conduction hearing implant (BCHI) surgery is dermatitis around the titanium skinpenetrating abutment.  
Objective: To describe the laser epilation of hair around a BCHI abutment using  the long-pulsed, 800-nm Light SheerTM diode laser (Lumenis, Inc.) as a treatment for  recurrent soft tissue reactions secondary to the in growth of hairs around the implant  site. 
Results: Laser therapy resulted in prevention of recurrent infections as a sequel of  an effective hair follicle reduction in our case. The patient was very satisfied with the  outcome and no side effects could be observed.
Recommendation: Diode laser therapy appears to be a successful therapeutic  option for patients suffering from recurrent infections around their BCHI abutment due  to the in growth of hair. This treatment can be proposed as a new alternative for  current standard therapies. 

• Diode laser therapy

• BAHA/BCHI

• Holgers

• Skin reactions

Samoy K, Goeteyn M, Lerut B (2016) Laser Epilation as a Treatment for Recurrent Infections around Bone Conduction Implant Abutment. Ann Otolaryngol Rhinol 3(7): 1116.

One of the most frequent complications of percutaneous BCHI involves a soft tissue reaction around the titanium skinpenetrating implant or peri-abutment dermatitis.

The most commonly used classification for this soft tissue reaction is the Holgers’ classification [1]. Grade 0 means no irritation; whereas a grade 1 stands for reddish discoloration of the skin around the implant; a grade 2 stands for a reddish skin with moist surface of the skin around the implant; a grade 3 reaction results in the formation of granulation tissue around the implant and a Holgers’ grade 4 shows extensive soft tissue reaction requiring implant removal. Obesity, dermatologic diseases such as eczema and psoriasis, diabetes mellitus and a history of cardiovascular disease might influence soft tissue reactions post-BCHI surgery [2,3]. Also in growth of hair around the abutment may cause problems of recurrent infections around the BCHI implant.

Hair can be removed by many techniques; however, laser treatment has emerged as the criterion standard in hair depilation. There are many kinds of epilation laser systems, including the long-pulsed alexandrite laser, the neodymium-doped yttrium aluminium garnet (Nd: YAG) laser and the diode laser. Diode lasers use the principle of selective photothermolysis (SPTL) or photoepilation to target the melanin in the hair shaft. Hereby, the laser damages the melanin by selectively heating it while leaving surrounding tissue unharmed. This results in the disruption of hair growth and regeneration, thus providing hair loss. A diode laser can be complemented by cooling technology, or other pain reducing methods which improve treatment efficacy and patient comfort [4].

There are already many reports that detail the clinical importance of those systems. However, to date, laser epilation in reconstructive surgery of auricular malformations is the only found indication in otology [5,6]. We want to add recurrent periabutment dermatitis as a result of in growth of hair as a new indication for laser hair removal in otology.

The patient was a 68 years old female with a medical history of Ramsay Hunt in December 2009, complicated with a vestibulocochlear dysfunction on the right side. Because of a progressive increase in sensorineural hearing loss on the right side with perceptive thresholds of 85 – 90 dB in April 2010, the decision was made to place a BCHI on the right side. A BIA210 was placed using the Nijmegen linear incision technique with soft tissue reduction. There were no complications postoperatively. During follow-up she complained about recurrent infections around the BCHI abutment. On clinical examination, a Holgers’ grade I, caused by in growth of hair around the abutment, could be observed on several occasions. Treatment consisted of excessive hair removal followed by local treatment with an ointment containing hydrocortisone and ocytetracycline (Terracortril® suspension) and instead of opting for a revision surgery to reduce the amount of hair follicles, the patient was referred to the colleagues of dermatology to perform a laser epilation in an ambulant setting. The laser treatment took place after local control of the infection.

