Tattoo Laser Removal

In most cases, laser treatment leads to good fading or complete removal of the tattoo without significant side effects. Serious side effects are very unusual but sometimes occur, and one must be adept at dealing with these side effects.

Incomplete Tattoo Removal

The most common problem with tattoo treatment is incomplete fading or removal of the tattoo. This is an issue with intricate multicolored tattoos. Not all tattoo inks respond, and rarely specific colors can get worse. Massive professional tattoos may not completely fade. In some cases, changing to a different laser may be worthwhile due to the intrinsic differences in wavelengths, pulse durations, and spot sizes.

Dyspigmentation and Textural Changes

The increased melanin absorption seen with shorter wavelengths increases the risk of hypopigmentation. With 510-nm and 532-nm wavelengths, the hypopigmentation typically resolves; however, with the QSRL, long-term hypopigmentation is possible. However, hyperpigmentation is more related to the patient’s skin type, with darker skin more prone regardless of the wavelength. Treatment with hydroquinone and broad-spectrum sunscreens usually resolves the hyperpigmentation within a few months, although, in some patients, it can prolong resolution. Transient textural changes are often noted but resolve within 1-2 months; however, permanent textural changes and scarring. If a patient is prone to pigmentary or textural changes, longer treatment intervals are recommended.

Blistering

Vesicle and bullae formation are common occurrences following picosecond laser tattoo treatment than Q-switched.  These typically resolve without sequelae within one week but can sometimes be significant and unsettling to patients undergoing laser treatment.

Allergic reactions

Local allergic responses to many tattoo pigments have been reported, and reactions to tattoo pigment after Q-switched laser treatment are also possible. Unlike the destructive modalities previously described, Q-switched lasers mobilize the ink and may generate a systemic allergic response. If an allergic reaction to ink is noted, Q-switched laser treatment is not advised. Erbium and high-energy, pulsed carbon dioxide lasers can de-epithelialize the tattoo, promoting trans-epidermal elimination of the ink. Multiple treatments are required, and the risk for dyspigmentation and scarring is increased. Oral antihistamines and anti-inflammatory steroids, such as prednisone, have also been used.

Ink darkening

Paradoxical darkening of flesh-tone, red, and white tattoo inks with QSRL.  In clinical practice, multiple colors, including flesh tones, red, white, and brown containing pigments (iron oxide, titanium dioxide) and several green and blue tattoo pigments, changed to black when irradiated with Q-switched laser pulses. This change results from an oxidation-reduction reaction or the ignition of ferric oxide above 1400°C. These reactions require the extreme temperatures generated during the short pulse of Q-switched lasers; several hundred to thousands of degrees Celsius are estimated. The darkening usually becomes apparent once the immediate whitening has faded.

For this reason, a single small inconspicuous test spot is recommended to ensure that this complication does not occur.  Even after testing, it is appropriate to obtain the patient’s written consent that they understand tattoo ink darkening may still arise during future treatments. It may be permanent Approach the laser treatment of cosmetic tattoos with caution, especially those of red or flesh tone. The resulting gray-black tattoo may prove challenging to remove and is certainly more visible than the flesh tone; therefore, test sites are recommended with patient consent. If darkening occurs, immediately re-treat the area, then wait several weeks to assess the darkened tattoo’s response. If it has lightened significantly, treatment can proceed. Q-switched lasers seem ideal for removing large black facial tattoos (tarsal fanning of pigment, eyebrow tattoo). However, the beam size (2-6.5 mm) may make removing small dots of precisely confined tattoo pigment (e.g., eyeliner tattoo) technically challenging without risk of temporary or permanent hair loss from heat damage to the terminal hair. For those patients, I use a spot size of less than 1mm. Alternatively, eyeliner patients may be treated with high-powered carbon dioxide and erbium lasers because of the precision available and/or the need to bypass the ink-darkening phenomenon. The picosecond laser may also be an option to treat paradoxical tattoo darkening.

