- Email: [email protected]
Tattoo removal
Clinics in Dermatology (2007) 25, 388–392
Tattoo removal Katy Burris, MD a,⁎, Karen Kim, MD b a
Department of Dermatology, State University New York Health Science Center at Brooklyn, Brooklyn, NY 11203, USA Karen H. Kim, Laser and Skin Surgery Center of New York, New York, NY 10016, USA
b
Abstract Tattoos have been a part of costume, expression, and identification in various cultures for centuries. Although tattoos have become more popular in western culture, many people regret their tattoos in later years. In this situation, it is important to be aware of the mechanisms of tattoo removal methods available, as well as their potential short- and long-term effects. Among the myriad of options available, laser tattoo removal is the current treatment of choice, given its safety and efficacy. Published by Elsevier Inc.
Introduction A tattoo is a mark or design made by inserting pigment into the skin, causing dermal pigmentation. Tattoos have been used for centuries and may be a part of costume, expression, or identification in many cultures. The motivation for obtaining a tattoo generally is thought to be a form of quest for personal identity1; however, the tattoos of younger years may become the bane of maturity or even an embarrassment by the age of 40. Studies suggest that at least 50% of individuals later regret their tattoos.2 In addition, some people may develop an acute inflammatory, allergic, hypersensitivity, or granulomatous type reaction that warrants tattoo removal.3 The most frequent motivations for tattoo removal seem to be poor decision making and subsequent personal regret; therefore, viable methods and accessibility to tattoo removal techniques are important. Other common reasons for tattoo removal are to improve self-esteem, to remove an undesirable design, to appear more professional, and to increase ⁎ Corresponding author. New York, NY 10016, USA. E-mail address: [email protected] (K. Burris). 0738-081X/$ – see front matter. Published by Elsevier Inc. doi:10.1016/j.clindermatol.2007.05.011
credibility with friends.4 Tattoo removal can be attempted or achieved by a variety of modalities, some of which may be painful, expensive, and not without adverse effects.
Tattoo removal mechanisms The earliest report of attempted tattoo removal was from Aetius, a Greek physician who described salabrasion in 543 CE.4 Since then, tattoo removal techniques have included the destruction or removal of the outer skin layers by either mechanical, chemical, or thermal methods. By damaging the epidermis, the pigment is then able to migrate transdermally through denuded skin to the surface. The inflammatory response, combined with increased macrophage activity and phagocytosis, allows for additional pigment to be expelled during the healing phase.2
Mechanical methods Salabrasion involves abrading the superficial dermis with coarse granules of common table salt and a moist gauze pad. Salt is applied to the wound surface and left under a surgical dressing for 24 hours. A variation on this method is removal
Tattoo removal of the salt immediately after salabrasion to minimize scarring and hypopigmentation.5 Salabrasion seems to be most effective for the removal of amateur tattoos,6,7 but given the associated risk of scarring, this technique has decreased in popularity over the last decade and is now rarely used. Dermabrasion is another method of mechanical tissue destruction. During this method of treatment, a rapidly spinning diamond fraise wheel or a wire brush abrades the skin that is usually prepared with a skin refrigerant to produce a hard surface.8 Traumatic tattoos tend to be superficial and may thus only require a single treatment. Professional or amateur tattoos tend to be deeper and often require multiple treatments.9 Dermabrasion has also been used in combination with surgical excision for complex traumatic tattoos. Dermabrasion removes the superficial portion of the tattoo, exposing the deeper component, which then may be removed surgically.10 Surgical excision of skin containing tattoo pigment is another alternative. Surgical excision is a potential option for the removal of small tattoos located in areas of adequate skin laxity or for cosmetic or traumatic tattoos. Surgery in an area with abundant laxity can result in a cosmetically acceptable scar. An advantage of surgical excision is the possibility of complete tattoo removal in a single procedure; however, for larger tattoos, especially in areas with greater skin tension, complete tattoo removal might entail multiple surgeries along with greater risk of complications. Adverse effects have been reported with surgical excisions including the necessity of complex wound closures, which can complicate wound healing; possible skin grafts; hypertrophic scarring or keloids; and possible tissue or anatomic distortion, all of which can be ultimately less cosmetically acceptable to the patient than the original tattoo.11 A superficial, tangential excision of a professional tattoo by a Brown dermatome can be performed as a low-risk, inexpensive procedure for tattoo removal. This procedure produced minimal scarring, and little pigment remained posttreatment.12 This may be an option for small superficial, amateur tattoo, but is likely to be impractical for large professional tattoos with deeper pigment. It has a higher risk of scarring and dyspigmentation. Mechanical methods of tattoo removal may be less expensive and time-consuming as compared to thermal methods; however, the main disadvantage with all types of mechanical destruction is the high risk of scarring. Hypertrophic scars are common when tissue is removed deeply in an attempt to extract all of the tattoo pigment. In addition, there is often residual tattoo pigment after treatment. Postoperative pain and possible bleeding are other side effects of these destructive treatments.11
Chemical methods Chemical tissue destruction methods using compounds such as tannic acid and silver nitrate have also been described. The
389 technique known as the French method involves disruption of the skin surface with punctures and incisions, followed by the application of caustic chemicals. An eschar forms in the subsequent 2 to 3 weeks, leading to removal of the tattoo.13 This technique can be used for the removal of amateur tattoos of any size. The results and complication risks are comparable to cryotherapy, infrared coagulation, and focal salabrasion.6 This method is rarely used today.
