EDITORIAL
Grinning and Baring It—The Downside of Genital Hair Removal f you have noticed more young female and male patients coming in with rashes and infections in their genital region, then you are likely aware of the recent war being waged on pubic hair. Over the past decade, young women have migrated from partial to full removal of hair from the bikini area, and men have taken to grooming below the waist as well. In an Australian survey of 235 female undergraduates, women cited femininity and sexual attractiveness as reasons for hair removal.1 According to a Cosmopolitan survey of 1,000 young men, 95% fully groom their private parts.2 Reasons for both sexes may include the perception of cleanliness and sexual attractiveness, but recent reports suggest an upswing in complications that may defeat aesthetic goals by inducing secondary issues. The results for both sexes include the prospect of a marked increase in genitourinary injuries and infections from ingrown hairs and sexually transmitted infections (STIs). After examining data from the National Electronic Injury Surveillance System 2002-2010, Glass and colleagues noted a fivefold increase in genitourinary injuries related to grooming product over that time period.3 While the majority of injuries among men and women were related to shaving with razors, about one-quarter of injuries reported by women involved laceration from razors, wax burn or foreign body injury. Besides the types of injuries noted above, the trend to shave/wax the bikini area is also reportedly raising the risk of infections, such as Molluscum contagiosum, folliculitis and warts.4,5 Experts theorize this is a result of microtrauma to the skin (via nicks and abrasion) that provides entry points for viruses and bacteria. Researchers in France suggested an association between the trend of complete hair removal and a surge in cases of Molluscum contagiosum.4 They based this theory on their clinical
I
DOI 10.2310/7750.2014.EDIT18.5 # 2014 Canadian Dermatology Association
observations after enquiring about pubic hair removal among 30 infected patients (24 were male) who presented with the pox virus at a private skin care clinic in Nice in 2011 and 2012. They found that 70% of them shaved the pubic area, while the remainder used waxing or clipping. However, controlled studies have yet to definitively show a causal relationship between the two trends. Besides shaving, other hair removal methods can also traumatize skin in the genital region. Schmidtberger and colleagues noted that ‘‘waxing causes deficits in the microcutaneous barrier,’’ thus potentially increasing opportunities for STIs to gain a foothold.5 These authors even went so far as to recommend that individuals abstain from sex for a certain period after waxing pubic hair to limit the possibility of STI transmission. Laser hair removal can also cause burns to the skin, scarring or discoloration. However, the authors of the French study noted that lasering did not factor into the association with an elevated risk of Molluscum contagiosum. That is primarily because laser therapy generally does not produce any microscopic cuts or bleeding during hair removal. In addition, some suggest that individuals who are more likely to practice full hair removal may have greater interest in sex and be engaging in more casual sex, which would naturally raise the risk of STIs.6 In support of this theory, Herbenick and colleagues reported that pubic hair removal is a more common practice among those who are sexually active or in a sexual relationship.6 Conversely, a ‘‘lack of sexual activity’’ was cited as a reason for discontinuing pubic hair removal. The trend is also more common in youth and not unexpectedly, shows a decrease with each decade of life. For example, a U.S. study of 2400 women ages 18-68 found that 20% of women 18-24 reported total hair removal, but only 12% of women 25-29; 8% of women 3039; 6.5% of women 40-49 and 2% of women over 50.7 Historically, hair removal habits among women have generally paralleled fashion trends—the more clothing
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 5 (September/October), 2014: pp 291–292
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revealed bare skin during the last 60 years, the more concerned women became with body hair. In concert with this, the advent of the bikini swim suit made pubic hair removal a fashion necessity.8 If there is a possible silver lining to this hairless pursuit, the incidence of pubic lice is on the downswing, which some suspect may be related to hair removal.9 Given there has been a simultaneous increase in the numbers of gonorrhea and chlamydia, which Armstrong and colleagues also reported9, the dramatic fall in pubic lice does not suggest a drop in sexual activity or unsafe sexual practices. The medical community has already learned about the pitfalls of hair removal in the context of preparing a patient for surgery. After noting a direct link between preoperative shaving of a surgical site and an increased risk of post-operative infections, there was a shift to the use of surgical clippers or depilatories.10 The surgical community had an epiphany after a prospective, randomized study in 1971 reported that the wound infection rate was 5.6% after hair removal using a razor, and 10 times higher compared to the rate when a depilatory was used (0.6%) or no hair removal occurred.10 Clippers remove hair close to the skin surface but without causing abrasions and cuts that often accompany shaving. At present, efforts to reduce the incidence of surgical site infections have included the recommendation to use appropriate hair removal methods, such as the use of surgical clippers or depilatories.11 It may not be a problem related to pubic hair removal that brings patients to a dermatologist’s office, since this may be too embarrassing and personal for some individuals to discuss. But as skin experts, we can seek opportunities to counsel patients about the relative safety of available techniques and how to avoid complications, especially if a patient raises any issues concerning facial or body hair removal in general. Advice can include outlining the risks of home-based and professional hair removal methods—as we have been doing with regards to laser hair removal—and providing recommendations for the prevention of related injuries and infections. Our role is
