Topical Imiquimod as an Adjuvant to Laser Removal of Mature Tattoos in an Animal Model

BACKGROUND: Lasers are a commonly employed method of tattoo removal; however, numerous treatments are often needed and laser treatment may fail to eliminate the tattoo completely. It has been shown in animal studies that topical application of imiquimod cream, alone, fades tattoos. It is suspected that the combination of both imiquimod and laser treatment will result in enhanced tattoo pigment clearance. OBJECTIVE: The objective was to evaluate the efficacy of topical imiquimod cream as an adjuvant to laser removal of mature tattoos. METHODS: Fourteen albino guinea pigs were tattooed with black ink, then randomly assigned into two groups: one underwent sequential laser treatments with a Q-switched alexandrite laser in conjunction with triweekly applications of 5% imiquimod cream, while the other group underwent laser therapy alone. Subjects were evaluated with clinical photographs and skin biopsies after six laser treatment sessions. RESULTS: The combination laser and imiquimod treated group was clinically and histologically rated as having less pigment than the tattoos that were treated with laser alone (p=.012 and p=.047, respectively). Adjuvant imiquimod treatment had greater inflammation (p=.002) and fibrosis (p=.002) on posttreatment skin biopsies. CONCLUSION: Imiquimod appears to be a useful adjuvant to experimental laser tattoo removal in guinea pigs.     

Lasers for tattoo removal: a review

Tattoos have existed and have been used as an expression of art by man for ages—and so have the techniques to remove them. Lasers based on the principle of selective photothermolysis are now being used to remove black as well as colorful tattoos with varying successes. The commonly used lasers for tattoo removal are the Q-switched 694-nm ruby laser, the Q-switched 755-nm alexandrite laser, the 1,064-nm Nd:YAG laser, and the 532-nm Nd:YAG laser. Newer techniques and methods are evolving in tattoo removal with lasers. Choosing the right laser for the right tattoo color is necessary for a successful outcome. Our review aims to understand the principles of laser tattoo removal and their applications for different types and colors of tattoos. The review also highlights the complications that can occur such as dyspigmentation, allergic reactions, epidermal debris, ink darkening, and so on, in this process and how to prevent them.     

Laser ablation of facial cosmetic tattoos

The application of facial cosmetic tattoos (eyeliner, lipliner, and rouge) has become popular over the past five years and has resulted in an increasing number of patients requesting removal of these permanent cosmetics. Poor positioning or misapplication of the tattoo pigment has been the most common reason for requesting removal. Because of the almost inevitable probability of scarring, removal of these facial tattoos has been difficult at best. We report the successful removal of facial cosmetic tattoos in ten different patients with the use of five different lasers. We have found the superpulsed C0₂ laser and the Q-switched alexandrite laser to be effective in removal of black tattoo pigment. The alexandrite laser is effective without causing scarring, and the C0₂ laser is extremely precise and provides the capability of removing tattoo pigment between eyelash or eyebrow hairs without damaging the hair follicles. Both the argon laser and the flashlamp pumped dye laser reacted with red tattoo pigment and offered some improvement but were not ideally suited for tattoo removal. However, the flashlamp pumped dye laser for pigment was very effective in removing red tattoo pigment possibly because of its short pulse width (300 ns) in addition to its appropriate wavelength. The combination of these three lasers (superpulsed CO₂, alexandrite, and flashlamp pigment lasers) is very effective in removing black and red (or shades thereof) facial tattoos. Caution must be taken to determine the presence of flesh-colored tattoo pigment, as this pigment (FE₂O₃) will reduce to black (FeO) upon laser impact.     