Thermal methods Lasers have been used to remove tattoos since the 1970s14-16 and have undergone many advances. The argon laser is a continuous wave laser that emits nonionizing bluegreen light and can be preferentially absorbed by the tattoo pigment. Because of the continuous laser emission, however, early attempts to use this laser for tattoo removal resulted in scars because of excessive heat energy that spread from the tattoo granules to the surrounding skin.17 The carbon dioxide laser emits energy at 10,600 nm and is used to superficially ablate tissue. Because of the excellent absorption properties of this wavelength by water, the carbon dioxide laser vaporizes superficial skin, making it a potential option for removing skin containing unwanted tattoo pigment. Although its nonselective nature makes it similar to other destructive modalities, there is greater control and precision with the carbon dioxide laser for more precise ablation of superficial layers of skin as compared to other, more primitive methods,17 thereby reducing the risk of hypertrophic scarring. The carbon dioxide laser can be helpful, especially for the removal of cosmetic tattoos on the face, such as lip or eyeliner tattoo18 ; however, it is impractical for areas off the face or for large, extensive tattoos, where tattoo pigment deposition is deeper, and risks of postoperative scarring and long-term hypopigmentation are high. The infrared coagulator is another tool that has been used in the removal of tattoos in the past. The infrared coagulator was developed almost 20 years ago in Germany in 1979 and uses a noncoherent, multispectral light source.19 In one study, 42 tattoos were treated, using pulses of 1.125 or 1.25 seconds, and amateur tattoos were satisfactorily treated in over 80% of cases, regardless of dose.20 Adverse effects included deep collagen necrosis and scarring, more so with the 1.25-second pulse. One study compared the infrared coagulator to the carbon dioxide laser and demonstrated that the infrared coagulator had the advantages of a more rapid healing time, an easierto-care-for treatment site, and an equivalent cosmetic result in comparison with the carbon dioxide laser.21 Scarring is not uncommon and will most likely be more significant than that seen with the more recent Q-switched lasers because the coagulator does not allow for selective photothermolysis of pigment particles. Q-switched lasers have become more popular over recent years for tattoo removal and are now the treatment of choice
390 for tattoo removal. Q-switching refers to a switch that allows the release of all of the energy in one powerful pulse such that the target is heated so rapidly that it will shatter, allowing for selective photothermolysis.22 The Q-switched laser has been shown to provide efficacious removal of tattoos with minimal side effects. It allows for restriction of tissue injury to the target tissue, thereby enabling the sparing of other chromophores in the skin, such as melanin or hemoglobin, depending on the wavelength of the laser system.23 Because treatment with the Q-switched lasers is painful, use of a local injection with lidocaine or topical anesthetic is often used before treatment. After the procedure, topical broadspectrum antibacterial ointment or petroleum-based ointment is applied immediately to facilitate healing.24 The most common Q-switched lasers being used for this purpose are the Q-switched ruby (QSR) laser (694 nm); Q-switched Nd:YAG laser (532 and 1064 nm); and the Q-switched alexandrite laser (755 nm). Q-switched lasers are the best method of tattoo removal at this time; however, it is more expensive than the other methods described, and multiple treatment sessions are usually required. The QSR laser has historically been extremely effective at removing black and blue tattoo pigments. The QSR laser (694 nm) effectively removes both blue-black inks as well as green ink.25 In general, amateur tattoos tend to respond much more rapidly to treatment with the QSR laser than professionally placed tattoos do.17,26 In 1990, 101 amateur and 62 professional tattoos were treated with a QSR laser. The laser utilized a 5- to 8-mm spot size and fluences of 2 to 4 J/cm2. On average, 3 treatments were required for complete pigment removal of 4 tattoos, nearly complete pigment removal in 84, significant pigment removal in 11, and minimal pigment removal in 2 amateur tattoos. In the case of professional tattoos, there was complete pigment removal in 2, nearly complete pigment removal in 5, significant pigment removal in 18, minimal pigment removal in 25, and very little pigment removal in 12. Professional tattoos with red, yellow, and green pigments faded incompletely, requiring multiple retreatments. Blue and black inks were found to be much more responsive.27 The Q-switched Nd:YAG laser was developed in 1989 with an emission of 1064 nm and a pulse duration of 10 to 20 nanoseconds. In addition, the laser can be modified to a green light with an emission of 532 nm by placing a potassium-titanyl-phosphate crystal within the laser cavity.24 The Q-switched Nd:YAG 1064-nm laser appears to be just as effective as the QSR laser in the removal of blue-black tattoos at 6 J/cm2.28 This laser has the advantage of treating blue, green, and black pigments when using the 1064-nm laser. Red and yellow pigments can be treated with the 532-nm laser.11 Among the different tattoo colors, black tattoos tend to respond most favorably. The QSR laser is superior in the removal of green tattoo ink.29 For darkskinned patients, the Nd:YAG is a better option for tattoo removal because of its longer wavelength and its decreased affinity for melanin as compared to the QSR laser.30,31
K. Burris, K. Kim The Q-switched alexandrite laser, with a wavelength of 755 nm and a pulse duration of 50 to 100 nanoseconds, has similar absorption properties as that of the QSR laser. The Q-switched alexandrite laser is highly effective in removing multicolored professional and amateur tattoos. The 510 nm pulsed dye alexandrite laser can be helpful in eliminating red tattoo pigment.32 For skin types III-IV, tattoo pigment removal by Q-switched alexandrite laser can be used safely with minimal side effects.33 The Q-switched alexandrite laser is also effective in the removal of traumatic tattoos. The best response, defined as greater than 95% clearance, has been achieved in blacktop, surgical pen, and gravel tattoos, although an acceptable degree of lightening could be obtained in tattoos due to gunpowder or fireworks as well.34 The 755-nm alexandrite laser is safe and effective in the eradication of amalgam tattoos and cosmetic tattoos, such as permanent makeup.35,36 Although there is no single laser system that holds the answer for tattoo removal, Q-switched lasers can fade most tattoos. Patients should be aware of the limitations of lasers to have realistic expectations. Complete clearance of all treated tattoos is rare, and there is no guarantee that any treatment will make the skin look completely normal again. Depending on the color of the tattoo and the number of treatment sessions completed, practitioners can expect 75% clearance in half the cases they treat with lasers.37 Although Q-switched lasers have been shown to be highly effective in tattoo removal, they are not without adverse effects. Acute events include purpura, crusting, blistering, infection, and oxidative darkening of pigment.38 The most common chronic adverse effect of Q-switched lasers is transient or permanent hypopigmentation, especially in the treatment of dark-skinned patients with the QSR or alexandrite lasers.11 Although the exact mechanism for thermally induced destruction of melanocytes is not known, there are a number of possible explanations, including damage from shock waves, the physical effects of thermal expansion, and extreme temperature gradients within the cells.38,39 Hyperpigmentation can occur as well, in which the darkening of the skin in or around the treatment site results from increased melanin production by epidermal and follicular melanocytes in response to thermal changes. Hyperpigmentation is generally temporary, but the recovery time varies widely among patients.39 Scarring and textural changes may occur as well, but are less frequent. The incidence of pigmentary change is also dependent on the type of laser used. The QSR laser has the highest clearance rate in blue-black tattoos; yet, it also had the highest incidence of long-lasting hypopigmentation, whereas the Nd:YAG had no incidence of hypopigmentation.40 Blister formation is due to epidermal thermal damage and can occur after Q-switched laser irradiation for tattoo removal. Explanations for its development include use of excessive laser fluence or inadvertent absorption of laser energy attributable to the tattoo pigment. The concomitant use of tissue cooling system, such as through a contact chill
Tattoo removal
Fig. 1
Tattoo appearance before laser treatment.
