Laser hair removal (LHR) has become increasingly more popular in today's society and is available in most dermatology and plastic surgery offices. Interested consumers may also find this procedure in a variety of other medical office and salon settings (Hilton, 2015). Both men and women of all age groups, and with various skin types, seek this popular cosmetic service. Although growing in popularity, numerous concerns still exist in the LHR industry. The list includes a lack of standardized training, the degree of supervision required, and the lack of available safe and effective laser parameters that produce known results (Hilton, 2015). The primary concern with untrained LHR providers is their potential to cause harm to the patient, resulting in possible legal action or corrective treatment expenses (Jalian, Jalian, & Avram, 2014).
Literature on LHR dates as far back as 1988; however, as technology evolves, the most recent research associated with newer technology is manufacturer specific. The newest hair removal lasers on the market are being marketed as faster, more efficient, and virtually pain free. Each of the lasers reviewed within the literature has received both positive and negative reviews and is geared toward targeted audiences based on their skin type. Some lasers may be used on all skin types. The largest manufacturers of laser equipment such as Syneron Candela, Cynosure, and Alma are mentioned within the literature.
The term “laser” is an acronym, which stands for “light amplification by stimulated emission of radiation.” Theodore H. Maiman invented the first laser in the year 1960 (Patil & Dhami, 2008). A ruby is a laser medium that produces powerful flashes of intense light; consequently, it was named the “ruby laser” (Patil & Dhami, 2008). Since the dawn of the ruby laser, other lasers have been invented, and the technology continues to evolve today (Patil & Dhami, 2008). Lasers that are being used for hair removal include the alexandrite, the neodymium-doped yttrium aluminum garnet (Nd:YAG), and the diode laser, with several models and manufacturers throughout the world. Intense pulsed light systems are not lasers but are being used to reduce hair growth. They are less expensive and may be useful for some cosmetic treatments as well.
Advanced practice registered nurses in primary care are providing this service within their scope of practice in most states or referring to specialty offices for LHR treatments. Lasers can be either purchased or rented. In some instances, the sales representative will return to train the staff on the use of the equipment, although the sales representatives have no medical training, experience, or expertise in the hair removal process. The purpose of this narrative literature review is to determine if there are sufficient data available for new providers to offer safe and effective laser treatments without national guidelines in place.
THE CLINICAL SCHOLAR MODEL
The Clinical Scholar Model (CSM) will provide the context and structure for recommendations based on the most recent evidence that leads to safe and effective treatments (Schultz, 2005). The CSM is a five-step process designed to change clinical practice based on the evidence that exists or is sought through research and qualitative studies. These five steps include “observe,” “analyze,” “synthesize,” “evaluate,” and “disseminate” (Honess, Gallant, & Keane, 2009). The initial query was derived out of curiosity and knowledge based on current LHR practices. The data were analyzed and will be discussed within the body of the article. A review of the table of evidence and the quality of evidence is the most important step in this process (Gallant, 2005). Synthesizing the data determines the strength of the evidence, and pertinent data are represented in table form within this narrative literature review (Kent, 2005). The evaluation step in the CSM is where the decision takes place to determine if the evidence is strong enough to be applied to current practice (Kent, 2005). This will be described in detail in the literature review to determine if there is a need to change current practice or if a need exists to conduct additional research. In addition, a determination on the need for protocols or guidelines will also be discussed. The last step of the CSM is to disseminate the findings. When new providers utilize the recommendations contained within this narrative review, they will have the ability to offer safe and effective LHR treatments. Providers can then protect the patient as well as the provider from unnecessary side effects and potential litigation.
REVIEW OF CURRENT LITERATURE
Significant and current studies (2008–2017) were retrieved through a series of searches conducted in CINAHL, Cochrane, and MEDLINE databases using Boolean terms/phrases. Pertinent results are described under the subheadings of “Conditions,” “Safety,” and “Parameters.” Most of the studies focus on safe and effective treatment responses aimed at increasing the patient experience. Inclusion criteria for the literature presented in this narrative review were determined based on the ability to answer the initial query on safe and effective LHR treatments. Steps 2 and 3 of the CSM are analyzed and synthesized. These two steps merge in the research process as the inclusion and exclusion of data process are achieved. This process may be visualized on the CSM provided (Figure 1). The evidence is presented in both data and table forms. These select studies are described in narrative form with supporting tables reflecting the most pertinent data.