Areolar Cosmetic Tattoo Ink Darkening: A Complication of Q-Switched Alexandrite Laser Treatment

BACKGROUND AND OBJECTIVE: Medical tattooing of the areola is widely performed in Korea. However, cosmetic tattoos containing flesh-tone, purple-red, and yellow dyes are sometimes resistant to Q-switched laser and may even become darker. METHOD: Two Korean women in their 30s who had a mastectomy got light brown to red areolar medical tattoos but they were not satisfied with the shape and size of the tattoos. They underwent Q-switched alexandrite laser treatment with a 3 mm collimated beam at fluences of 7.5-8 J/cm2 in order to trim the irregular contour and reduce the diameter of the tattoos. RESULTS: Within 5 minutes a dark gray to black discoloration of the treated area was evident and remained dark for 6 weeks. Improvement was not noted after two further Q-switched Nd:YAG laser treatments. CONCLUSION: Medical areolar tattoos should be approached with extra caution when attempting their removal with high-energy pulsed lasers such as Q-switched alexandrite laser and a small test site should be performed prior to treatment.     

Successful treatment of treatment-resistant laser-induced pigment darkening of a cosmetic tattoo

BACKGROUND AND OBJECTIVE: Cosmetic tattoo removal has a reported risk of immediate pigment darkening when treated with a high energy, nanosecond pulsed-laser system. Surgical treatment options for this reaction are limited and carry significant risk of scarring and permanent pigment alterations. This report describes the response of a resistant Q-switched ruby laser-induced cosmetic tattoo ink darkening to multiple treatments with the Q-switched alexandrite laser and Q-switch Nd:YAG laser and textural improvement with the UltraPulse CO(2) laser. STUDY DESIGN/MATERIALS AND METHODS: A woman with Q-switched ruby laser-induced pigment darkening of a cosmetic tattoo of the upper lip resistant to four further treatments with the ruby laser and two chemical peels received a total of 26 treatments with the Q-switched alexandrite and Nd:YAG lasers and a single treatment with the UltraPulse CO(2) laser, most treatments being done at monthly intervals. RESULTS: Treatment of the affected areas with the Q-switched alexandrite and Nd:YAG lasers resulted in complete clearing of the pigment without scarring, but revealed some preexisting textural changes. Use of the UltraPulse CO(2) laser smoothed the surface irregularities. CONCLUSION: The Q-switched pigment lasers are a useful modality for treating this pigment darkening reaction. As in this case, multiple treatment sessions with the laser may be necessary but the pigment can be expected to clear eventually without scarring. Any textural changes may be blended with the UltraPulse CO(2) laser with further improvement.     

Use of the Q-switched alexandrite laser (755 nm, 100 nsec) for eyebrow tattoo removal.

BACKGROUND AND OBJECTIVE: Permanent tattooing for cosmetic reasons has increased in recent years; as a consequence, there has been an increase of requests for pigment removal due to complications or undesired results. The Q-switched alexandrite laser has been found useful in removing black exogenous pigment, which is the most popular color in eyebrow enhancement. We report the case of a patient with black-pigment eyebrow cosmetic tattoo after treatment with the Q-switched alexandrite laser. STUDY DESIGN/MATERIALS AND METHODS: Treatment conditions included 755-nm wavelength, 100 +/- 10-nsec pulse width, and 3-mm spot size. Fluence threshold was determined, and a spot test was made at the first visit. Single impact technique with 10% overlapping was applied to the whole tattoo. Five treatments were performed with a mean fluence of 7 J/cm(2). RESULTS: Complete pigment removal was achieved after five sessions. Superficial bleeding and vesicle formation was observed. CONCLUSIONS: Eyebrow tattooing can be treated efficiently with the use of the Q-switched alexandrite laser when black pigment has been used for cosmetic reasons.     

Q-switched laser treatment of tattoos

In the last decade, Q-switched lasers have expanded the clinician’s ability to treat decorative, cosmetic and traumatic tattoos without scarring. Previous methods of gross tissue removal with resultant scarring have been replaced by the highly selective removal of tattoo pigment with minimal changes in skin texture or pigmentation. This article reviews use of the Q-switched ruby, Q-switched neodymium-yttrium-aluminum-garnet and Q-switched alexandrite lasers in the clinical management of patients with tattoos.     

