effective method, particularly for pediatric patients.

Patient Considerations

The review also yielded various considerations for addressing common patient concerns.

Paradoxical hypertrichosis, has been observed in a subset of patients treated with intense pulsed light, particularly in females with abundant vellus hairs in the maxillary region. Despite this adverse effect, repeat light-based sessions effectively addressed the newly developed hairs, suggesting both the cause and potential solution lie within light-based interventions.

Pain management also emerged as a crucial consideration, especially in pediatric cases. While plucking and waxing pose discomfort and potential epidermal involvement, electrolysis is generally deemed more painful than intense pulsed light and laser modalities. Various methods to mitigate pain, such as topical anesthetics like lidocaine, cryogen spray, or forced refrigerated air, were reference. Dosage guidelines for topical anesthetics are emphasized to prevent systemic toxicity, and the option of general anesthesia for more painful procedures was highlighted, along with with considerations for potential neurotoxic effects in young children.

The review also yielded a discussion of the risk of post-inflammatory hyperpigmentation (PIH) associated with different hair removal modalities, particularly in individuals with darker skin types. While the Nd:YAG laser exhibited the lowest rate of PIH, intense pulsed light, with its shorter wavelengths, poses a higher risk in darker-skinned individuals, necessitating adjustments in fluence and pulse duration.

Another patient-related concern and challenge that emerged from the review was the perception of children's skin fragility and its impact on adverse events during hair removal procedures. Conflicting evidence regarding the thickness of children's skin compared to adults was discussed, and researchers deemed a need for further evaluation, particularly concerning outcomes secondary to laser therapy.

Misconceptions surrounding hair regrowth after shaving and concerns about hormonal changes during puberty influencing the efficacy of laser hair removal were also addressed by the review. There is a lack of scientific evidence supporting claims of augmented hair growth patterns in adulthood following laser therapy during childhood or adolescence, researchers found.

Safety considerations for individuals undergoing isotretinoin therapy should also be taken into account. While historical guidelines recommended delaying cosmetic and surgical procedures post-isotretinoin due to concerns about impaired wound healing and skin fragility, newer recommendations deem hair removal lasers and lights safe during isotretinoin therapy. However, caution is advised with waxing, as case reports suggest potential epidermal stripping in patients on oral and topical retinoids.

Ethical Considerations

In addition to clinician considerations of modalities and their efficacy and safety, as well as patient-centered considerations and worries, researchers also delved into ethical considerations that can stem from the topic of hair removal in children.

Children may express distress over excess hair, prompting parents to seek treatment options. Laser hair removal is considered safe for children of all ages, although it may not be medically necessary. Excess hair can lead to embarrassment and psychological distress, similar to other dermatologic conditions. However, performing cosmetic hair removal on a child who is not bothered by it infringes on their autonomy, researchers wrote.

Clinicians should decline such requests and educate parents on alternative measures.

Adolescents may undergo cosmetic procedures with realistic goals and sufficient maturity, as laser hair removal also plays a significant role in gender-affirming procedures.

Final Thoughts

"All methods of hair removal appear to be safe and generally well tolerated in children, and there are no age restrictions to any modality," wrote review authors. "Thoughtful collaboration with the patient and family can inform clinical guidance. Careful consideration of body area involved, level of tolerance, and degree of distress can help identify the best course of action to provide the desired outcome. As each patient has different needs and cosmetic goals, counseling should be tailored to the individual patient."

Researchers recommended methods like shaving, trimming, plucking, and depilatory creams for small body areas, and electrical trimming or shaving for larger areas like the back or abdomen. They also suggested trying these methods first before considering laser hair removal or electrolysis, which may have higher costs and potential risks.

Additionally, they emphasized the importance of seeking treatment from board-certified dermatologists and warns against risks associated with inexperienced personnel performing hair removal procedures.

"To enhance our understanding of hair removal practices in the pediatric population, further research is warranted," according to Sanfilippo et al.

References

1. Sanfilippo E, Castelo-Soccio L, Yasmine Kirkorian A. A review of hair removal modalities in pediatric patients: Ethical and clinical considerations. Pediatr Dermatol. February 2, 2024. Accessed March 5, 2024. DOI: 10.1111/pde.15564
2. Remien K, Kanchan T. Parental consent. StatPearls. StatPearls Publishing; 2023 Accessed March 5, 2024. http://www.ncbi.nlm.nih.gov/books/ NBK555889/
3. Wendelin DS, Pope DN, Mallory SB. Hypertrichosis. J Am Acad Dermatol. 2003;48(2):161-182. Accessed March 5, 2024. doi:10.1067/mjd.2003.100