In non-cosmetic tattoos, the presence of pastel colors such as light blue, turquoise, yellow, light green, lavender, and pink should also raise suspicion of white ink additives. Treatment may result in immediate and permanent tattoo darkening in white and even in red tattoos.  The laser pulse can reduce ink from rust-colored ferric oxide (Fe2O3) to jet-black ferrous oxide (FeO).  Similarly, white ink made up of titanium dioxide (TiO2, T4+) can be reduced to blue Ti3+ upon laser treatment. If pigment darkening does occur in a decorative tattoo, it may be improved with subsequent treatment with the QS Nd: YAG laser operated at 1064 nm.

Textural Changes and Mild Scarring

Although true scarring is very unlikely, there can be some slight change in the skin’s texture (1-2% of cases). Sometimes there is pre-existing texture change in the skin caused by the tattooing process or previous unsuccessful attempts. There can also be some loss of natural tanning ability in the treated area, which usually improves with time. You can reduce the chance of irregular tanning by protecting the tattooed area from sun exposure.  Hypopigmentation (lightening of the skin) or hyperpigmentation (darkening of the skin) are infrequent and always temporary. Prof. Moawad uses Q-switched Nd: YAG laser, which is the safest in the world for dark skin colors.  African, Asian, and Mediterranean people can safely treat their tattoos without changing the surrounding skin color. He recommends using bleaching agents before initiating laser treatment and between laser sessions to prevent darkening of the skin in dark-skinned and tanned patients.

Tattoo Removal by Non-Medical Laypeople

The introduction of quality-switched lasers has provided an effective removal method that tattoo studios themselves are increasingly being exploited. Dermatologists, however, are frequently confronted with complications and side effects of tattoo removals that were performed by non-professionals.  I identified four major problem areas: rare but potentially severe allergic or toxic effects of decomposition products of the tattoo pigments; bodily harm caused by out-of-specification usage of the laser devices; a malignant disease that is obscured within the area of a tattoo and requires accurate dermatological diagnosis; and preliminary pre-operative consultation of patients about the risks, side effects and realistic expectations on the therapeutic outcome. It became apparent that tattoo removal by medical laypeople is unacceptable from the point of view of patient safety, and laws need to ban this practice swiftly.

Tattoo or Laser Tattoo Removal Skin Reaction

The introduction of foreign substances into the skin can result in several adverse effects, including toxic or immunologic reactions to the tattoo pigments, the transmission of infectious diseases, and the localization of skin disease within the tattoo.  Complications resulting from decorative tattoos are surprisingly rare, but the incidence is increasing.

Acute inflammatory reactions

Acute inflammatory reactions are associated with physical tissue injury and pigment, dyes, or metals into the skin. This reaction usually recedes without consequence within 2-3 weeks and is an expected adverse effect of the tattooing process. Many reports describe allergic contact dermatitis from a temporary henna tattoo (technically not a tattoo but a painted-on skin decoration). The reaction is due to the brightener in the henna, which is often para-phenylenediamine, a known allergen. There have been several cases of generalized allergic reactions after laser treatment, presumably because of the release of antigenic tattoo ink particles into systemic/lymphatic circulation.

Eczematous hypersensitivity reactions

Once any acute inflammatory changes have resolved, the most frequent response observed with tattoos is an allergic sensitivity to one of its pigments. Allergic reactions to red tattoo pigments are the most common and may be caused by various pigments. Hypersensitivity reactions to a tattoo pigment result in contact dermatitis or photoallergic dermatitis. These conditions may manifest clinically as localized eczematous eruptions or, rarely, as exfoliative dermatitis.

Photo-aggravated Reactions

Photo-aggravated reactions are most commonly caused by yellow (cadmium sulfide) tattoo pigment. Edema and erythema may develop upon exposure to sunlight. Although the mechanism is not precise, cadmium sulfide is the light-sensitive material used in photoelectric cells; therefore, the reaction is believed to be phototoxic. Red tattoos have been associated with photo-aggravated tattoo reactions less frequently than yellow tattoos. These reactions may relate to the trace amounts of cadmium added to brighten the red pigment.