tip or cryogen spray, can protect the epidermis from excessive thermal damage during laser irradiation and may reduce epidermal injury.41 Another important adverse effect that is seen with laser treatment is irreversible immediate darkening of the tattoo. Red, brown, and white pigments, which are used for cosmetic tattoos, are at highest risk for this type of reaction. The darkening reaction may first be masked by an immediate whitening action after the laser treatment, caused gas bubbles that can intensely scatter light. Most cosmetic tattoos contain iron oxide or titanium dioxide inks. After laser irradiation by a Q-switched or pulsed laser system, a theorized mechanism involving the reduction of ferric oxide to the ferrous oxide form may help explain the paradoxical darkening. The ferrous oxide form is black and insoluble, thus accounting for the darkened tattoo.3 Patients should be warned of the potential for cosmetic tattoo darkening, and test spot treatment should be performed initially. In some cases, subsequent laser treatments may remove the blackened ink.3 The Ultrapulse carbon dioxide laser can be helpful in many instances where cosmetic tattoos have undergone this reaction.42 A useful option to offer patients is a test spot with the laser. It provides an opportunity to test a particular laser, if there is a question about suitability of skin phototype or tattoo response to laser treatment. A small area may be treated with a laser, and then the site can be reevaluated in 1 month. Postprocedure, patients are instructed to keep the
Fig. 2
Tattoo appearance after 3 laser treatments.
391
Fig. 3 Tattoo appearance immediately after laser treatment. Note immediate whitening of epidermis.
area with a petrolatum-based emollient (ie, Aquaphor) until the scab falls off.17 Patients are also informed that complete removal of tattoo cannot be guaranteed and that multiple treatments are usually necessary. The number of treatments varies because the tattoo pigment varies from patient to patient, and older tattoos tend to respond better than new ones. Although patients undergo treatment, they should practice strict sun avoidance in the area of the tattoo to minimize the risk of scar or hypopigmentation.
Other options One of the newest methods for tattoo removal under study is the use of imiquimod cream. In animal studies, topical application of imiquimod cream fades tattoos. The combination of both imiquimod and laser treatment may result in enhanced tattoo pigment clearance in guinea pigs. In a study, the combination of laser and imiquimod treated group was clinically and histologically rated as having less pigment than the tattoos that were treated with laser alone. The adjuvant imiquimod treatment had greater inflammation and fibrosis on posttreatment skin biopsies.43 Camouflaging a tattoo is another option for people who may want to cover their tattoo for professional reasons, however, do not want it removed. There are specialized
Fig. 4
Scarring present post surgical excision.
392 formulations of concealing makeup (ie, Dermablend), which were developed to camouflage tattoos, port wine stains, and other types of birthmarks (Figs. 1-4).
Conclusions Among the different methods of tattoo removal, no method has proven to be perfect, and adverse events may occur with all methods of removal. Q-switched laser treatment is widely used for tattoo removal and can be quite effective. It is thus the standard of care today. For each patient, the physician must take a detailed history and determine the correct laser to use, as it will vary based on tattoo pigments, skin color, and tattoo etiology. Many tattoos in Western culture are composed of multiple colors, which may necessitate that a variety of laser systems of different wavelengths be employed. There is ongoing research being conducted in search of a method with complete pigment clearance and a low incidence of adverse effects.
