Clinical Review

Tattoo Removal by Q-Switched Laser

Clinician Reviews. 2010 September;20(9):16-19

References

1. Mariwalla K, Dover JS. The use of lasers for decorative tattoo removal. Skin Therapy Lett. 2006;11(5):8-11.

2. Braverman PK. Body art: piercing, tattooing, and scarification. Adolesc Med Clin. 2006; 17(3):505-519.

3. Roberts TA, Ryan SA. Tattooing and high-risk behavior in adolescents. Pediatrics. 2002; 110(6):1058-1063.

4. Burris K, Kim K. Tattoo removal. Clin Dermatol. 2007;25(4):388-392.

5. Sweeney SM. Tattoos: a review of tattoo practices and potential treatment options for removal. Curr Opin Pediatr. 2006;18(4):391-395.

6. Pfirrmann G, Karsai S, Roos S, et al. Tattoo removal: state of the art. J Dtsch Dermatol Ges. 2007;5(10):889-897.

7. Reid WH, Miller ID, Murphy MJ, et al. Q-switched ruby laser treatment of tattoos: a 9-year experience. Br J Plastic Surg. 2001;43(6): 663-669.

8. Kuperman-Meade M, Levine VJ, Ashinoff R. Laser removal of tattoos. Am J Clin Dermatol. 2001;2(1):21-25.

9. Adatto MA. Laser tattoo removal: benefits and caveats. Med Laser Appl. 2004;19:175-185.

10. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science. 1983; 220(4596):524–527.

11. Beute TC, Miller CH, Timko AL, Ross EV. In vitro spectral analysis of tattoo pigments. Dermatol Surg. 2008;34(4):508-515.

12. Bernstein EF. Laser treatment of tattoos. Clin Dermatol. 2006;24(1):43-55.

13. Prinz BM, Vavricka SR, Graf P, et al. Efficacy of laser treatment of tattoos and using lasers emitting wavelengths of 532nm, 755nm and 1064nm. Br J Dermatol. 2004;150(2):245-251.

14. Talakoub L, Wesley NO. Differences in perceptions of beauty and cosmetic procedures performed in ethnic patients. Semin Cutan Med Surg. 2009;28(2):115-129.

15. Taylor CR, Gange WR, Dover JS, et al. Treatment of tattoos by Q-switched ruby laser. Arch Dermatol. 1990;126(7):893-899.

16. Jones A, Roddey P, Orengo I, Rosen T. The Q-switched Nd:YAG laser effectively treats tattoos in darkly pigmented skin. Dermatol Surg. 1996;22(12):999-1001.

17. Kilmer SL, Lee MS, Grevelink JM, et al. The Q-switched Nd:YAG laser effectively treats tattoos: a controlled, dose-response study. Arch Dermatol. 1993;129(8):971-978.

18. Gundogan C, Greve B, Hausser I, Raulin C. Repigmentation of persistent laser-induced hypopigmentation after tattoo ablation with the excimer laser [in German]. Hautarzt. 2004;55(6):549-552.

19. Rauscher GE, Maneckshana BT, Schwartz RA, Mekles TJ. Preoperative evaluation and management. http://emedicine.medscape.com/article/1127055-overview. Accessed August 18, 2010.

20. Ho WS, Ying SY, Chan PC, Chan HH. Use of onion extract, heparin, allantoin gel in prevention of scarring in Chinese patients having laser removal of tattoos: a prospective randomized controlled trial. Dermatol Surg. 2006; 32(7):891-896.

21. Ho DD, London R, Zimmerman GB, Young DA. Laser-tattoo removal: a study of the mechanism and the optimal treatment strategy via computer simulations. Lasers Surg Med. 2002;30(5):389-397.

22. Gorouhi F, Davari P, Kashani MN, Firooz A. Treatment of traumatic tattoo with the Q-switched Nd:YAG laser. J Cosmet Laser Ther. 2007;9(4):253-255.

23. Herd RM, Alora MB, Smoller B, et al. A clinical and histologic prospective controlled comparative study of the picosecond titanium:sapphire (795 nm) laser versus the Q-switched alexandrite (752 nm) laser for removing tattoo pigment. J Am Acad Dermatol. 1999;40(4):603-606.

24. Ross V, Naseef G, Lin G, et al. Comparison of responses of tattoos to picosecond and nanosecond Q-switched Neodymium:YAG lasers. Arch Dermatol. 1998;134(2):167-171.

25. Solis RR, Diven DG, Colome-Grimmer, et al. Experimental nonsurgical tattoo removal in a guinea pig model with topical imiquimod and tretinoin. Dermatol Surg. 2002;28(1):83-86.

26. Ricotti CA, Colaco SM, Shamma HN, et al. Laser-assisted tattoo removal with topical 5% imiquimod cream. Dermatol Surg. 2007;33(9): 1082-1091.