Women may experience hirsutism, which is defined as terminal hairs in a male pattern (Lizneva, Gavrilova-Jordan, Walker, & Azziz, 2016). These unwanted hairs are the result of androgen excess. Differential diagnoses for hirsute patients include polycystic ovarian syndrome (PCOS), idiopatic hirsutism, hyperandrogenic insulin-resistant acanthosis nigricans syndrome, 21-hydroxylase-deficient nonclassic congenital adrenal hyperplasia, and androgen-secreting neoplasms (Lizneva et al., 2016). To date, there are no valid data on LHR efficacy in patients with PCOS-related facial hirsutism (Lee, 2017; Table 1). Eflornithine hydrochloride 13.9% (Vaniqa) cream has been used as an adjunct therapy in LHR treatments in women (Xia et al., 2012). With the proper diagnosis, medication, and hair removal treatments, the patient with unwanted hair, as a result of androgen excess, will be able to reduce the amount of hair growth and regain self-confidence. Most patients report an increased confidence and an increased quality of life. LHR treatments for women, in particular, can significantly increase their quality of life by helping them regain their femininity.
Pseudofolliculitis barbae (PFB) is an inflammatory condition that is most frequently seen in African American men and may also be seen in African American hirsute women. This condition is related to curly hair that has been cut short and then reenters the skin. There is a high incidence of PFB in the military because of strict military regulations for a clean-shaven face. A randomized, double-blinded, placebo-controlled study on the use of eflornithine hydrochloride 13.9% cream in conjunction with LHR treatments was approved by the Walter Reed Army Medical Center (Xia et al., 2012). This pharmacological agent aids in the reduction of hair growth by inhibiting ornithine decarboxylase, an enzyme involved in hair cell division (Xia et al., 2012). Twenty-seven patients experiencing PFB were enrolled in this study (Xia et al., 2012). Fifteen of the patients were treated with eflornithine hydrochloride cream and LHR treatments. Twelve of the patients received only LHR treatments (Xia et al., 2012). The results showed that the patients who were treated with eflornithine hydrochloride in addition to their LHR treatments had a greater reduction in hair growth at both the 8- and 16-week follow-up visits (Xia et al., 2012).
Pilonidal sinus disease (PSD) is a recurrent condition that is more prevalent in teenagers and young adults, with men being affected three times more than women (Marza, 2013). PSD is a chronic inflammatory disease process, which usually occurs in the sacrococcygeal area, in the natal cleft, approximately 5 centimeters from the anus (Dragoni et al., 2017). This painful disorder can be debilitating and requires surgery to relieve pressure associated with inflamed hair follicles. Surgery and antibiotic therapy are usually the first line of treatment for PSD (Marza, 2013). The recurrence rate associated with PSD is around 50% with surgery and is usually associated with secondary infections caused by additional buildup of hair or debris in the sinus tract (Marza, 2013). Numerous studies have been conducted that have shown that LHR reduces the recurrence of PSD (Dragoni et al., 2017; Koch et al., 2015; Marza, 2013). To decrease the incidence of folliculitis in the sacrococcygeal area, many surgeons are now recommending laser treatments to their patients to prevent recurrence of PSD.
Koch et al. (2015) discuss PSD as well as a broad spectrum of LHR indications and their efficacy in a comprehensive literature review. Also included in the review were patients' case notes from the Birmingham Regional Skin Laser Center between 2003 and 2011 (Koch et al., 2015). Indications for LHR treatment include Becker's nevus, genital region for gender reassignment, PSD, PFB, and intraoral hair-bearing flap (Koch et al., 2015). The results show significant improvement in hair reduction in all cases. Patient satisfaction is highly rated in all of the procedures documented. These studies promote the effectiveness of LHR treatments and the need for increased awareness by practitioners in the medical field (Koch et al., 2015).
Trained laser technicians and providers should follow a protocol or use the recommended laser manufacturer guidelines to prevent laser-induced injuries. Lasers, excluding the intense pulsed light, are known as Class 4 medical devices. Certain precautions must be taken to ensure the safety of the patient as well as everyone in the room. A primary example is ocular injury, which can occur when the laser light is exposed to the eye (Asiri et al., 2017). Closing one's eyes is not enough protection from injury because of the depth of penetration associated with the laser beam (Asiri et al., 2017). Ocular injuries associated with alexandrite LHR treatments have been documented (Table 2). Each patient presented differently, yet all had decreased visual acuity that resolved with pharmacological intervention or rest (Asiri et al., 2017). Although these patients did recover after receiving medical treatment by an ophthalmologist, it is important to take note that each patient who presented with ocular injuries had a delayed response (Asiri et al., 2017).