They performed photoepilation with the diode laser Light Sheer Duet system at a wavelength of 800 nm. The Light Sheer ET hand piece was used to treat the small area with the following parameters: spot size 9 x 9 mm, energy density 30 - 40 J/cm2 , pulse duration 15 - 20 ms, cooling with the Light Sheer’s cooled sapphire device. Laser treatment was carried out 2 cm around the abutment, as near as possible to the abutment. The area to be treated was shaved immediately before laser epilation. No local anesthesia was applied before the laser treatment. After irradiation, an ointment containing Sulfadiazine (Flammazine®) was applied routinely for several days. The treatment was well tolerated and provided a quick and effective hair reduction. For a satisfying result, 4 sessions during a period of 7 months were necessary. During the treatment, the patient had mild to moderate pain and after treatment, there was redness and mild oedema around the hair follicles. These side-effects can be considered as normal.

The latest check-up, 11 months after completion of the laser epilation, showed a Holgers’ grade 0 (Figure 1).

Figure 1: Outcome after four diode laser treatments.

Local inflammatory skin reactions at the skin/abutment interface are the most common complications of BCHI. Frequent and attentive cleaning of the abutment site is necessary in an attempt to prevent infections. If local infection does occur, the traditional treatment algorithm may consist of one of the following treatment options: local wound care (including general cleaning, topical antibiotics and in-office silver nitrate cautery of granulation tissue), topical clobetasol cream, localized triamcinolone injections, and, in the case of more significant local infections, even oral antibiotics or revision surgery (including fitting of a longer abutment and/or subcutaneous soft tissue reduction) [2,7-9].

The mechanisms of the inflammatory reaction around the skin-penetrating device are not completely understood, but are supposed to include infections by bacterial and fungal pathogens, a foreign body reaction and shear stresses from surrounding soft tissues [10]. We feel that in growth of hair can also be a cause of recurrent infections around a BCHI abutment.

Titanium has an excellent biocompatibility and integrates readily with bony structures, but the implant does not demonstrate sufficient integration with the skin in order that the skin-implant interface can offer a complete isolation with the internal environment. It is known that there is epidermal down growth along the implant surface, which tends to form a pocket with cellular debris and hair shafts between the implant and the skin at the epidermal-implant interface. This can permit pathogens to enter the body, which may cause infections [11]. Whether the new generation coated abutments provide sufficient barrier and complete skin in growth to prevent peri-abutment dermatitis still remains to be proven by long-term studies.

In the older techniques with tissue reduction, the problem of hair in growth may be due to an insufficient removal of the hair follicles around the abutment implant site. Another explanation is that the hair shafts get broken off and get pushed down into the dermis along with the pylon during the implantation surgery, by which they are placed in a different direction, grow in and elicit an inflammatory response which can secondary get infected. In the current techniques, where a new longer abutment without any need for soft tissue reduction is used, there’s no more removal of hair follicles. This may give rise to hair growth around the skin penetrating abutment leading to entangling of the abutment or in growth. That’s why we introduced the laser hair removal technique in patients with this problem. The downside of this technique is a strict patient selection. A complete and detailed history should be obtained to rule out associated illness. This should include photo-aggravated skin diseases and medical illness, e.g., systemic lupus erythematosus; treatment area with active cutaneous infections, e.g., herpes or staphylococcal infections; history of any photosensitizing drugs (minocycline, isotretinoin) and keloid or hypertrophic scars. Also proper patient selection and tailoring of the fluence used to the patient’s skin type, remain important factors in efficacious and well tolerated laser treatment. Individuals with skin photo types III to V can be effectively and safely treated with the diode laser; individuals with blond, grey and white hair does not respond well to this treatment [4,12].

Different laser systems have been used for hair epilation, in our case the diode laser has been used. Hereby, SPTL leads to destruction of the pigmented hair follicles and thus ensuring a long-lasting, however, not permanent hair removal. For this reason repeated treatments may prove beneficial for the maintenance of an optimal treatment outcome. Possible side effects include slight to moderate pain and redness or oedema around the hair follicle. Pain can be prevented with anesthetic gels or creams. We only saw mild adverse reactions in our patient and the epilation result was satisfactory. So, this case report shows the positive effect and the efficacy of the laser epilation in reducing hair growth and preventing recurrent infections around the BCHI abutment. We think that this treatment may decrease the need for invasive postoperative treatment options such as revision surgery in patients with BCHI. In our department, several patients were already treated with success with this treatment.