292
not to discourage patients from embracing a growing trend, but to help smooth out some problems that may arise along the way. Jason K. Rivers MD, FRCPC JCMS Editor in Chief
References 1. Tiggemann M, Hodgson S. The hairlessness norm extended: reasons for and predictors of women’s body hair removal at different body sites. 2008 Sex Roles 59(11–12):889–97, doi:10.1007/s11199-0089494-3. 2. The New Male Grooming Obsession, Cosmopolitan 2011 Jun 9. Available at: http://www.cosmopolitan.com/sex-love/dating-advice/ men-shaving-pubic-hair. 3. Glass AS, Bagga HS, Tasian ET, et al. Pubic hair grooming injuries presenting to US emergency departments. Urology 2012;80(6): 1187–91, doi:10.1016/j.urology.2012.08.025. 4. Desruelles F, Cunningham SA, Dubois D. Pubic hair removal: a risk factor for ‘minor’ STI such as molluscum contagiosum? Sex Transm Infect 2013;89(3):216, doi:10.1136/sextrans-2012-050982. 5. Schmidtberger L, Ladizinski B, Ramirez-Fort MK. Wax on, wax off: pubic hair grooming and potential complications. JAMA Dermatol 2014;150(2):122, doi:10.1001/jamadermatol.2013.8364. 6. Herbenick D, Hensel D, Smith NK. Pubic hair removal and sexual behavior: findings from a prospective daily diary study of sexually active women in the United States. J Sex Med 2013;10(3):678–85, doi:10.1111/jsm.12031. Epub 2012 Dec 13. 7. Herbenick D, Schick V, Reece M, et al. Pubic hair removal among women in the United States: Prevalence, methods, and characteristics. J Sex Med 2010;7(10):3322–30, doi:10.1111/j.1743-6109. 2010.01935.x. 8. The Sex InformationEducation Council of Canada Female Pubic Hair Removal. April 2012. Available at: http://sexualityandu.ca/ uploads/files/CTR_PubicHairRemoval_APR2012-EN.pdf. 9. Armstrong NR, Wilson JD. Did the ‘‘Brazilian’’ kill the pubic louse? Sex Transm Infect 2006;82(3):265–6, doi:10.1136/sti.2005. 018671. 10. Seropian R, Reynolds BM. Wound infections after preoperative depilatory versus razor preparation. Am J Surg 1971;121:251–4, doi:10.1016/0002-9610(71)90199-1. 11. How-to Guide: Prevent Surgical Site Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012. Available at www.ihi.org.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 5 (September/October), 2014: pp 291–292
Grinning and Baring It—The Downside of Genital Hair Removal f you have noticed more young female and male patients coming in with rashes and infections in their genital region, then you are likely aware of the recent war being waged on pubic hair. Over the past decade, young women have migrated from partial to full removal of hair from the bikini area, and men have taken to grooming below the waist as well. In an Australian survey of 235 female undergraduates, women cited femininity and sexual attractiveness as reasons for hair removal.1 According to a Cosmopolitan survey of 1,000 young men, 95% fully groom their private parts.2 Reasons for both sexes may include the perception of cleanliness and sexual attractiveness, but recent reports suggest an upswing in complications that may defeat aesthetic goals by inducing secondary issues. The results for both sexes include the prospect of a marked increase in genitourinary injuries and infections from ingrown hairs and sexually transmitted infections (STIs). After examining data from the National Electronic Injury Surveillance System 2002-2010, Glass and colleagues noted a fivefold increase in genitourinary injuries related to grooming product over that time period.3 While the majority of injuries among men and women were related to shaving with razors, about one-quarter of injuries reported by women involved laceration from razors, wax burn or foreign body injury. Besides the types of injuries noted above, the trend to shave/wax the bikini area is also reportedly raising the risk of infections, such as Molluscum contagiosum, folliculitis and warts.4,5 Experts theorize this is a result of microtrauma to the skin (via nicks and abrasion) that provides entry points for viruses and bacteria. Researchers in France suggested an association between the trend of complete hair removal and a surge in cases of Molluscum contagiosum.4 They based this theory on their clinical
I
DOI 10.2310/7750.2014.EDIT18.5 # 2014 Canadian Dermatology Association