Another concern is the danger to healthcare workers or technicians who are exposed to laser plume on a daily basis. Plume produced from LHR treatments contains potentially harmful organic compounds that may pose long-term health problems including cancers (Chuang et al., 2016). A recent case study showed that there were 62 organic compounds identified within laser plume, including toxins and 13 known carcinogens (Chuang et al., 2016). A few of these chemicals exceeded Occupational Safety and Health Administration (OSHA) daily-allowed limits (Chuang et al., 2016). Smoke evacuators and N95 or N99 masks worn properly can reduce the amount of airborne particles that the provider will encounter.
With the increasing popularity of LHR services, there has also been an increase in legal claims associated with cutaneous laser treatments and nonphysician operators (Jalian et al., 2014). A search of a legal national database, Westlaw Next, from January 1999 to December 2012 generated 175 cases, 75 of which involved nonphysician operators (Jalian et al., 2014). The most common allegations associated with LHR claims include failure to supervise, failure to hire and train appropriate staff, negligent entrustment, failure to recognize and treat an injury, failure to operate with the proper licensure, and failure to properly operate a laser (Jalian et al., 2014). Physicians must be sure that their staff is properly trained (Jalian et al., 2013). Physicians, advanced practice registered nurses, and physician assistants need to be aware of the state laws associated with LHR within their state. Throughout the nation, the individual states maintain the rules and regulations associated with the operation and supervision requirements for LHR treatments. National guidelines are nonexistent, leaving providers and operators to learn this trade by trial and error, which in turn puts consumers at risk for burns and ineffective treatments from inexperienced operators (Jalian et al., 2014).
Burns are the most preventable reaction to a laser treatment. Therefore, it is important to always start by using the manufacturers' recommended settings or to provide a test sample in an inconspicuous area. Hypopigmentation, hyperpigmentation, and histamine reactions are all known adverse events in laser treatments. These events will require aftercare and are directly related to the settings used on the patient and their skin sensitivity. The alexandrite laser is powerful and works best on Skin Types I–III on the Fitzpatrick scale (Figure 2). In one recent comparison study between two lasers, the alexandrite and the Nd:YAG, the alexandrite was found to be superior based on its efficacy, with a 53% hair reduction for the alexandrite and a 39% hair reduction for the Nd:YAG, resulting in a follow-up study (Karaca, Doğruk KaÃ§ar, & Ozuğuz, 2012; Table 3). A chart review from the Birmingham Regional Skin Laser Center between 2003 and 2011 reveals that, in each case where the alexandrite laser was used, the results were effective, which was determined through follow-up visits and hair reduction (Koch et al., 2015). The parameters varied and were in correlation with the body part being treated. The setting range for the alexandrite 755-nm laser was varied, according to the charts reviewed. The settings range from 10 to 40 J/cm2. Patients with PSD might have a setting of 22–26 J/cm2 with a 10-mm spot size, whereas a patient seeking gender reassignment receives LHR treatments of scrotal skin that is premeditated by tetracaine topical gel and, in turn, will have settings that range from 18 to 30 J/cm2 using a 12-mm spot size (Koch et al., 2015). One long-term outcome report followed a patient who developed paradoxical hypertrichosis after treatment with the alexandrite laser (Honeybrook, Crossing, Bernstein, Bloom, & Woodward, 2017). The 21-year-old patient, with Skin Type II, received three LHR treatments on patchy areas of dark hair that affected various body parts (Honeybrook et al., 2017). After three treatments, the patient noticed an increase in density as well as an increase in the length of the hairs (Honeybrook et al., 2017). The selected settings were 20–22 J/cm2 at 10- to 12-week intervals (Honeybrook et al., 2017). The patient was followed for 10 years, at which point, he felt he was now back where he originally began before receiving LHR treatments. No pretreatment photos were taken (Honeybrook et al., 2017). Another case study reported within the literature involved an adverse affect of total body bromhidrosis and paradoxical hypertrichosis (Helou, Haber, Kechichian, & Tomb, 2015; Helou, Maatouk, Moutran, & Obeid, 2013; Honeybrook et al., 2017). Although this is a rare phenomenon that requires further studies, patients need to be made aware of the possible adverse affects associated with treatments.