Use of Q-switched alexandrite laser (755 nm, 100 nsec) for removal of traumatic tattoo of different origins

BACKGROUND AND OBJECTIVES: Q-switched laser systems have been used for removal of tattoo-related carbon, graphite, and other particles. We assessed elimination of traumatic tattoos of different origin with Q-switched alexandrite laser in nine patients. STUDY DESIGN/MATERIALS AND METHODS: Fluence threshold was determined and a spot test was made. Q-switched alexandrite laser, with a fluence range 4.5-8.0 J/cm(2) (mean, 7.16 +/- 1.18), was used at 4-5-week intervals. Total treatment ranged from 3-12 sessions (mean, 6.1 +/- 3.6 sessions). Double-pulse technique was used in black/black-bluish areas, but single-shot was applied to slate-gray pigment. RESULTS: More than 95% lightening was achieved in five patients after 5.2 +/- 2.3 sessions, and >75% lightening in six subjects after 6.1 +/- 3.1 sessions of treatment. Blacktop, surgical pen, and gravel tattoos presented a better response than gunpowder/fireworks tattoos (>95% vs. 68.7 +/- 23.9% clearance), or tattoos of unknown origin (>95% vs. 62.5 +/- 53% clearance). Epidermal splattering and pinpoint bleeding were observed in one case. No pigmentary alteration or scarring was seen. CONCLUSION: The Q-switched alexandrite laser is a useful system for removal of traumatic tattoos of diverse origin. The best response (>95% clearance) was achieved in blacktop, surgical pen, and gravel tattoos, although an acceptable degree of lightening may be obtained in tattoos due to gunpowder or fireworks.     

Role of the alexandrite laser for removal of tattoos

Background and Objective: The development of the Alexandrite laser for the removal of blue-black tattoos is described. Study Design/Materials and Methods: The responses of an animal study, using professionally tattooed skin and a human study involving 22 (professional and nonprofessional) blue-black tattoos, to the Alexandrite laser are reported. Results: Histopathologic evaluation of tattooed pig skin biopsies demonstrated the method of removal of dermal tattoo pigment. An average 11.6 treatments were required to remove completely the ten human blue-black professional tattoos compared to an average of 10.3 treatments to reach the same endpoint in six subjects with nonprofessional tattoos. Conclusion: Of significance was the fact that unlike the Q-switched Ruby and Nd: YAG lasers where punctate bleeding and tissue splattering have been reported to occur during laser tattoo removal, epidermal integrity was maintained during exposure of tattooed skin to the Q-switched Alexandrite laser at therapeutic fluences used. © 1995 Wiley-Liss, Inc.     

Clinical,histologic, and ultrastructural evaluation of tattoos treated with three laser systems

We examined the response of tattoo pigments treated with three commercially available lasers: Q-switched ruby, Q-Switched neodynium:yttrium, aluminum, garnet (Nd:YAG), and the alexandrite. Tattoos applied to hairless guinea pigs and treated with the aforementioned lasers were evaluated clinically, histologically, and ultrastructurally. Clinical evaluation showed red brown, dark brown, and orange pigment responded best to the Nd:YAG laser (1064 nm). The alexandrite laser was most effective for removing blue and green pigment, the Q-switched ruby laser was most effective for removing purple and violet pigment, and the NdYAG laser (532 nm) removed red pigment the best. Black pig ment was lightened equally with the Nd:YAG laser (1064 nm) and (532 nm) and the alexandrite laser (755 nm). No clinical scarring was observed; however, some colors turned black after treatment. Histologic and ultrastructural examination showed epidermal and dermal damage to be most evident after treatment with the Nd:YAG laser. Our study shows that certain tattoo pigments respond better to different laser systems. © 1994 WiIey-Liss, Inc.     