Laser hair removal with the diode laser led to a complete resolution of recurrent infections in our case. To our knowledge, no cases of laser hair removal for the treatment of recurrent infections around a BCHI abutment due to the in growth of hair have been reported so far.

In conclusion, diode laser treatment appears an effective alternative in the treatment of recurrent infections around a BCHI abutment due to in growth of hair. Laser hair removal for this indication seems a safe and well-tolerated treatment option resulting in sustained symptomatic improvement. Further study is needed. A large randomized controlled trial comparing laser hair removal with other treatment modalities for this indication would be helpful in order to determine the place of this new treatment option in the existing treatment algorithm.

The individual whose case and picture are presented in this article has provided written informed consent to publish her case details.

Sitting of a percutaneous bone conduction hearing implant (BCHI) may give rise to adverse skin reactions.

This paper describes a patient with recurrent infections around her BCHI abutment due to the in growth of hair, which was successfully treated with laser hair removal therapy.

In order to confirm the effectiveness of this treatment mode, long term results need to be documented in a considerable number of patients.

1. Holgers KM, Tjellström A, Bjursten LM, Erlandsson BE. Soft tissue reactions around percutaneous implants: a clinical study of soft tissue conditions around skin-penetrating titanium implants for boneanchored hearing aids. Am J Otol. 1988; 9: 56-59.

2. Rebol J. Soft tissue reactions in patients with bone anchored hearing aids. Ir J Med Sci. 2015; 184: 487-491.

3. Den Besten CA, Nelissen RC, Peer PGM, Faber HT, Dun CAJ, de Wolf MJ, et al. A retrospective cohort study on the influence of comorbidity on soft tissue reactions, revision surgery and implant loss in boneanchored hearing implants. Otol Neurotol 2015; 36: 812-818.

4. Gan SD, Graber EM. Laser hair removal: a review. Dermatol Surg. 2013; 39: 823-838.

5. Ono I. Therapeutic effect of using a long-pulsed alexandrite laser system with a cooling device for epilation in reconstructive surgery of auricular malformations. Ann Plast Surg. 2002; 48: 115-123.

6. Takase M, Hashimoto I, Nakanishi H, Tanaka S, Matsumoto K, Matsuo S. Reconstruction of microtia with laser hair removal before transplantation of costal cartilage. J Plast Reconstr Aesthet Surg. 2008; 61 Suppl 1: S86-91.

7. House JW, Kutz JW Jr. Bone-anchored hearing aids: incidence and management of postoperative complications. Otol Neurotol. 2007; 28: 213-217.

8. Hildrew DM, Guittard JA, Carter JM, Molony TB. Clobetasol’s Influence on the Management and Cost of Skin Overgrowth Associated with the Bone-Anchored Hearing Aid. Ochsner J. 2015; 15: 277-283.

9. Van Rijswijk JB, Mylanus EAM. Intralesional triamcinolone acetonide injection in hypertrophic skin surrounding the percutaneous titanium implant of a bone-anchored hearing aid. J Laryngol Otol 2008; 122:1368-1370.

10. Van Hoof M, Wigren S, Duimel H, Savelkoul PH, Flynn M, Stokroos RJ. Can the Hydroxyapatite-Coated Skin-Penetrating Abutment for Bone Conduction Hearing Implants Integrate with the Surrounding Skin? Front Surg. 2015; 2: 45.

11. Farrell BJ, Prilutsky BI, Ritter JM, Kelley S, Popat K, Pitkin M. Effects of pore size, implantation time, and nan-surface properties on rat skin in growth into percutaneous porous titanium implants. J Biomed Mater Res Part A. 2014:102:1305-1315.

12. Buddhadev RM, IADVL Dermatosurgery Task Force. Standard guidelines of care: laser and IPL hair reduction. Indian J Dermatol Venereol Leprol. 2008; 74 Suppl: S68-74.