27. Elsaie ML, Nouri K, Vejjabhinanta V, et al. Topical imiquimod in conjunction with Nd:YAG laser for tattoo removal. Lasers Med Sci. 2009; 4(6):871-875.

28. Freedom 2™, Inc. InfinitInk™. www.infinitink.com/intro/intro.html. Accessed August 18, 2010.

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In order to avoid darkening, a spot test is recommended. The patient should return to the studio, if possible, and have a sample of the pigment to be removed tattooed in the axillary region. After a month, a laser test spot can be performed. If laser treatment fails, the test spot can be removed by surgical excision, and laser treatment abandoned.⁹

Blistering
Blistering can occur as a result of overaggressive laser treatment or inadvertent absorption of laser energy due to the specific pigment. Blisters may be avoided by using a tissue-cooling system, such as a contact chill tip or cryogen spray.⁴ To avoid adverse effects such as wheals, punctate bleeding, blisters, and crusts, a minimum of four weeks between sessions should be maintained. Topical antiseptics can be used to prevent infection.⁶

Allergic Reactions
Tattoos containing metal salts—mercury (red), cadmium (yellow), chrome (green), or cobalt (blue)—may be subject to a local allergic or photoallergic skin reaction.⁶ A preexisting local allergic reaction may be exacerbated by laser treatment, resulting in urticaria or a systemic allergic reaction. The tattoo should be treated with corticosteroids and an allergist consulted.¹ Some providers recommend avoiding laser therapy altogether.

Red is the pigment most often associated with allergic reactions, resulting in nodular, scaly, pruritic areas.¹² Removal of areas of red pigment with the 532-nm Nd:YAG laser can help prevent complications.⁹ Photoallergic reactions most commonly involve cadmium. Affected patients typically report a history of pruritus in the tattoo and raised skin after UV exposure.

Allergic reactions can also be treated with topical or intralesional corticosteroids.¹²

Scarring
Cobblestone texture is a sign of early scarring, usually appearing within two weeks of treatment. The risk for scarring is highest on the chest, outer upper arm, and ankle.¹

The risk is especially great in laser treatment of areas that have been retattooed (ie, a second tattoo applied to cover an older tattoo) because of the high density of pigment and increased laser resistance.⁹ Patients should be asked about the possible presence of a cover-up tattoo, since this may not be detectable on casual inspection.

In a study of Chinese patients who underwent laser removal of professional blue-black tattoos,²⁰ prophylactic use of a gel containing onion extract, heparin, and allantoin had no effect on pigment clearance, but it reduced the rate of scarring, compared with controls. Additional studies are needed to evaluate the gel’s effectiveness in patients with other skin types and with tattoos containing pigments of various colors.²⁰

Topical steroids are sometimes helpful for scarring.¹ More pronounced scarring resulting from laser tattoo removal can be treated with the erbium:YAG laser or pulsed CO2 laser, as well as fractional photothermolysis.⁶

Cutaneous Lymphoma
Two types of red azo dyes have been shown to generate toxic or carcinogenic decomposition products (eg, nitroaniline) under in vitro conditions; whether this occurs in vivo is unknown. Concern has been expressed that laser stimulation of lymphocytes or dendritic cells could lead to cutaneous lymphoma.⁶

Resistance
Certain pigments are resistant to laser treatment, and multicolored tattoos are difficult to treat because of the limited number of laser wavelengths.¹¹ If a tattoo’s nonresponsive area exceeds 10% of its total area, laser treatment should be abandoned for financial reasons.⁹ A smaller resistant area, however, may be treated with ablative lasers (ultrapulse CO2, pulsed erbium:YAG ). This requires numerous sessions, one to three months apart. Aggressive measures, such as attempting to remove all of the pigment in one session, should be avoided, since heavy scarring can occur.⁹

Better Options on the Horizon?
Computer simulations have confirmed that laser tattoo removal is photoacoustic and that shorter pulses delivering the same amount of laser energy as longer pulses may be more efficient. According to Ho et al,²¹ the optimal pulse length is approximately 10 to 100 picoseconds. Thus, picosecond lasers (such as the 795-nm titanium:sapphire laser), which have been shown to be effective in removing traumatic tattoos, are being investigated for application in decorative tattoos.^8,22,23 It is hoped that these lasers, with action that increases phagocytosis or transepidermal elimination, will achieve higher rates of clearance with fewer treatments, less collateral damage, and improved cosmetic outcomes. Currently, only prototypes of this laser are available for removal of decorative tattoos.^1,24

Topical imiquimod 5% cream and tretinoin have been studied in conjunction with laser therapy to remove tattoos. In one animal study in which these agents were applied shortly after tattooing, pigments faded significantly, but inflammation and fibrosis occurred.²⁵ In subsequent small studies in humans, imiquimod cream used in conjunction with Q-switched laser treatment yielded only slight improvements, compared with placebo-enhanced laser treatments.^26,27 Larger studies of imiquimod and similar agents may be warranted.⁵