New York State has a problem with laser hair removal
“We see this a lot,” the dermatologist said, his face inches from mine under the glare of a lamp at his practice in the New York City suburb where I live. My head began to spin. What have I done?
The day before, a rainy Thursday in May 2017, I’d driven my kids to school and continued on to an appointment at expensive salon in a neighboring town for laser hair removal on my upper lip.
Until that day, my experience with salons consisted of haircuts and the very occasional manicure. I’m a nerd. Even for my wedding I’d worn minimal makeup, and at almost 50, I still owned barely any. But I’d been self-conscious about the shadow on my face since I was in high school, and I felt like it was becoming more noticeable with age.
Now, when I looked in the mirror, my eye was drawn to a line a couple of millimeters above my mouth, slightly longer on the left side than on the right, faint but unmistakable.
I’d fallen into a trap.
In Westchester County where I live, and in Manhattan where I work as a financial news editor, I saw laser centers here and there. But I’d never been to a cosmetic dermatologist, or any dermatologist, so I didn’t know that doctors also do laser hair removal. Frequently. It was done some 450,000 times by dermatologists and more than a million times by plastic surgeons in 2017. But in most states, the treatment is also done in medical spas and salons like the one I went to, in uncounted numbers.
Stories about injury from inexpertly done laser hair removal — burns and skin discoloration, mainly — abound in the beauty press, and there’s been general interest coverage as well. I hadn’t seen any of it.
But I could have read a handful of those articles and still walked into that salon in Scarsdale — the suburban outpost of a chain with several locations in Manhattan — assuming nothing could go wrong. The metro area bleeds expertise. And I was in New York, which the libertarian Cato Institute ranks the most highly regulated U.S. state.
In fact, New York State is the riskiest place in the country to undergo laser hair removal outside of a doctor’s office, because it’s the only state where the treatment is wholly unregulated. In New York salons, the person who cuts your hair, and the person who does your nails, and the person who waxes your brows all have to undergo exams by state licensing authorities, but nothing is done to ensure the competence of the operator of a machine that can disfigure your face. All esthetic laser treatments except hair removal are regulated as the practice of medicine. The exclusion is an accident of the law.
The injuries aren’t being counted, but there are indications that they are more frequent and severe in New York than in any other state. Professional Program Insurance Brokerage, which sells liability policies to medical spas, rates premiums the same way across the country, except in New York, where the average claim is three times the national average.
Dr. Roy Geronemus, a Manhattan dermatologist who has served as president of the American Society for Dermatologic Surgery and the American Society for Laser Medicine & Surgery, told me his practice sees complications from laser hair removal “on a daily basis. A year or two ago it would be several a month.” The number of horrific cases is not declining, he said. “In my opinion, we are now dealing with a public health issue.”
In May 2017, the same month I was treated, an industry-backed bill was introduced in the state legislature that would require a course of study to perform the treatment in non-medical settings, akin to what exists for other salon workers. It hasn’t gone anywhere. In a textbook example of the perfect being the enemy of the good, it’s opposed by the association representing the state’s doctors, who say the level of physician supervision it calls for isn’t sufficient.
All but six U.S. states consider laser hair removal to be a medical treatment, along with all the other so-called esthetic laser treatments, which include skin rejuvenation and tattoo removal. That means if you want it, you’re going to at least be seen by a doctor.
In the most strictly regulated state — New Jersey — only a physician can fire the laser. In others, a doctor can delegate, and standards vary for whether the operator needs any medical training (as a nurse, for example, or a physician assistant) and how close by the doctor needs to be during the treatment.
Where laser hair removal isn’t considered a medical treatment (Georgia, Massachusetts, Oregon, Texas and Vermont), there is still some level of oversight, said Michael Byrd, CEO of ByrdAdatto in Dallas, which provides legal services to med spas nationwide. In Texas, for example, anyone can own a clinic, but it must have a consulting physician.
“New York is in a class by itself in the sense that laser hair removal is not considered medical and is not regulated,” Byrd said. “The practical effect is that anyone can do laser hair removal and there’s not any regulatory control over that.”
Laser hair removal technology came onto the scene in the 1990s, when doctors at Massachusetts General Hospital in Boston discovered that pigment in the hair could absorb laser light, destroying the capillary that feeds the follicle.
Operating a laser hair removal device is simple. A pulse of light is delivered to a tiny area via a hand-held wand. “A monkey could do it,” said Dr. Bryan Sofen, a dermatologist who practices in Michigan and whose peer-reviewed publications include a journal article about managing adverse reactions to lasers. “You hold it up and press a button.”