Patients with tans and darker skin tones are more susceptible to burns because of the melanin within their skin. The 800- or 810-nm diode and the 1064-nm Nd:YAG can bypass the melanin in the skin, penetrating deeper into the dermis and targeting the root at the base of the hair follicle (Patil & Dhami, 2008). These lasers are safer for people with Skin Types IV–VI on the Fitzpatrick scale. A recent clinical study using an 810-nm diode that resulted in a high efficacy using a low fluence with high repetition makes the claim that the diode laser is now the gold standard in laser treatments (Agarwal et al., 2016). The diode laser can safely treat all skin types on the Fitzpatrick scale. Many are designed with a cool Safire tip that glides quickly across the skin, allowing for a virtually pain-free treatment. Others use vacuum technology to pull the skin up into the hand piece to reduce pain. Numerous studies have been conducted with the diode laser, with most testing the efficacy and pain-free feature of this new technology. A long-term comparison of a large-spot-size, vacuum-assisted hand piece versus a small-spot-size hand piece of the 800-nm diode laser was tested in 26 women (Youssef, Rizk, Ibrahimi, & Tannous, 2017). The treatment results were similar in long-term and short-term hair counts at follow-up visits. The patients indicated that the vacuum-assisted hand piece was the less painful treatment and, subsequently, the most preferred (Youssef et al., 2017). The settings used for this study were selected using the patients' Fitzpatrick skin type and the thickness of the hairs (Youssef et al., 2017). A low-fluence, high-repetition-rate, 810-nm diode laser study evaluated the efficacy of a 15-J/cm2 and 5-Hz repetition rate to a controlled shaved area (Barolet, 2012). Setting selection should be determined using the patient's Fitzpatrick skin type and the laser manufacturer recommended settings (Figure 2). The patient with Skin Type II did not respond to treatment but instead had an increase in hair growth (Barolet, 2012). Hypertrichosis has been noted in two studies and is said to happen when settings are below the manufacturers' recommendations (Barolet, 2012; Honeybrook et al., 2017). Five additional diode laser clinical trials testing the efficacy of low fluence and high repetition over a single-pass higher fluence mode were reviewed. Low fluence and high repetition rate do not only effectively remove hair, but it is also more tolerable because of the pain reduction associated with the speed of the treatment (Koo et al., 2014; Lapidoth et al., 2014; Li et al., 2016; Pavlovic et al., 2015; Royo et al., 2017; Table 3). Laser settings can be reduced by 30% and still maintain efficacy in LHR treatments (Pavlovic et al., 2015). Diode lasers offer two modes: a pulse-by-pulse mode or a stamping mode. The continuous mode is good for large areas, whereas the single-pulse option is good for small or uneven areas (Omi, 2017). The diode lasers, both the 800 and 810 nm, offer an alternative for patients who may otherwise opt out because of the pain associated with the treatments.
Patients with Skin Types IV and V are at the highest risk for burns and pigmentation changes. The 1064-nm Nd:YAG is a reliable laser that is still in use today and continues to provide safe and effective treatments for patients with Skin Types IV and V (Gan & Graber, 2013; Vachiramon, Brown, & McMichael, 2012; Wanitphakdeedecha, Thanomkitti, Sethabutra, Eimpunth, & Manuskiatti, 2012). This laser is multifaceted and is used for more than just hair removal. It is the only laser that will safely treat Skin Types IV and VI (Gan & Graber, 2013; Vachiramon et al., 2012; Wanitphakdeedecha et al., 2012). However, even this laser is not free from complications. The most common side effect that can occur with this laser is hyperpigmentation (Chan & Dover, 2013). One report about the Nd:YAG, by two expert physicians, shared their first treatment setting for patients with darker skin tones (Chan & Dover, 2013). The pulse duration selection is generally 3 milliseconds using a 12-mm spot size, and a fluence in the range of 24–32 J/cm2, and is directly related to the patients' skin type and the location being treated (Chan & Dover, 2013). Fluence can be increased with each visit, based on the patient's response.
The data evaluated in the context of the CSM for this narrative literature review imply that there are no sufficient data available on safe and effective laser treatments for new practitioners interested in offering LHR services without having national guidelines in place. The discussion associated with the strengths and limitations of the narrative review is categorized within the same subheadings to describe the relevant studies. The strengths and limitations of the studies contained within this narrative review are presented.