References 1. Sweeney S. Tattoos: a review of tattoo practices and potential treatment options for removal. Curr Opin Pediatr 2006;19:391-5. 2. Kilmer S, Fitzpatrick R. Tattoo lasers. Retrieved March 12, 2007. Website: http://www.emedicine.com/derm/topic563.htm. 3. Tanzi E, Micheal E. Tattoo reactions. Retrieved March 17, 2007. Website: http://www.emedicine.com/DERM/topic512 2007. 4. Armstrong ML, Stuppy DJ, Gabriel DC, et al. Motivation for tattoo removal. Arch Dermatol 1996;132:412-6. 5. Koerber Jr WA, Price NM. Salabrasion of tattoos. A correlation of the clinical and histological results. Arch Dermatol 1978;114:884-8. 6. van der Velden EM, van der Walle HB, Groote AD. Tattoo removal: tannic acid method of Variot. Int J Dermatol 1993;32:376-80. 7. Johannesson A. A simplified method of focal salabrasion for removal of linear tattoos. J Dermatol Surg Oncol 1985;11:1004-5. 8. Boo-chai K. The decorative tattoo: its removal by dermabrasion. Plast Reconstr Surg 1963;32:559-63. 9. Peris Z. Removal of traumatic and decorative tattoos by dermabrasion. Acta Dermatovenerol Croat 2002;10:15-9. 10. Sun B, Guan W. Treating traumatic tattoo by micro-incision. Chin Med J 2000;113:670-1. 11. Kim KH, Geronemus RG. Tattoo removal. Med Lett 2003;45:95-6. 12. O'Donnell BP, Mulvaney MJ, James WD. Thin tangential excision of tattoos. Dermatol Surg 1995;21:601-3. 13. Penoff J. The office treatment of tattoos: a simple and effective method. Plast Reconstr Surg 1987;79:186-91. 14. Apfelberg DB, Maser MR. Argon laser treatment of decorative tattoos. Br J Plast Surg 1979;32:141-4. 15. Maser MR, Apfelberg DB, Lash H. Clinical applications of the argon and carbon dioxide lasers in dermatology and plastic surgery. World J Surg 1983;7:684-91. 16. Brady SC, Blockmanis A, Jewett L. Tattoo removal with carbon dioxide laser. Ann Plast Surg 1978;2:482-90. 17. Bernstein E. Laser treatment of tattoos. Clin Dermatol 2006;24:43-55. 18. Mafong EA, Kauvar AN, Geronemus RG. Surgical pearl: removal of cosmetic lip-liner tattoo with the pulsed carbon dioxide laser. J Am Acad Dermatol 2003;48:271-2.
K. Burris, K. Kim 19. Colver G. The infrared coagulator in dermatology. Dermatol Clin 1989;7:155-67. 20. Venning VA, Colver GB, Millard PR, et al. Tattoo removal using infrared coagulation: a dose comparison. Br J Dermatol 1987;117:99-105. 21. Groot DW, Arlette JP, Johnston PA. Comparison of the infrared coagulator and the carbon dioxide laser in the removal of decorative tattoos. J Am Acad Dermatol 1986;3:518-22. 22. Habif T. Dermatologic surgical procedures. In: Habif T, editor. Clinical dermatology. Mosby; 2004. p. 937-8. 23. Anderson RR, Geronemus R, Kilmer SL. Cosmetic tattoo ink darkening. A complication of Q-switched and pulsed-laser treatment. Arch Dermatol 1993;129:1010-4. 24. Kuperman-Beade M, Levine VJ, Ashinoff R. Laser removal of tattoos. Am J Clin Dermatol 2001;2:21-5. 25. Kilmer SL, Anderson RR. Clinical use of the Q-switched ruby and the Q-switched Nd:YAG (1064 nm and 532 nm) lasers for treatment of tattoos. J Dermatol Surg Oncol 1993;19:330-8. 26. Taylor CR, Gange RW, Dover JS. Treatment of tattoos by Q-switched ruby laser. A dose-response study. Arch Dermatol 1990;126:893-9. 27. Scheibner A, Kenny G, White W. A superior method of tattoo removal using the Q-switched ruby laser. J Dermatol Surg Oncol 1990;16: 1091-8. 28. DeCoste SD, Anderson RR. Comparison of Q-switched ruby and the Q-switched Nd:YAG laser treatment of tattoos. Lasers Surg Med Suppl 1991;3:64. 29. Levine VJ, Geronemus R. Tattoo removal with the Q-switched ruby laser and the Q-switched Nd:YAG laser: a comparative study. Cutis 1995;55:291-6. 30. Grevelink JM, Duke D, van Leeuwen RL, et al. Laser treatment of tattoos in darkly pigmented patients: efficacy and side effects. J Am Acad Dermatol 1996;34:653-6. 31. 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;129:971-8. 32. Alster T. Q-switched alexandrite laser treatment (755 nm) of professional and amateur tattoos. J Am Acad Dermatol 1995;33:69-73. 33. Bukhari I. Removal of amateur blue-black tattoos in Arabic women of skin type (III-IV) with Q-switched alexandrite laser. J Cosmet Dermatol 2005;4:107-10. 34. Moreno-Arias GA, Casals-Andreu M, Camps-Fresneda A, et al. Use of Q-switched alexandrite laser (755 nm, 100 nsec) for removal of traumatic tattoo of different origins. Lasers Surg Med 1999;25:445-50. 35. Moreno-Arias GA, Camps-Fresneda A. The use of Q-switched alexandrite laser (755 nm, 100 ns) for eyeliner tattoo removal. J Cutan Laser Ther 1999;1:113-5. 36. Shah G, Alster TS. Treatment of an amalgam tattoo with a Q-switched alexandrite (755 nm) laser. Dermatol Surg 2002;28:1180-1. 37. Mariwalla K, Dover JS. The use of lasers for decorative tattoo removal. Retrieved April 15, 2007. Website: http://www.skintherapyletter.com/ 2006/11.5/2.html. 38. Handley J. Adverse events associated with nonablative cutaneous visible and infrared laser treatment. J Am Acad Dermatol 2006;55: 482-9. 39. Lanigan S. Incidence of side effects after laser hair removal. J Am Acad Dermatol 2003;49:882-6. 40. Leuenberger ML, Mulas MW, Hata TR, et al. Comparison of the Q-switched alexandrite, Nd:YAG, and ruby lasers in treating blue-black tattoos. Dermatol Surg 1999;25:10-4. 41. Willey A, Anderson RR, Azpiazu JL, et al. Complications of laser dermatologic surgery. Lasers Surg Med 2006;38:1-15. 42. Fitzpatrick RE, Lupton JR. Successful treatment of treatment-resistant laser-induced pigment darkening of a cosmetic tattoo. Lasers Surg Med 2000;27:359-61. 43. Ramirez M, Magee N, Diven D, et al. Topical imiquimod as an adjuvant to laser removal of mature tattoos in an animal model. Dermatol Surg 2007;33:319-25.