observations after enquiring about pubic hair removal among 30 infected patients (24 were male) who presented with the pox virus at a private skin care clinic in Nice in 2011 and 2012. They found that 70% of them shaved the pubic area, while the remainder used waxing or clipping. However, controlled studies have yet to definitively show a causal relationship between the two trends. Besides shaving, other hair removal methods can also traumatize skin in the genital region. Schmidtberger and colleagues noted that ‘‘waxing causes deficits in the microcutaneous barrier,’’ thus potentially increasing opportunities for STIs to gain a foothold.5 These authors even went so far as to recommend that individuals abstain from sex for a certain period after waxing pubic hair to limit the possibility of STI transmission. Laser hair removal can also cause burns to the skin, scarring or discoloration. However, the authors of the French study noted that lasering did not factor into the association with an elevated risk of Molluscum contagiosum. That is primarily because laser therapy generally does not produce any microscopic cuts or bleeding during hair removal. In addition, some suggest that individuals who are more likely to practice full hair removal may have greater interest in sex and be engaging in more casual sex, which would naturally raise the risk of STIs.6 In support of this theory, Herbenick and colleagues reported that pubic hair removal is a more common practice among those who are sexually active or in a sexual relationship.6 Conversely, a ‘‘lack of sexual activity’’ was cited as a reason for discontinuing pubic hair removal. The trend is also more common in youth and not unexpectedly, shows a decrease with each decade of life. For example, a U.S. study of 2400 women ages 18-68 found that 20% of women 18-24 reported total hair removal, but only 12% of women 25-29; 8% of women 3039; 6.5% of women 40-49 and 2% of women over 50.7 Historically, hair removal habits among women have generally paralleled fashion trends—the more clothing
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 5 (September/October), 2014: pp 291–292
291
revealed bare skin during the last 60 years, the more concerned women became with body hair. In concert with this, the advent of the bikini swim suit made pubic hair removal a fashion necessity.8 If there is a possible silver lining to this hairless pursuit, the incidence of pubic lice is on the downswing, which some suspect may be related to hair removal.9 Given there has been a simultaneous increase in the numbers of gonorrhea and chlamydia, which Armstrong and colleagues also reported9, the dramatic fall in pubic lice does not suggest a drop in sexual activity or unsafe sexual practices. The medical community has already learned about the pitfalls of hair removal in the context of preparing a patient for surgery. After noting a direct link between preoperative shaving of a surgical site and an increased risk of post-operative infections, there was a shift to the use of surgical clippers or depilatories.10 The surgical community had an epiphany after a prospective, randomized study in 1971 reported that the wound infection rate was 5.6% after hair removal using a razor, and 10 times higher compared to the rate when a depilatory was used (0.6%) or no hair removal occurred.10 Clippers remove hair close to the skin surface but without causing abrasions and cuts that often accompany shaving. At present, efforts to reduce the incidence of surgical site infections have included the recommendation to use appropriate hair removal methods, such as the use of surgical clippers or depilatories.11 It may not be a problem related to pubic hair removal that brings patients to a dermatologist’s office, since this may be too embarrassing and personal for some individuals to discuss. But as skin experts, we can seek opportunities to counsel patients about the relative safety of available techniques and how to avoid complications, especially if a patient raises any issues concerning facial or body hair removal in general. Advice can include outlining the risks of home-based and professional hair removal methods—as we have been doing with regards to laser hair removal—and providing recommendations for the prevention of related injuries and infections. Our role is
292
not to discourage patients from embracing a growing trend, but to help smooth out some problems that may arise along the way. Jason K. Rivers MD, FRCPC JCMS Editor in Chief
References 1. Tiggemann M, Hodgson S. The hairlessness norm extended: reasons for and predictors of women’s body hair removal at different body sites. 2008 Sex Roles 59(11–12):889–97, doi:10.1007/s11199-0089494-3. 2. The New Male Grooming Obsession, Cosmopolitan 2011 Jun 9. Available at: http://www.cosmopolitan.com/sex-love/dating-advice/ men-shaving-pubic-hair. 3. Glass AS, Bagga HS, Tasian ET, et al. Pubic hair grooming injuries presenting to US emergency departments. Urology 2012;80(6): 1187–91, doi:10.1016/j.urology.2012.08.025. 4. Desruelles F, Cunningham SA, Dubois D. Pubic hair removal: a risk factor for ‘minor’ STI such as molluscum contagiosum? Sex Transm Infect 2013;89(3):216, doi:10.1136/sextrans-2012-050982. 5. Schmidtberger L, Ladizinski B, Ramirez-Fort MK. Wax on, wax off: pubic hair grooming and potential complications. JAMA Dermatol 2014;150(2):122, doi:10.1001/jamadermatol.2013.8364. 6. Herbenick D, Hensel D, Smith NK. Pubic hair removal and sexual behavior: findings from a prospective daily diary study of sexually active women in the United States. J Sex Med 2013;10(3):678–85, doi:10.1111/jsm.12031. Epub 2012 Dec 13. 7. Herbenick D, Schick V, Reece M, et al. Pubic hair removal among women in the United States: Prevalence, methods, and characteristics. J Sex Med 2010;7(10):3322–30, doi:10.1111/j.1743-6109. 2010.01935.x. 8. The Sex InformationEducation Council of Canada Female Pubic Hair Removal. April 2012. Available at: http://sexualityandu.ca/ uploads/files/CTR_PubicHairRemoval_APR2012-EN.pdf. 9. Armstrong NR, Wilson JD. Did the ‘‘Brazilian’’ kill the pubic louse? Sex Transm Infect 2006;82(3):265–6, doi:10.1136/sti.2005. 018671. 10. Seropian R, Reynolds BM. Wound infections after preoperative depilatory versus razor preparation. Am J Surg 1971;121:251–4, doi:10.1016/0002-9610(71)90199-1. 11. How-to Guide: Prevent Surgical Site Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012. Available at www.ihi.org.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 5 (September/October), 2014: pp 291–292