In contrast to hypersensitivity reactions to red tattoos, responses to pigments created by green, blue, and black tattoos are much less common. Chromium in green tattoo pigment has been associated with localized eczematous reactions at the dye site, eczema of the hands, and generalized eczematous results. Previously quiescent green-colored tattoos may become inflamed during patch testing in potassium dichromate–sensitive individuals.  Blue tattoos that contain cobalt aluminate have been linked to localized hypersensitivity reactions and (rarely) the spontaneous development of uveitis. Allergic reactions to black tattoo pigment are infrequent. These individuals are sensitive to carbon.

Granulomatous Reactions

Most red pigment is associated with a granulomatous tattoo reaction; however, several reactions involving chromium (green pigment) and cobalt (blue dye) have also been reported. In contrast to an eczematous hypersensitivity tattoo reaction in which patch test results may be positive, granulomatous tattoo reactions are associated with negative patch test results. Manganese causes a granulomatous reaction in purple tattoos, but enough evidence is not available to establish manganese as the definitive etiologic agent. Granulomatous reactions have been reported in permanent eyeliner tattoos. Treatment is painful because of the proximity to the lid margin.

Pseudo-lymphomatous Reactions

Pseudo-lymphomatous reactions can develop after a variety of foreign substance exposures, including insect bites, acupuncture, antigen injections, earrings, and tattoos. Tattoo-induced pseudo-lymphoma occurs primarily within red portions of the tattoo. Green or blue tattoos rarely induce this reaction.

Lichenoid Reactions

Lichenoid hypersensitivity tattoo reactions are less common than eczematous reactions. Evidence exists that the lichenoid response is an expression of delayed hypersensitivity to a lymphocytic T-cell infiltrate, which may simulate the graft-versus-host response. Mercury (red pigment) is responsible for most lichenoid tattoo reactions. Clinically, warty papules or plaques typical of hyperkeratotic lichen planus are usually confined to the red portion of the tattoo. Like granulomatous tattoo reactions, lichenoid reactions are associated with negative patch test results.

Localization of Disease in Tattoos

Several cutaneous disorders show a preference for tattooed skin. Lichen planus, psoriasis, sarcoidosis, and lupus erythematosus have been associated with localization to a tattoo site.  Keratoacanthoma, a keratinizing squamous cell neoplasm of unknown origin characterized by rapid growth, has been observed with various types of skin injury. Although rare, eruptive keratoacanthomas have been reported in both red and multicolored tattoos. The eruption may represent the initial manifestation of the disease or the accentuation of an existing disorder in the tattoo. Several cases of skin cancer occurring at the site of tattoos have been reported, including squamous cell carcinoma, basal cell carcinoma, and melanoma. While tattooing results in the deposition of metallic salts and organic dyes in the skin, potentially for the remainder of the recipient’s lifetime, the carcinogenic effects remain unclear. Further research is needed to explore this relationship.

How to treat Allergic Reactions?

Unfortunately, there are currently few requirements or regulations and no legislation for the safety of tattoos. The sterility of the pigments and equipment is uncertain as many are being performed on the roadside and in makeshift salons. In contrast to drugs and cosmetics, tattoo pigments have never been controlled or regulated in any way, and the exact composition of a given tattoo pigment is often kept a “trade secret” by the manufacturer. Allergic reactions can occur after treatment, especially if you already have an allergic reaction (redness and itching) in your tattoo.  Allergic granulomas to tattoo ink are most commonly seen in the cinnabar in red-colored inks.  Allergic reactions are usually caused by metallic dyes, which contain mercury, manganese, chromium, cobalt, or cadmium. Treatment of allergic tattoo reactions is challenging, mainly when surgical excision is not practical or desired. QS frequency-doubled Nd: YAG lasers have been used for the removal of red allergic tattoos. Prof. Moawad treats such reactions with topical or intralesional corticosteroids and avoids laser treatment altogether as it may worsen the allergic reaction and produce systemic symptoms or even anaphylactic response. I can employ an ablative laser, such as carbon dioxide, to remove the offending ink and destroy the granulomas at the same time. Before laser treatment, biopsies should be considered to rule out sarcoidosis, infectious granulomas such as atypical mycobacterial infections, and other entities.