Tattoo removal Katy Burris, MD a,⁎, Karen Kim, MD b a
Department of Dermatology, State University New York Health Science Center at Brooklyn, Brooklyn, NY 11203, USA Karen H. Kim, Laser and Skin Surgery Center of New York, New York, NY 10016, USA
b
Abstract Tattoos have been a part of costume, expression, and identification in various cultures for centuries. Although tattoos have become more popular in western culture, many people regret their tattoos in later years. In this situation, it is important to be aware of the mechanisms of tattoo removal methods available, as well as their potential short- and long-term effects. Among the myriad of options available, laser tattoo removal is the current treatment of choice, given its safety and efficacy. Published by Elsevier Inc.
Introduction A tattoo is a mark or design made by inserting pigment into the skin, causing dermal pigmentation. Tattoos have been used for centuries and may be a part of costume, expression, or identification in many cultures. The motivation for obtaining a tattoo generally is thought to be a form of quest for personal identity1; however, the tattoos of younger years may become the bane of maturity or even an embarrassment by the age of 40. Studies suggest that at least 50% of individuals later regret their tattoos.2 In addition, some people may develop an acute inflammatory, allergic, hypersensitivity, or granulomatous type reaction that warrants tattoo removal.3 The most frequent motivations for tattoo removal seem to be poor decision making and subsequent personal regret; therefore, viable methods and accessibility to tattoo removal techniques are important. Other common reasons for tattoo removal are to improve self-esteem, to remove an undesirable design, to appear more professional, and to increase ⁎ Corresponding author. New York, NY 10016, USA. E-mail address: [email protected] (K. Burris). 0738-081X/$ – see front matter. Published by Elsevier Inc. doi:10.1016/j.clindermatol.2007.05.011
credibility with friends.4 Tattoo removal can be attempted or achieved by a variety of modalities, some of which may be painful, expensive, and not without adverse effects.
Tattoo removal mechanisms The earliest report of attempted tattoo removal was from Aetius, a Greek physician who described salabrasion in 543 CE.4 Since then, tattoo removal techniques have included the destruction or removal of the outer skin layers by either mechanical, chemical, or thermal methods. By damaging the epidermis, the pigment is then able to migrate transdermally through denuded skin to the surface. The inflammatory response, combined with increased macrophage activity and phagocytosis, allows for additional pigment to be expelled during the healing phase.2
Mechanical methods Salabrasion involves abrading the superficial dermis with coarse granules of common table salt and a moist gauze pad. Salt is applied to the wound surface and left under a surgical dressing for 24 hours. A variation on this method is removal
Tattoo removal of the salt immediately after salabrasion to minimize scarring and hypopigmentation.5 Salabrasion seems to be most effective for the removal of amateur tattoos,6,7 but given the associated risk of scarring, this technique has decreased in popularity over the last decade and is now rarely used. Dermabrasion is another method of mechanical tissue destruction. During this method of treatment, a rapidly spinning diamond fraise wheel or a wire brush abrades the skin that is usually prepared with a skin refrigerant to produce a hard surface.8 Traumatic tattoos tend to be superficial and may thus only require a single treatment. Professional or amateur tattoos tend to be deeper and often require multiple treatments.9 Dermabrasion has also been used in combination with surgical excision for complex traumatic tattoos. Dermabrasion removes the superficial portion of the tattoo, exposing the deeper component, which then may be removed surgically.10 Surgical excision of skin containing tattoo pigment is another alternative. Surgical excision is a potential option for the removal of small tattoos located in areas of adequate skin laxity or for cosmetic or traumatic tattoos. Surgery in an area with abundant laxity can result in a cosmetically acceptable scar. An advantage of surgical excision is the possibility of complete tattoo removal in a single procedure; however, for larger tattoos, especially in areas with greater skin tension, complete tattoo removal might entail multiple surgeries along with greater risk of complications. Adverse effects have been reported with surgical excisions including the necessity of complex wound closures, which can complicate wound healing; possible skin grafts; hypertrophic scarring or keloids; and possible tissue or anatomic distortion, all of which can be ultimately less cosmetically acceptable to the patient than the original tattoo.11 A superficial, tangential excision of a professional tattoo by a Brown dermatome can be performed as a low-risk, inexpensive procedure for tattoo removal. This procedure produced minimal scarring, and little pigment remained posttreatment.12 This may be an option for small superficial, amateur tattoo, but is likely to be impractical for large professional tattoos with deeper pigment. It has a higher risk of scarring and dyspigmentation. Mechanical methods of tattoo removal may be less expensive and time-consuming as compared to thermal methods; however, the main disadvantage with all types of mechanical destruction is the high risk of scarring. Hypertrophic scars are common when tissue is removed deeply in an attempt to extract all of the tattoo pigment. In addition, there is often residual tattoo pigment after treatment. Postoperative pain and possible bleeding are other side effects of these destructive treatments.11
Chemical methods Chemical tissue destruction methods using compounds such as tannic acid and silver nitrate have also been described. The
389 technique known as the French method involves disruption of the skin surface with punctures and incisions, followed by the application of caustic chemicals. An eschar forms in the subsequent 2 to 3 weeks, leading to removal of the tattoo.13 This technique can be used for the removal of amateur tattoos of any size. The results and complication risks are comparable to cryotherapy, infrared coagulation, and focal salabrasion.6 This method is rarely used today.