Q开关Nd:YAG激光低能量祛除21例文身疗效观察

目的:探讨Q开关Nd:YAG激光多次低能量祛除文身的临床疗效观察。方法:临床选取21例文身患者,治疗采用自身对比:A区为试验区,使用Q开关1064nm波长激光,光斑直径4～6mm,能量密度为2.0～4.0J/cm2,平行均匀照射1遍,术后即刻反应皮损变白霜,无皮肤出血点,每天治疗1次,连续治疗3～4次;B区为对照区,使用Q开关1064nm波长激光,光斑直径3～4mm,能量密度为5.0～8.0J/cm2,均匀照射1遍,即刻反应皮损灰白或皮肤出血。两组病例均于术后6个月观察疗效。结果:术后6个月观察,试验区:治愈9例(42.8%),显效12例(57.2%),无瘢痕形成;对照区:治愈3例(14%),显效5例(24%),好转13例(62%),2例(9.5%)出现轻度增生性瘢痕。结论:采用Q开关Nd:YAG激光多次低能量治疗文身的方法可加快文身消退病程,减少文身治疗中能量密度过大形成瘢痕或色素脱失的风险,为文身治疗提供一种新的治疗方法。     

Q-switch laser and tattoo pigments: first results of the chemical and photophysical analysis of 41 compounds

BACKGROUND AND OBJECTIVE: In the Western world, there are at least 20-30 million people with tattoos. Improved self-image and social stigmatization are the main reasons for removing tattoos from skin. Q-switched lasers are applied to destroy the tattoo compounds in the skin. The treatment of tattoos containing ink often gives excellent results, whereas the results of treatments for coloured tattoos are not predictable and usually are worse. The chemical structure and the absorption spectra of the tattoo pigments are usually unknown. However, the efficacy of the treatment by using light of different Q-switched lasers (wavelengths 510, 532, 694, 755, 1064 nm) is correlated to both the chemical structure of the tattooed compounds yielding specific absorption spectra and the laser wavelength used. STUDY DESIGN/MATERIALS AND METHODS: A structural and spectroscopic analysis of 41 coloured pigments was performed. RESULTS: The 41 substances were identified, and they consist of 16 individual chemicals of different structured well-known industrial organic pigments. The absorption spectra of the 16 pigments were measured quantitatively. CONCLUSION: The results of the present analysis explain to some extent the outcome of clinical studies regarding laser therapy of coloured tattoos. Because the laser energy used produces a high temperature in the azo or polycyclic pigments, it is necessary to investigate whether that change causes possibly toxic or cancerogenic compounds.     

Laser tattoo removal

The availability of Q-switched ruby Nd:YAG and alexandrite lasers has revolutionized the treatment of tattoos. These modalities offer significant advantages over all previously available treatments and are currently the standard of care for the cosmetic removal of unwanted tattoos.     

Treatment of Gunpowder Traumatic Tattoo by Q-Switched Nd:YAG Laser: An Unusual Adverse Effect

BACKGROUND: The Q-switched Nd:YAG laser can completely eliminate traumatic tattoos. OBJECTIVE: We report the results of the unsuccessful removal of traumatic tattoos among three patients with dermal inclusions of gunpowder who were shot at close range. METHODS: Treatment was tried in each patient with a Q-switched Nd:YAG laser at a medium fluence (4-6 J/cm2). RESULTS: During treatment of our patients, each pulse provoked sparks and the immediate formation of bleeding trans- epidermal pits. After the healing process was completed, we observed poxlike scars and the spreading of pigments in the skin around the initial points of the tattoo. CONCLUSION: We hypothesize that the rapid transfer of high-energy pulses to powder particles creates microexplosions of these fragments resulting in cavitation and provoking transepidermal holes and subsequent scars. This adverse effect was only produced if the tattoo resulted from gun powder being shot at a short distance from the skin.     