The current literature reveals several conditions that a nurse practitioner will encounter in primary care. There are currently no studies that validate the effectiveness of LHR treatments in hirsute women diagnosed with PCOS. These patients are often excluded from studies because of treatment resistance. A randomized controlled study conducted under conditions is associated with PFB; a topical cream eflornithine hydrochloride 13.9% is shown to reduce facial hair growth during LHR treatments but has not been tested as a stand-alone therapy (Xia et al., 2012). Eflornithine hydrochloride 13.9% is only effective when used as directed; once the topical agent is discontinued, the benefits of the pharmacological agent cease. Nurse practitioners within the primary care setting may prescribe eflornithine hydrochloride 13.9%. However, this is only a temporary solution and provides no lasting effects (Somani & Turvy, 2014).
Individual case studies associated with PSD resulted positively, but only the alexandrite and Nd:YAG lasers were tested. Other limitations associated with the PSD case studies revealed a small sample size and the need for a longer follow-up posttreatment. Case notes from the Birmingham Regional Skin Laser Center promoted positive results in all cases documented. Case study limitations reveal a lack of uniformity in comparison. In addition, there were no unsatisfactory results provided within the case notes from the Birmingham Regional Skin Laser Center (Koch et al., 2015).
Data evaluated in the safety section of the safe and effective LHR treatment literature review revealed strong evidence on the dangers related to ocular injuries and plume inhalation. The limitations associated with the four ocular case studies were minor in comparison with the strength of the evidence presented through individual reports with the documented injuries. These limitations involve the formulation and measurement of chemicals identified within the study. Only chemicals soluble in hexane and chloroform were identified; other chemicals may exist, and a mere 30-second sample was measured without a smoke evacuator to provide a 26-fold increase in particle concentration (Chuang et al., 2016). The evidence revealed in the LHR plume case study is strong and includes preventative measures to decrease exposure for providers who perform LHR on a regular basis. No long-term evidence associated with LHR plume exposure is available (Chuang et al., 2016).
Since the inception of LHR practices, there has been an ongoing concern regarding delegation, training, and safe operation. At this time, there are no national standards or guidelines in place to regulate the practice of LHR. There is ambiguity and inconsistency associated with uniformity of practice and delegation in the LHR industry (Jalian et al., 2014). Published expert opinions associated with the lack of supervision and the potential for injury present the physician as the one at fault in most of the claims (Jalian et al., 2014). The search of legal claims associated with LHR litigation resulted in more than half of the cases having the doctor as the operator or supervising physician (Jalian et al., 2014). Physicians must be sure that their staff is properly trained (Jalian et al., 2014). There are no data available on training courses, yet they are required under some individual state statutes (Jalian et al., 2014). Current guidelines can be found by searching each individual state medical board and state legislature Web sites (Jalian et al., 2014). These guidelines are state specific and govern the practice of LHR.
The literature evaluated within this narrative review associated with settings and parameters can only be useful in the event the provider has the same laser and is treating the same area with the same Fitzpatrick skin type. The settings listed within the literature may be unclear for new providers because of the lack of knowledge that would enable the provider to convert laser parameters safely from one laser to another; this is not explained within the literature. Most LHR providers own and operate one laser; therefore, the safest way to provide a treatment without years of experience is to utilize the manufacturers' safe operating guidelines. Too many variables exist to provide a general standardized handbook on LHR parameters. Manufacturers of hair removal lasers provide operational training sessions to their consumers. Each laser will have safe operation guides within the context of the Fitzpatrick skin type chart, with suggestions for incremental setting increases based on the patient's response. One case reported within the literature discusses an uncommon adverse effect of paradoxical hypertrichosis (Honeybrook et al., 2017). The cause for this is unknown; however, there is mention that the parameters may have been too low to produce results but instead had an undesirable side effect of increased hair growth (Honeybrook et al., 2017). Although a rare phenomenon that requires further research, patients need to be made aware of the possible adverse effects associated with treatments. Some of the limitations associated with these studies involve a small sample size, short-term studies, one type of laser studied or compared, a lack of uniformity in comparison, short follow-ups, areas that respond well to treatment being used to test parameters instead of more difficult body areas to treat, and most of the diode studies testing the newest diode technology from Alma (Agarwal et al., 2016; Karaca et al., 2012; Koo et al., 2014; Lapidoth et al., 2014; Li et al., 2016; Pavlovic et al., 2015; Royo et al., 2017; Kim et al., 2014). Adverse effects studied are included within this narrative review to increase the knowledge level of the new practitioners offering LHR services.