Thermal methods Lasers have been used to remove tattoos since the 1970s14-16 and have undergone many advances. The argon laser is a continuous wave laser that emits nonionizing bluegreen light and can be preferentially absorbed by the tattoo pigment. Because of the continuous laser emission, however, early attempts to use this laser for tattoo removal resulted in scars because of excessive heat energy that spread from the tattoo granules to the surrounding skin.17 The carbon dioxide laser emits energy at 10,600 nm and is used to superficially ablate tissue. Because of the excellent absorption properties of this wavelength by water, the carbon dioxide laser vaporizes superficial skin, making it a potential option for removing skin containing unwanted tattoo pigment. Although its nonselective nature makes it similar to other destructive modalities, there is greater control and precision with the carbon dioxide laser for more precise ablation of superficial layers of skin as compared to other, more primitive methods,17 thereby reducing the risk of hypertrophic scarring. The carbon dioxide laser can be helpful, especially for the removal of cosmetic tattoos on the face, such as lip or eyeliner tattoo18 ; however, it is impractical for areas off the face or for large, extensive tattoos, where tattoo pigment deposition is deeper, and risks of postoperative scarring and long-term hypopigmentation are high. The infrared coagulator is another tool that has been used in the removal of tattoos in the past. The infrared coagulator was developed almost 20 years ago in Germany in 1979 and uses a noncoherent, multispectral light source.19 In one study, 42 tattoos were treated, using pulses of 1.125 or 1.25 seconds, and amateur tattoos were satisfactorily treated in over 80% of cases, regardless of dose.20 Adverse effects included deep collagen necrosis and scarring, more so with the 1.25-second pulse. One study compared the infrared coagulator to the carbon dioxide laser and demonstrated that the infrared coagulator had the advantages of a more rapid healing time, an easierto-care-for treatment site, and an equivalent cosmetic result in comparison with the carbon dioxide laser.21 Scarring is not uncommon and will most likely be more significant than that seen with the more recent Q-switched lasers because the coagulator does not allow for selective photothermolysis of pigment particles. Q-switched lasers have become more popular over recent years for tattoo removal and are now the treatment of choice
390 for tattoo removal. Q-switching refers to a switch that allows the release of all of the energy in one powerful pulse such that the target is heated so rapidly that it will shatter, allowing for selective photothermolysis.22 The Q-switched laser has been shown to provide efficacious removal of tattoos with minimal side effects. It allows for restriction of tissue injury to the target tissue, thereby enabling the sparing of other chromophores in the skin, such as melanin or hemoglobin, depending on the wavelength of the laser system.23 Because treatment with the Q-switched lasers is painful, use of a local injection with lidocaine or topical anesthetic is often used before treatment. After the procedure, topical broadspectrum antibacterial ointment or petroleum-based ointment is applied immediately to facilitate healing.24 The most common Q-switched lasers being used for this purpose are the Q-switched ruby (QSR) laser (694 nm); Q-switched Nd:YAG laser (532 and 1064 nm); and the Q-switched alexandrite laser (755 nm). Q-switched lasers are the best method of tattoo removal at this time; however, it is more expensive than the other methods described, and multiple treatment sessions are usually required. The QSR laser has historically been extremely effective at removing black and blue tattoo pigments. The QSR laser (694 nm) effectively removes both blue-black inks as well as green ink.25 In general, amateur tattoos tend to respond much more rapidly to treatment with the QSR laser than professionally placed tattoos do.17,26 In 1990, 101 amateur and 62 professional tattoos were treated with a QSR laser. The laser utilized a 5- to 8-mm spot size and fluences of 2 to 4 J/cm2. On average, 3 treatments were required for complete pigment removal of 4 tattoos, nearly complete pigment removal in 84, significant pigment removal in 11, and minimal pigment removal in 2 amateur tattoos. In the case of professional tattoos, there was complete pigment removal in 2, nearly complete pigment removal in 5, significant pigment removal in 18, minimal pigment removal in 25, and very little pigment removal in 12. Professional tattoos with red, yellow, and green pigments faded incompletely, requiring multiple retreatments. Blue and black inks were found to be much more responsive.27 The Q-switched Nd:YAG laser was developed in 1989 with an emission of 1064 nm and a pulse duration of 10 to 20 nanoseconds. In addition, the laser can be modified to a green light with an emission of 532 nm by placing a potassium-titanyl-phosphate crystal within the laser cavity.24 The Q-switched Nd:YAG 1064-nm laser appears to be just as effective as the QSR laser in the removal of blue-black tattoos at 6 J/cm2.28 This laser has the advantage of treating blue, green, and black pigments when using the 1064-nm laser. Red and yellow pigments can be treated with the 532-nm laser.11 Among the different tattoo colors, black tattoos tend to respond most favorably. The QSR laser is superior in the removal of green tattoo ink.29 For darkskinned patients, the Nd:YAG is a better option for tattoo removal because of its longer wavelength and its decreased affinity for melanin as compared to the QSR laser.30,31
K. Burris, K. Kim The Q-switched alexandrite laser, with a wavelength of 755 nm and a pulse duration of 50 to 100 nanoseconds, has similar absorption properties as that of the QSR laser. The Q-switched alexandrite laser is highly effective in removing multicolored professional and amateur tattoos. The 510 nm pulsed dye alexandrite laser can be helpful in eliminating red tattoo pigment.32 For skin types III-IV, tattoo pigment removal by Q-switched alexandrite laser can be used safely with minimal side effects.33 The Q-switched alexandrite laser is also effective in the removal of traumatic tattoos. The best response, defined as greater than 95% clearance, has been achieved in blacktop, surgical pen, and gravel tattoos, although an acceptable degree of lightening could be obtained in tattoos due to gunpowder or fireworks as well.34 The 755-nm alexandrite laser is safe and effective in the eradication of amalgam tattoos and cosmetic tattoos, such as permanent makeup.35,36 Although there is no single laser system that holds the answer for tattoo removal, Q-switched lasers can fade most tattoos. Patients should be aware of the limitations of lasers to have realistic expectations. Complete clearance of all treated tattoos is rare, and there is no guarantee that any treatment will make the skin look completely normal again. Depending on the color of the tattoo and the number of treatment sessions completed, practitioners can expect 75% clearance in half the cases they treat with lasers.37 Although Q-switched lasers have been shown to be highly effective in tattoo removal, they are not without adverse effects. Acute events include purpura, crusting, blistering, infection, and oxidative darkening of pigment.38 The most common chronic adverse effect of Q-switched lasers is transient or permanent hypopigmentation, especially in the treatment of dark-skinned patients with the QSR or alexandrite lasers.11 Although the exact mechanism for thermally induced destruction of melanocytes is not known, there are a number of possible explanations, including damage from shock waves, the physical effects of thermal expansion, and extreme temperature gradients within the cells.38,39 Hyperpigmentation can occur as well, in which the darkening of the skin in or around the treatment site results from increased melanin production by epidermal and follicular melanocytes in response to thermal changes. Hyperpigmentation is generally temporary, but the recovery time varies widely among patients.39 Scarring and textural changes may occur as well, but are less frequent. The incidence of pigmentary change is also dependent on the type of laser used. The QSR laser has the highest clearance rate in blue-black tattoos; yet, it also had the highest incidence of long-lasting hypopigmentation, whereas the Nd:YAG had no incidence of hypopigmentation.40 Blister formation is due to epidermal thermal damage and can occur after Q-switched laser irradiation for tattoo removal. Explanations for its development include use of excessive laser fluence or inadvertent absorption of laser energy attributable to the tattoo pigment. The concomitant use of tissue cooling system, such as through a contact chill
Tattoo removal
Fig. 1
Tattoo appearance before laser treatment.