A case of labial lentigines in Peutz-Jeghers syndrome treated using a Q-switched alexandrite laser

Peutz-Jeghers syndrome (PJS) is a polygenic autosomal dominant disease characterized by multiple gastrointestinal polyps and pigmentation of the mucosa and skin. While there are a few reports regarding successful treatment of intestinal polyps in PJS, there is little research regarding treatment of mucocutaneous melanosis. This study investigated the many advantages of using a Q-switched alexandrite laser to treat mucocutaneous melanosis. In this case, a 19-year-old male with PJS presented with labial lentigines and received two Q-switched alexandrite laser treatments in 2018. Subsequently, the efficacy of the treatment was evaluated. The result of the evaluation was that, after the two laser treatments, the labial lentigines were successfully removed, and there were no complications.     

Multiple Color Changes Following Laser Therapy of Cosmetic Tattoos

OBJECTIVE: To emphasize the wisdom of small test areas when treating cosmetic tattoos and the need for multiple laser systems. METHODS: A 48-year-old woman requested removal of permanent makeup (cosmetic tattoos) of her eyebrows and around her lips. Physical examination revealed a brown tattoo of both eyebrows and dark red lip liner around both lips. A test area was performed on the red tattoo of the lips. A frequency-doubled Nd:YAG laser (532 nm, 2.0 J/cm2, 2 mm spot size) was used for the lip area, while the same laser at 1064 nm, 3.9 J cm2, 2 mm spot size was utilized for the eyebrows. The lip area immediately turned black. The patient returned for follow-up 1 month later; the black ink on the lip was treated with the same laser at 1064 nm, 3 mm spot size, 4.2 J/cm2, with satisfactory resolution in two monthly treatments. Both brown eyebrow turned bright orange and were treated with 532 nm, 3 mm, 3.0 J/cm2. One month later the eyebrows were a mixture of yellow ink and dark green. The yellow area was treated with 532 nm, 3 mm, 2.3 J/cm2, while the dark green was treated with the 1064 nm, 3 mm spot size, 4.2 J/cm2. One month later little improvement was noted, so Q-switched ruby laser at 694 nm, 6 mm spot size, 16 J/cm2 was utilized. An additional four monthly treatments were given utilizing a combination of both ruby and 532 nm ND:YAG lasers for green and yellow pigment, respectively. RESULTS: Significant but incomplete resolution of the tattoo ink was achieved. CONCLUSION: Multiple laser systems are needed to remove cosmetic tattoos. Test areas must be done before treatment.     

Minocycline-Induced Hyperpigmentation Treated with a 755-nm Q-Switched Alexandrite Laser

BACKGROUND: Cutaneous pigmentation associated with minocycline therapy is an unusual adverse effect for which few successful treatments have been described. The pigment changes may persist for years, despite cessation of therapy, and is often cosmetically disfiguring, causing significant embarrassment and psychological depression in those affected. Few safe and effective treatments have been described in the past; however, recent pigment-specific laser technology has shown promise in the treatment of this condition. OBJECTIVE: The objective was to describe a series of patients with minocycline-induced hyperpigmentation who were successfully treated with a 755-nm Q-switched alexandrite laser. METHODS: Six patients with minocycline-induced hyperpigmentation on the face or legs were treated with a Q-switched alexandrite laser on a bimonthly basis until pigmentation was eradicated. RESULTS: Cutaneous pigmentation resolved completely in all patients in an average of four laser sessions. Side effects were limited to transient purpura and mild desquamation without scarring or dyspigmentation. CONCLUSION: Minocycline-induced cutaneous pigmentation can be effectively cleared without risk of adverse sequelae by Q-switched alexandrite (755-nm) laser irradiation.     

Use of Onion Extract, Heparin, Allantoin Gel in Prevention of Scarring in Chinese Patients Having Laser Removal of Tattoos: A Prospective Randomized Controlled Trial