Pigment in the skin complicates the treatment, however, which is why people with dark hair and fair skin are generally considered the best candidates. Skin discoloration — temporary or permanent — can result if the operator, physician or not, lacks expertise with the technology and the biology of skin.
Adverse reactions are most common in “people with darker skin types,” Dr. Anne Chapas, medical director of Union Square Dermatology in Manhattan, told me. “If you have more pigment in your skin, there’s more of a chance of something going wrong with lasers.”
My ancestry is mixed European, some northern, some southern, and my skin tone is olive. The dermatologist I saw on the day after my treatment said the laser had “blown up” pigment just below the surface, creating a series of gray spots that my eye connects into a line. Rarely have I sensed that someone has noticed, but in the mirror, my scar is all I can see. It tells my secrets. That I was ashamed of my appearance. That I’d lacked the sophistication to go to a doctor. That I hadn’t heard the whispers about what could happen to me.
Professional Program Insurance Brokerage, in Novato, California, insures medical spas against customer claims of error or omission. According to the American Med Spa Association, in 2017, 71% of them offered laser hair removal, which was the third-biggest revenue generator after toxins (like Botox) and other esthetician services (like facials).
“Claims are extraordinarily high in New York compared to anywhere else we do business,’’ Susan Etter, vice president for underwriting at PPIB and the former head of its medical spa line, told me. For 2012–2018, the average payout was $32,402, the highest of any state and nearly three times the national average of $11,528, “which is attributable to technicians not knowing what they are doing.” While those figures are for the medical spa line as a whole, most of the claims relate to laser hair removal, she said.
Policies are rated according to the types of technicians and the services they provide, but “as far as premiums go, the only state that we rate differently in is New York,’’ Etter said. Before adjustments, the price of insurance in New York is 20% higher than in any other state. “Based upon how much more these claims cost, it really should be more than that, but then you run into the problem of no one buying insurance.’’
PPIB has relatively little competition writing med spa insurance in New York, Etter said, with many insurers avoiding the state “because you guys don’t have any rules.’’ California requires at least registered nurse certification and majority ownership of the spa by a physician, she said, while Texas and Colorado are good examples of states with rigorous certification programs for non-medical professionals doing laser hair removal. For PPIB coverage in New York, laser technicians need 30 hours of formal training. “Ideally, legislation would be for more, but it’s hard for us to enforce more,’’ Etter said.
To remove hair with scissors in New York State, a person needs to take a three-hundred-hour approved course of study and pass written and practical exams.
New York’s executive branch has tried to contain the problem, but it hit a judicial roadblock.
In February 2002, the New York Times published an investigation about burns and skin discoloration resulting from laser hair removal by non-physicians. Three months later, the state medical board, part of the Education Department, decided that the use of a laser to treat any physical condition should be considered the practice of medicine.
By 2007, the medical board was telling people that medical licensure would soon be required to perform laser hair removal, according to legal memos by Jennifer Kirschenbaum, whose Garden City, New York firm has defended salons against complaints by the state on behalf of injured customers. But by 2009, the board had been informed by the Education Department’s Office of the Professions that its determination “could not be supported as it applied to hair removal” owing to legal precedent.
According to Kirschenbaum, the precedent is from 1937, when the state attempted to prosecute a beauty parlor owner for practicing medicine without a license by performing electrolysis, then the new hair-removal technology, on a state investigator (There’s the New York I know and love!). The court ruled that the medical statute “was never intended to cover this kind of beauty culture,” and established that removal of hair isn’t the practice of medicine in New York, regardless of the tool used to do it.
Correspondence shows that state officials in 2010 contemplated making a rule that would specify the circumstances under which salons could offer the treatment. In the meantime, they said it could be offered by licensed estheticians (whose main business is facials) and cosmetologists “provided that there is a clear, distinct disclaimer that the the practice of laser hair removal is not regulated in any way by the Department of State.”
The rule was ultimately deemed unnecessary, and the guidance on a disclaimer doesn’t have the force of law, Lee Park, a spokesman for the department, said. Instead, the licensing section of the state’s website carries this advisory:
“Laser hair removal services may be offered in licensed appearance enhancement business by licensed practitioners notwithstanding that such services are not included in the course of study for licensure.”
“It’s very different than the way the rest of the states have treated laser hair removal,” said Alex Thiersch, a partner at ByrdAdatto and director of the American Med Spa Association, which he founded in 2013 to provide legal and compliance services to the rapidly growing industry.