IMPLICATIONS FOR PRACTICE FOR PROVIDERS
Primary care providers will find that both men and women struggle with excessive hair growth. These symptoms should alert the provider that there may be an underlying disease process that needs investigating. Providers are finding opportunities to offer this growing service within their scope of practice (Jalian et al., 2014). Many nurse practitioners and physician assistants are offering this service, either within a local office or in a primary care setting. Providers who are not offering this service should be aware which offices offer the best LHR services to refer patients who may be in need of permanent hair reduction for various conditions and disease processes that will ultimately improve the patients' quality of life.
Today's patients are educating themselves and shopping for healthcare providers, so it is important that the provider is knowledgeable about the topic of hair removal. Patient education associated with before and after skin care and how to prepare for the first appointment begins in the consultation. During the consultation, it is important that the provider obtain a full pretreatment evaluation and medication history, being sure to evaluate for any preexisting conditions such as herpes simplex virus and photosensitive disorders as well as any recent photosensitizing medications such as isotretinoin (Gan & Graber, 2013; Spring et al., 2017). Patients with recurrent infections of herpes simplex virus on the mouth or genital region warrant a prescription of valacyclovir 500 mg twice daily for 10–14 days starting on the day before the procedure (Gan & Graber, 2013). A systematic review with consensus recommendations examined the use of isotretinoin and the timing of various procedures; 32 publications reported 1,485 procedures with insufficient evidence to support delaying LHR treatments for patients who are on isotretinoin therapy (Spring et al., 2017). Other medications such as over-the-counter dehydroepiandrosterone, herbals, and steroids may produce hair growth. Patients who need to take these medications must be told that the results of hair removal will be less effective but they will still see results from their treatments. Although LHR is safe for expectant mothers, patients who are expecting must obtain a note from their obstetrician before treatment of the breasts, abdomen, or genitals.
A spot test in an inconspicuous area, to ensure a patient's skin can tolerate a particular setting, before using the setting in a more noticeable location on the body, is a good practice for new providers. Spot testing should be performed on patients who may present with possible risk factors for burns or pigmentation changes (Jalian et al., 2013). Risk factors include photosensitizing medications, Skin Types IV–VI on the Fitzpatrick scale, history of keloids, patients who are allergic to the sun, and any patient who has vocalized a concern about how sensitive his or her skin can be. Any noted risk factors should raise suspicion and alert the provider to proceed with caution. LHR treatments do have a certain degree of pain, which varies from patient to patient, as does their pain tolerance. However, patient vocalization related to a painful treatment or a burning sensation is a good indication that the laser setting is too high (Fontana, Bonini, & Bagnato, 2013). Patients need to be informed of the risks associated with LHR treatments and the risk for burns and pigmentation changes, especially in Skin Types IV–VI on the Fitzpatrick scale. It is also important to note that having a signed informed consent, covering the risk factors associated with laser treatments, is key in the prevention of litigation (Jalian et al., 2013).
There is an ongoing need for more research on body areas that are more difficult to treat. Despite the increased popularity of LHR treatments and the advancement of technology, there are limited up-to-date information on safe and effective LHR treatments and minimal information regarding the importance of patient education. More research is necessary to determine the efficacy of LHR treatments in both men and women of all ages and skin types. Further studies that would be beneficial should include areas that are more resistant to treatment such as the hirsute woman, full bikini in women, and full back in men. Recent research showed varying treatment times and parameters; however, patients typically need six to eight treatments for most body parts, and each treatment should be scheduled 6–8 weeks apart.
Operating a laser requires training and, at a minimum, basic laser physics knowledge (Patil & Dhami, 2008). Thirty-hour training classes are available across the nation but not always required. Nurse practitioners interested in offering this service within the primary care setting or within their own location must verify with the board of nursing that operating a Class 4 medical device is within their scope of practice. The final step in the CSM is to disseminate the main finding associated with the narrative literature review. In this review, following the laser manufacturer's recommended settings continues to be the safest way to initiate a treatment regimen and to prevent burns (Karaca et al., 2012). With no LHR guidelines in place, the best practice for LHR treatments is contained within this literature review using the most recent research available to date.
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