Fitzpatrick V Client with Keloid History Requesting Three-Session Clearance
A 52-year-old client seeks electrolysis for chin and upper lip hair after 15 years of daily tweezing. She has diagnosed PCOS and is not currently on medication for it. She is Fitzpatrick V. Her history includes a raised earlobe after piercing and a C-section scar that widened and became raised. She had six laser sessions elsewhere two years ago that "did nothing" except leave dark patches on her chin that took about a year to fade. On examination: coarse, dark terminal hairs across the chin and upper lip, numerous ingrown hairs, and patchy post-inflammatory hyperpigmentation. No pacemaker, no metal implants, no bleeding disorder, not pregnant. She wants "everything gone in three sessions" before a family event in six weeks.
1. Select a modality and treatment approach, and justify it against her skin type and scarring history.
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Choose blend or galvanic with conservative settings and insulated probes - not short-duration high-intensity thermolysis.
Reasoning:
- Keloid history after a piercing and a C-section means her dermis responds to injury with excess collagen. Any modality that delivers heat widely into the surrounding dermis raises that risk.
- Fitzpatrick V plus a documented post-inflammatory hyperpigmentation response to laser means her melanocytes are reactive. Epidermal injury and thermal scatter both drive PIH.
- Thermolysis alone concentrates high-frequency energy in a short burst, and the heat spreads beyond the follicle wall into surrounding tissue. That is the profile you least want here.
- Blend combines a low galvanic current - which produces sodium hydroxide at the follicle and destroys the germinative cells chemically - with a minimal thermolysis component for comfort and speed. Lower thermal load per insertion means less collateral dermal heating.
- Insulated probes confine current to the follicle below the sebaceous duct and reduce energy at the skin surface, which directly targets the PIH mechanism.
Treat fewer hairs per session at lower intensity rather than more hairs at higher intensity, and never re-insert into the same follicle in one session.
2. Build a treatment plan with intervals, a test spot protocol, and aftercare, including what would make you stop.
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Test spot first. Treat 5–10 hairs on one side of the chin at conservative settings. Do not treat the full area on day one.
Two-to-four-week review: assess for PIH, induration, or a raised nodule at any insertion site. Only after clean healing do you expand the treatment area.
Schedule: every 4–6 weeks to catch hairs in anagen. Hairs grow in cycles, so any one clearance pass catches only the active fraction - this is why session counts are estimates, not promises.
Per session: cleanse, ice or a cool compress before and after; limit total insertions per square centimeter; work in a grid so you never treat the same site twice; use insulated probes; keep the galvanic current modest and the duration longer rather than the current high.
Aftercare: broad-spectrum SPF daily on the chin and lip, no picking or scrubbing for 48 hours, no waxing or tweezing between sessions, mild fragrance-free moisturizer, avoid sun exposure for a week.
Stop and refer if: a firm raised papule or nodule persists beyond a few weeks, PIH darkens rather than fades, or any site becomes indurated. Those are the signals that her keloid tendency is expressing, and continuing would compound it.
3. How do you answer her three-session, six-week demand, and what goes into informed consent?
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Answer directly and early, before any probe is inserted.
"Three sessions will not clear fifteen years of tweezing, and I won't promise it. Daily tweezing for that long distorts follicles and produces a dense mosaic of hairs growing on different cycles. Realistic progress is gradual thinning over many months of regular treatment. Six weeks from now you can expect a reduction in density, not clearance - and I would rather tell you that today than have you disappointed at the event."
Add the mechanical point: she must stop tweezing for roughly four to six weeks before treatment and stay off it between sessions. A tweezed hair is often in telogen and may be too short or distorted to treat, so continued tweezing quietly wastes her money.
Informed consent must document specifically:
- Fitzpatrick V skin type with prior laser-induced PIH, and the keloid history at two sites.
- The risks of PIH, hypopigmentation, and hypertrophic or keloid scarring at treatment sites - stated as risks, not rarities, given her history.
- That results are gradual and session counts are estimates.
- The no-tweezing rule and the consequences of breaking it.
- That she should raise her keloid history with her physician if she wants a medical opinion before proceeding.
- Her signature on the realistic-outcome statement, dated.