From a regulatory standpoint, treating it as esthetics is “odd because the practice of esthetics means you’re not impacting living tissue,” Thiersch said. “Number one, laser hair removal does appear to do that, and number two, it can cause burns. That’s why most states have considered it to be a medical treatment. The idea that it’s more safe than if you’re doing skin resurfacing — which is uniformly considered the practice of medicine — is a stretch.”
Because of the 1937 court ruling, fixing the problem requires legislation. Dr. Geronemus, the dermatologic laser surgeon, said there was an effort during David Paterson’s term as governor (2008–2010) that was defeated by various stakeholders.
The latest effort, from 2017, is backed by the Society for Clinical and Medical Hair Removal, an industry group that develops licensing and continuing-education courses for non-medical operators that are used in Texas, Florida and Tennessee.
Its current president, William Moore, is a non-physician operator and owner of Advanced Skin Fitness, a medical spa in Dallas, and was involved in the passage of legislation in Texas. In New York the group retained Albany lobbyist Elizabeth Lasky to draft a bill that would do three things: It would establish a professional license within esthetics to perform the treatment in non-medical settings and limit the licensee’s practice to that treatment. It would require non-medical providers to retain a safety officer and a physician trained in laser hair removal to conduct annual audits and see patients in the event of injury. And it would require them to carry at least $1 million in professional liability insurance. It’s sponsored in the state Assembly by Amy Paulin of Westchester and in the Senate by Diane Savino of Staten Island.
In Texas, certification requires 75 hours of continuing education every five years. Moore says there’s less risk in being treated by a certified operator than at a doctor’s office where laser hair removal is done only occasionally.
Chillingly, he explained that equipment audits are key because of an influx of cheap devices from China that aren’t cleared by the FDA. Moore forwarded me a handful of the hundreds of marketing emails he said he has received for non-compliant equipment, priced in the $5,000 to $10,000 range. The U.S.-made devices he buys for his spa cost between $90,000 and $175,000.
The doctor I visited on the day after my treatment asked if I knew what kind of laser had been used on me. (I didn’t.) He said the business was growing quickly and that cheap equipment was proliferating. But good devices could also do damage, he said.
“I am leading this movement primarily to protect the residents of New York from injury by having treatments performed by untrained individuals, but also to protect the integrity of our profession by requiring training, licensing and continuing education,” Moore said.
As I began to tell women I’m close to about what had happened to me, I caught a glimpse of the professional risk Moore is worried about. One friend said she’d never done it because she was afraid it would leave a mark. Someone had told her it could. She said it took a lot of guts for me to do it.
The state’s doctors immediately declared the Paulin/Savino bill dead on arrival. The medical society “vigorously opposes certification of non-physicians” to perform laser procedures because of the potential for “painful burns and permanent scarring,” its memo opposing the bill says.
It goes on to describe what apparently had happened to me (which wasn’t physically painful). “Even when used at the manufacturer’s recommended settings,” the devices can cause “subtle tissue whitening or graying” indicative of thermal injury. The ability to immediately recognize when that is happening and stop the treatment is part of the vast gulf in education and training that separates physicians from estheticians, it said.
I asked the medical society why, if they were opposing a bill that might reduce injuries, they hadn’t backed legislation that would advance their policy goal of more physician oversight. The dermatologic surgeons’ association in 2016 drafted a model bill that state legislatures can take off the shelf and adopt. It calls for on-site physician supervision of treatments involving lasers and other energy-based devices (because what the public thinks of as laser hair removal can also be done with a cheaper technology called intense pulsed light, or IPL, that isn’t technically a laser, though it works on the body in the same way).
The membership hasn’t been able to agree on how much physician oversight is enough, Morris Auster, the group’s chief legislative counsel, told me. Some think a doctor should be in the room. Others think it’s ok to be in the building, or within a certain distance. “These are the questions we have been attempting to reconcile in arriving at a revised policy and, by extension, a suggestion for legislation,” he said.
According to the med spa association, 48 percent of the businesses nationally (laser centers included) are owned by physicians, and 43 percent have a doctor on site full time. Making it a requirement would cut into the industry’s profits. Why agree to that if you’re running a successful business and delivering excellent results? In the meantime, at some unknown rate, the bad actors are minting new dermatology patients seeking treatment for burns and scars. (And, to the extent that disfigurement obliterates peace of mind, new mental health patients as well.)
This year Westchester joined Nassau and Suffolk counties and New York City in banning sparklers because of burn risk to children. Laser hair removal is different, though. It’s private. And in the case of the face (as opposed to, say, the legs) the market for it is women who feel ashamed of how they look. Hurt badly enough you might sue, but if the damage is minor, as in my case, maybe you’d just buy some better makeup and try to go on with your life.