tip or cryogen spray, can protect the epidermis from excessive thermal damage during laser irradiation and may reduce epidermal injury.41 Another important adverse effect that is seen with laser treatment is irreversible immediate darkening of the tattoo. Red, brown, and white pigments, which are used for cosmetic tattoos, are at highest risk for this type of reaction. The darkening reaction may first be masked by an immediate whitening action after the laser treatment, caused gas bubbles that can intensely scatter light. Most cosmetic tattoos contain iron oxide or titanium dioxide inks. After laser irradiation by a Q-switched or pulsed laser system, a theorized mechanism involving the reduction of ferric oxide to the ferrous oxide form may help explain the paradoxical darkening. The ferrous oxide form is black and insoluble, thus accounting for the darkened tattoo.3 Patients should be warned of the potential for cosmetic tattoo darkening, and test spot treatment should be performed initially. In some cases, subsequent laser treatments may remove the blackened ink.3 The Ultrapulse carbon dioxide laser can be helpful in many instances where cosmetic tattoos have undergone this reaction.42 A useful option to offer patients is a test spot with the laser. It provides an opportunity to test a particular laser, if there is a question about suitability of skin phototype or tattoo response to laser treatment. A small area may be treated with a laser, and then the site can be reevaluated in 1 month. Postprocedure, patients are instructed to keep the
Fig. 2
Tattoo appearance after 3 laser treatments.
391
Fig. 3 Tattoo appearance immediately after laser treatment. Note immediate whitening of epidermis.
area with a petrolatum-based emollient (ie, Aquaphor) until the scab falls off.17 Patients are also informed that complete removal of tattoo cannot be guaranteed and that multiple treatments are usually necessary. The number of treatments varies because the tattoo pigment varies from patient to patient, and older tattoos tend to respond better than new ones. Although patients undergo treatment, they should practice strict sun avoidance in the area of the tattoo to minimize the risk of scar or hypopigmentation.
Other options One of the newest methods for tattoo removal under study is the use of imiquimod cream. In animal studies, topical application of imiquimod cream fades tattoos. The combination of both imiquimod and laser treatment may result in enhanced tattoo pigment clearance in guinea pigs. In a study, the combination of laser and imiquimod treated group was clinically and histologically rated as having less pigment than the tattoos that were treated with laser alone. The adjuvant imiquimod treatment had greater inflammation and fibrosis on posttreatment skin biopsies.43 Camouflaging a tattoo is another option for people who may want to cover their tattoo for professional reasons, however, do not want it removed. There are specialized
Fig. 4
Scarring present post surgical excision.
392 formulations of concealing makeup (ie, Dermablend), which were developed to camouflage tattoos, port wine stains, and other types of birthmarks (Figs. 1-4).
Conclusions Among the different methods of tattoo removal, no method has proven to be perfect, and adverse events may occur with all methods of removal. Q-switched laser treatment is widely used for tattoo removal and can be quite effective. It is thus the standard of care today. For each patient, the physician must take a detailed history and determine the correct laser to use, as it will vary based on tattoo pigments, skin color, and tattoo etiology. Many tattoos in Western culture are composed of multiple colors, which may necessitate that a variety of laser systems of different wavelengths be employed. There is ongoing research being conducted in search of a method with complete pigment clearance and a low incidence of adverse effects.