The appropriate treatment interval is critical and yet poorly understood. Early on, patients were treated every four weeks. The current recommendation is to treat at 6- to 8-week intervals unless a more extended period of 2-3 months is needed for tissue recovery. For highly motivated patients, I schedule them every two weeks if only QS lasers are used. Fractional CO2 or Ultra-pulse CO2 is used every 4-6 weeks to help skin recover. It would be best if higher fluences and shorter pulse widths remove tattoo pigment more rapidly but may induce excessive shock wave tissue reaction; therefore, I must balance them with the desire to remove dye without scarring or hypopigmentation. our thought of the fading and eventual elimination of your tattoo as a project which you might work on from time to time over the next year or two.

In many cases, the tattoo can be made to disappear or fade to the point where you are the only person who can find a trace of it because you know where to look. At this point, I used the fractional CO2 laser alone to change the geometry of the tattoo shadow. Also, I may use E-light or long-pulsed Nd: YAG (1320nm or 1064nm) to treat residual pigmentation, hypopigmentation, and textural changes. Dark (blue/black) inks and red inks usually fade the best. Oranges and purples often respond well. Dark inks respond quicker than bright-colored inks because dark colors absorb laser energy better. Light colors such as light green, yellow, and turquoise can be challenging to remove. Multicolored professional tattoos, especially on the lower legs, tend to respond slowly to laser treatments. Quite a few colorful tattoos will need ten or more treatment sessions for good fading or complete removal.  Sometimes chemicals like iron oxide or titanium dioxide are added to tattoo ink to brighten the tattoo – but these chemicals make it much more difficult to remove the tattoo. Fluorescent “Day Glow” pigments are almost impossible to extract. Some tattoos are now made with dark tar-based ink or “laser resistant ink,” I can only remove these tattoos (fortunately are pretty rare) by cutting them out. Tattoos on the face and trunk often respond faster to laser treatment than tattoos on the ankles.

Some people choose to over-tattoo (use “cover-art”) to hide an undesirable tattoo.  This is especially common when the original tattoo contains the name of a former lover. If you have one tattoo on top of an older tattoo, other laser treatments will be needed because there will likely be a large amount of ink (ink from the new cover-up tattoo plus ink from the old tattoo). Many tattoo artists encourage customers to have several laser treatments to lighten an existing tattoo before covering it with a new one. This will reduce any chance that the old tattoo will be visible through the new tattoo. It would be best if you waited a month or two after your final laser treatment before having a new tattoo placed in the treated area.

A significant issue until recently, with laser tattoo removal, was the inability to predict or estimate the number of sessions needed to eliminate tattoos. Patients often wish to obtain a rough estimate of the number of sessions required to give a significant clearing of tattoos. This indirectly impacts the financial implications so the patients can plan their budget for the laser sessions. It is well accepted that the number of sessions depends more on the kind of the tattoo than on the laser used; thus, 5-10 sessions are standard for amateur tattoos and 15-20 for professional tattoos, even up to 25 courses in rare cases. The number of treatment sessions also depends on pigment color, composition, density, depth, age of the tattoo, body location, and the amount of tattoo ink present. The Kirby-Desai Scale is a valuable index to correlate with the number of treatment sessions required for satisfactory tattoo removal. This is based on the following six factors:

• Fitzpatrick skin type
• Location
• Color
• Amount of ink used
• Scarring and tissue damage
• Ink layering

By allotting a numeric value to each of these and totaling it, a rough estimate can be made as to the number of sessions for a given tattoo. This is a significant step forward as patient counseling becomes easier. Because there is a great deal of variability in the kinds, mixtures, and quantities of ink used in tattoos, and because there is some variability in people’s natural ability to clear away tattoo pigment after laser treatment, it is not possible to “promise” you that a particular result will happen after a fixed number of procedures.  Prof. Moawad will explain what is likely to happen, but he cannot precisely predict or guarantee what will happen in any case. Prof. Moawad will show you photos illustrating the range of results, from fading through to the complete disappearance of the tattoo. I can remove some lightly pigmented, black, or dark blue homemade tattoos in one treatment.  Amateur tattoos (usually have a small amount of superficial ink) are often bright after two to six treatments.  New tattoos need more treatment sessions because they have more ink than old tattoos. Older tattoos have less ink because, like tattoo ages, the body absorbs some of the ink.