Dr. Chapas of Union Square Dermatology sounded pleasantly surprised when I contacted her, saying I planned to write about my experience. “I’ve seen so many patients with complications after laser procedures who won’t even report the business to the Better Business Bureau,” let alone allow themselves to be interviewed, she wrote.
When we spoke I asked her why, though I already knew. It had taken me months to get up the nerve to post a Yelp review of the salon warning people to do their homework, because I didn’t want to be recognized. The patients “all feel embarrassed,” Dr. Chapas said. “They say, ‘Why did I go? It looked reputable. I didn’t know these things could go wrong.’”
Many of the injured “don’t even realize that they’re healing improperly from a procedure because it’s minimized when they report it to spa staff,” she said.
I’d begun to consider the treatment only after hearing about it from a few friends who’d done it. I told my doctor I was thinking about it; she told me to go to a reputable place. I read WebMD, which said it was among the most common esthetic treatments and that permanent side effects were rare. (Unfortunately I didn’t also read the Mayo Clinic, which says to “be cautious about spas, salons or other facilities that allow non-medical personnel to do laser hair removal.”) I signed a waiver that said the treatment carried the risk of skin discoloration, calling permanent changes “extremely rare.” And when I called the salon a few hours later to report my result, the technician said she’d never heard of such a thing. (Presumably to lead me to believe I was some kind of a freak.)
So even as the Westchester dermatologist’s words kept ringing in my ears (We see this a lot.) the notion that I was anything other than unlucky didn’t cross my mind for months. I did wonder about the waiver’s basis for “extremely rare” because I wasn’t being counted in any way I was aware of. But the possibility that I had the wrong narrative didn’t sink in until I began to do research on a topical remedy that a couple of doctors had endorsed.
That led me into the medical literature on skin discoloration, “a frequent complaint in the cosmetic consultation as it is psychologically distressing,” readers of the January 2016 issue of Skin Therapy Letter (Dr. Sofen, the Michigan dermatologist, is the article’s primary author) were told. And the cause of “an increasing number of patients of all skin types seen in practice” as a result of “improperly performed cosmetic procedures by non-core or untrained physicians inducing color changes.” Only then did I start asking questions about what had happened to me, since apparently even doctors can’t always get it right.
Dr. Chapas said that patients undergoing elective cosmetic treatments are informed about risks in percentage terms. For laser hair removal, she said the risk of complications is given at 1 to 2 percent, most of which resolve, though some can be permanent. Extremely rare indeed. But that’s based on results of medical studies, not the experience of salon clients in New York.
Because there’s a non-zero chance that something like this could have happened at a medical practice, what may have been operator error can be characterized as a risk that the customer assumed. Spruce & Bond, where I was treated, has a polished website that claims you’re safer with their technicians than in a doctor’s office because they do so many more treatments. However the FAQ about the safety of laser hair removal offered the assurance that “our industry is regulated and monitored by state and local governing agencies.” No, it isn’t.
I asked about that when I spoke with the company’s president, Robin Moraetes, for this article in September 2018. Within a couple of weeks, that language was gone from the website.
Moraetes said it pained her to be lumped together in my story with the real villains — companies that rely on Groupon and Gilt to generate lucrative business, without regard for training and safety. She said she could count on one hand the number of times something like this has happened in her company’s 20-year history. Later in the conversation she said two hands. I asked for an exact number, as well as a copy of my treatment record. I received neither.
I no longer cry every day, but my spirit is broken. My shame is, quite literally, branded on my face. Social interactions are stressful, and I avoid looking in mirrors, except from safe distances. And I’m one of the lucky ones.
Syneron Candela, the leading U.S. manufacturer of laser hair removal devices, touts the treatment’s growth potential to doctors on its website. Sixty-one percent of women are interested, but only nine percent have had it done.
There are 8.5 million women in New York State. Some unknown percent of them will make the mistake I did — assuming expertise based on zip code — and some unknown percent of those will regret it for the rest of their lives. No matter how small the unknown values are, that’s a lot of broken spirits.
Author’s note: I began to report this story without knowing where it would ultimately reside. I work for Bloomberg News, but this was pretty far off the reservation. Bloomberg gave permission to publish it on different platform, for which I’m grateful. I’m also grateful to everyone who reviewed drafts, made suggestions and supplied encouragement. You can read about the fact-finding I did on Twitter @markedstory