References 1. Sweeney S. Tattoos: a review of tattoo practices and potential treatment options for removal. Curr Opin Pediatr 2006;19:391-5. 2. Kilmer S, Fitzpatrick R. Tattoo lasers. Retrieved March 12, 2007. Website: http://www.emedicine.com/derm/topic563.htm. 3. Tanzi E, Micheal E. Tattoo reactions. Retrieved March 17, 2007. Website: http://www.emedicine.com/DERM/topic512 2007. 4. Armstrong ML, Stuppy DJ, Gabriel DC, et al. Motivation for tattoo removal. Arch Dermatol 1996;132:412-6. 5. Koerber Jr WA, Price NM. Salabrasion of tattoos. A correlation of the clinical and histological results. Arch Dermatol 1978;114:884-8. 6. van der Velden EM, van der Walle HB, Groote AD. Tattoo removal: tannic acid method of Variot. Int J Dermatol 1993;32:376-80. 7. Johannesson A. A simplified method of focal salabrasion for removal of linear tattoos. J Dermatol Surg Oncol 1985;11:1004-5. 8. Boo-chai K. The decorative tattoo: its removal by dermabrasion. Plast Reconstr Surg 1963;32:559-63. 9. Peris Z. Removal of traumatic and decorative tattoos by dermabrasion. Acta Dermatovenerol Croat 2002;10:15-9. 10. Sun B, Guan W. Treating traumatic tattoo by micro-incision. Chin Med J 2000;113:670-1. 11. Kim KH, Geronemus RG. Tattoo removal. Med Lett 2003;45:95-6. 12. O'Donnell BP, Mulvaney MJ, James WD. Thin tangential excision of tattoos. Dermatol Surg 1995;21:601-3. 13. Penoff J. The office treatment of tattoos: a simple and effective method. Plast Reconstr Surg 1987;79:186-91. 14. Apfelberg DB, Maser MR. Argon laser treatment of decorative tattoos. Br J Plast Surg 1979;32:141-4. 15. Maser MR, Apfelberg DB, Lash H. Clinical applications of the argon and carbon dioxide lasers in dermatology and plastic surgery. World J Surg 1983;7:684-91. 16. Brady SC, Blockmanis A, Jewett L. Tattoo removal with carbon dioxide laser. Ann Plast Surg 1978;2:482-90. 17. Bernstein E. Laser treatment of tattoos. Clin Dermatol 2006;24:43-55. 18. Mafong EA, Kauvar AN, Geronemus RG. Surgical pearl: removal of cosmetic lip-liner tattoo with the pulsed carbon dioxide laser. J Am Acad Dermatol 2003;48:271-2.
K. Burris, K. Kim 19. Colver G. The infrared coagulator in dermatology. Dermatol Clin 1989;7:155-67. 20. Venning VA, Colver GB, Millard PR, et al. Tattoo removal using infrared coagulation: a dose comparison. Br J Dermatol 1987;117:99-105. 21. Groot DW, Arlette JP, Johnston PA. Comparison of the infrared coagulator and the carbon dioxide laser in the removal of decorative tattoos. J Am Acad Dermatol 1986;3:518-22. 22. Habif T. Dermatologic surgical procedures. In: Habif T, editor. Clinical dermatology. Mosby; 2004. p. 937-8. 23. Anderson RR, Geronemus R, Kilmer SL. Cosmetic tattoo ink darkening. A complication of Q-switched and pulsed-laser treatment. Arch Dermatol 1993;129:1010-4. 24. Kuperman-Beade M, Levine VJ, Ashinoff R. Laser removal of tattoos. Am J Clin Dermatol 2001;2:21-5. 25. Kilmer SL, Anderson RR. Clinical use of the Q-switched ruby and the Q-switched Nd:YAG (1064 nm and 532 nm) lasers for treatment of tattoos. J Dermatol Surg Oncol 1993;19:330-8. 26. Taylor CR, Gange RW, Dover JS. Treatment of tattoos by Q-switched ruby laser. A dose-response study. Arch Dermatol 1990;126:893-9. 27. Scheibner A, Kenny G, White W. A superior method of tattoo removal using the Q-switched ruby laser. J Dermatol Surg Oncol 1990;16: 1091-8. 28. DeCoste SD, Anderson RR. Comparison of Q-switched ruby and the Q-switched Nd:YAG laser treatment of tattoos. Lasers Surg Med Suppl 1991;3:64. 29. Levine VJ, Geronemus R. Tattoo removal with the Q-switched ruby laser and the Q-switched Nd:YAG laser: a comparative study. Cutis 1995;55:291-6. 30. Grevelink JM, Duke D, van Leeuwen RL, et al. Laser treatment of tattoos in darkly pigmented patients: efficacy and side effects. J Am Acad Dermatol 1996;34:653-6. 31. 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;129:971-8. 32. Alster T. Q-switched alexandrite laser treatment (755 nm) of professional and amateur tattoos. J Am Acad Dermatol 1995;33:69-73. 33. Bukhari I. Removal of amateur blue-black tattoos in Arabic women of skin type (III-IV) with Q-switched alexandrite laser. J Cosmet Dermatol 2005;4:107-10. 34. Moreno-Arias GA, Casals-Andreu M, Camps-Fresneda A, et al. Use of Q-switched alexandrite laser (755 nm, 100 nsec) for removal of traumatic tattoo of different origins. Lasers Surg Med 1999;25:445-50. 35. Moreno-Arias GA, Camps-Fresneda A. The use of Q-switched alexandrite laser (755 nm, 100 ns) for eyeliner tattoo removal. J Cutan Laser Ther 1999;1:113-5. 36. Shah G, Alster TS. Treatment of an amalgam tattoo with a Q-switched alexandrite (755 nm) laser. Dermatol Surg 2002;28:1180-1. 37. Mariwalla K, Dover JS. The use of lasers for decorative tattoo removal. Retrieved April 15, 2007. Website: http://www.skintherapyletter.com/ 2006/11.5/2.html. 38. Handley J. Adverse events associated with nonablative cutaneous visible and infrared laser treatment. J Am Acad Dermatol 2006;55: 482-9. 39. Lanigan S. Incidence of side effects after laser hair removal. J Am Acad Dermatol 2003;49:882-6. 40. Leuenberger ML, Mulas MW, Hata TR, et al. Comparison of the Q-switched alexandrite, Nd:YAG, and ruby lasers in treating blue-black tattoos. Dermatol Surg 1999;25:10-4. 41. Willey A, Anderson RR, Azpiazu JL, et al. Complications of laser dermatologic surgery. Lasers Surg Med 2006;38:1-15. 42. Fitzpatrick RE, Lupton JR. Successful treatment of treatment-resistant laser-induced pigment darkening of a cosmetic tattoo. Lasers Surg Med 2000;27:359-61. 43. Ramirez M, Magee N, Diven D, et al. Topical imiquimod as an adjuvant to laser removal of mature tattoos in an animal model. Dermatol Surg 2007;33:319-25.