1. Detailed clinical history to rule out infections, drug intake, etc.
2. Hormonal evaluation to assess causes of hirsutism.
3. Counsel the patient to manage expectations. It must be stressed that the procedure provides permanent hair reduction rather than removal.
4. Evaluate skin and hair types to choose the right laser and parameters.
5. Avoid hair epilation by plucking or waxing for 6 weeks before the procedure.
6. Sunscreens may be prescribed 4 to 6 weeks before the procedure, especially on exposed areas.
7. Pre-procedure photographs, with due consent, to maintain a record for evaluation of treatment response.
8. Shave the area long enough before the procedure to allow a slight stubble to develop; this will provide enough of a target for the laser without absorbing too much energy in the hair shaft itself.
9. Obtain an informed consent.
10. If need be, a topical anesthetic cream may be applied one-half to one hour before the procedure.[14][15]

1. Clean the area to remove oils from the skin
2. Position the patient comfortably.
3. Use eye protection for both the operator and the patient.
4. Avoid reflecting surfaces or metallic objects near the laser.
5. Individualize the parameters to each patient's skin and hair type and the type of laser being used. 
6. Place the handpiece perpendicular to the skin. Ensure that it is pressed down gently but firmly to bring the follicles close to the surface and temporarily decrease the blood supply to the treatment area.
7. Perifollicular edema and erythema is an expected side effect, and this must be explained to the patient prior to the procedure.[14][15]

Post-Procedure Care

1. Although most machines have inbuilt cooling systems, ice packs or cooling agents may be used post-procedure to minimize pain and swelling.
2. In case of inadvertent epidermal injury, topical antibiotics may be used.
3. Strict sun protection and the use of sunscreens is a must.
4. Topical steroid creams may be prescribed to minimize erythema and swelling.[14][11]

The hair matrix is only sensitive to laser treatment during the anagen phase of the hair growth cycle; therefore multiple treatments will be necessary in order to address all hair follicles when they are most sensitive to treatment. In the initial phase of hair removal therapy, 4 to 6 sessions spaced 4 to 6 weeks apart are the minimum required to achieve adequate results. Subsequently, patients may need maintenance treatments once every 6 to 12 months as small vellus hair may grow back.[16]

Various factors may affect the outcome, such as:

1. Hair location (axillary and pubic hair respond better than hair on the extremities and chest)
2. Skin and hair color (light skin of Fitzpatrick skin types I-IV with dark hair achieve the best results due to the lack of melanin in the skin and the abundance of melanin to absorb laser energy in the hair follicles)
3. Hair growth stage (anagen hair being most sensitive)
4. Laser type
5. Hormonal status
6. Treatment plan[2]

Adjacent epidermal structures other than melanin within the hair bulb can compete for absorption, and may cause laser energy to be absorbed by pigment in the epidermis. This hampers the effectiveness of the treatment and causes adverse effects due to adjacent epithelial damage. [17]

Common adverse effects of laser or IPL-based hair removal include post-treatment erythema, pain, and burning.[18]

More severe adverse effects include blistering, crusting, dyspigmentation, purpura, and sometimes scarring.[19][20] Ocular complications due to accidental injury may be seen. Paradoxical hypertrichosis may rarely occur, more commonly in skin type III and with the use of IPL systems.[21][22][23]

Selecting the correct lasers with the appropriate parameters, individualized to each patient, is very important, particularly in patients with intrinsically dark skin. Most complications are preventable when adequate precautions are taken with adjustment of the fluence, spot size, wavelength, and the use of appropriate cooling. Thus, it is all the more important that trained personnel with a thorough knowledge of the mechanisms, techniques, and complications carry out these procedures.

Laser hair removal is performed by many healthcare workers including nurses, dermatologists, plastic surgeons, primary care providers and other cosmetic surgeons. Unfortunately, because of lack of oversight, complications are common during this procedure. To make matters worse, patients are often given unrealistic expectations. The key is to use the correct laser, especially in dark skinned individuals. Common adverse effects of laser or IPL-based hair removal include post-treatment erythema, pain, and burning.[18] More severe adverse effects include blistering, crusting, dyspigmentation, purpura, and sometimes, scarring.[19][20] Ocular complications due to accidental injury may be seen. Paradoxical hypertrichosis may rarely occur, more commonly in skin type III and with the use of IPL systems.[21][22][23]

Overall, lasers can remove hair but rarely does the procedure provide a permanent cure for hair growth. Touch up maintenance treatments are required for most patients in the long term.