BACKGROUND: With rapid advancement in cutaneous laser therapy, Q-switched lasers have become the standard treatment for tattoo removal. The longer wavelength Q-switched Nd:YAG laser is used when removing tattoos in darker skin patients to avoid scarring and permanent pigment changes. Nevertheless, the local experience revealed that nearly 25% of the Chinese patients developed scarring. Meanwhile, multiple clinical studies have shown that Contractubex gel (Merz Pharma, Frankfurt, Germany) was effective in the treatment and prevention of hypertrophic scars and keloids. OBJECTIVE: To evaluate the efficacy of Contractubex gel in the prevention of scarring after laser removal of tattoos in Chinese patients. METHODS: A total of 120 Chinese patients with 144 professional blue-black tattoos were recruited into the study. They were randomly assigned into the Contractubex group or the control group. All patients were treated with a QS 1,064-nm Nd:YAG laser using a 3-mm spot size, a 10-Hz repeat rate, a pulse duration of 6 nanoseconds, and fluences that ranged from 3.6 to 4.8 J/cm2 (mean fluence, 4.2 J/cm2). The treated areas were assessed 3 months after the last treatments for clinical clearance and complications. RESULTS: Fifty-two patients with 61 tattoos in the Contractubex group were able to achieve a mean clearing rate of 82.3+/-11.6%. There were 7 tattoos in 7 patients that developed scarring, 4 patients had permanent hypopigmentation, and 3 patients had transient hyperpigmentation. In contrast, 55 patients with 68 tattoos in the control group had a mean clearing rate of 80.4+/-11.3%. Among them, 16 tattoos in 14 patients developed scarring, 4 patients had permanent hypopigmentation, and 5 patients had transient hyperpigmentation. Although there was no significant difference in age, sex, fluence, treatment session, and clinical clearance between the two groups, the Contractubex group had a statistically significantly lower rate of scarring than the control group (p<.05). CONCLUSION: Contractubex gel is effective in scar prevention in Chinese patients having laser removal of tattoos.     

The Kirby-Desai Scale: A Proposed Scale to Assess Tattoo-removal Treatments

Background: As tattoos have become increasingly popular in the Western world, tattoo-removal requests have also increased, as patients’ personal identities advance. Laser tattoo removal is the current treatment of choice given its safety and efficacy. However, due to varying types of tattoos, it has been difficult to quantify the number of laser treatments required with certainty when discussing laser tattoo removal with our patients. Objective: To propose a practical numerical scale to assess the number of laser tattoo-removal treatments necessary to achieve satisfactory results. Methods and materials: A retrospective chart review was performed on 100 clinic patients who presented for laser tattoo removal. An algorithm was proposed to assign a numerical score to each tattoo across six different categories (skin type, location, color, amount of ink, scarring, and layering). The cumulative score (Kirby-Desai score) is proposed to correlate with the number of treatment sessions required for satisfactory tattoo removal. Results: A correlation coefficient of 0.757 was achieved, with satisfactory tattoo removal in all subjects (N=100, p<0.001). Conclusion: We propose the Kirby-Desai scale as a practical tool to assess the number of laser tattoo-removal sessions required, which will translate into a more certain cost calculation for the patient.The art of tattooing has a long-dated history in civilization with origins dating back to 12,000 BC.¹ From ancient times to modern day, tattoos have gained increasing popularity among many demographic populations with current estimates of more than 20 million people (3–5% of the population) having at least one tattoo.^2,3 However, tattoos often become a personal regret, as up to 50 percent of adults older than 40 seek tattoo removal as a means to fix their tattoo quest.⁴ Lasers have been used to remove tattoos since the late 1970s and have in recent years become the mainstay for removal due to their high efficacy and low incidence of deleterious side effects. Although a patient’s decision to remove a tattoo is definitive, the logistical uncertainty remains—such as the number of treatments and whether laser tattoo removal will be successful—adding unwanted burdens on the patient.In this paper, we propose the Kirby-Desai scale to assess the potential success and number of treatments necessary for laser tattoo removal, assuming the medical practitioner is using a quality-switched Nd:YAG (neodymium-doped yttrium aluminum garnet) or Alexandrite laser incorporating selective photothermolysis with 6 to 8 weeks between treatments. This scale can be used by the physician during preconsultation to determine the number of treatments required for tattoo removal, decreasing the uncertainty of the laser-removal process. Currently, patients receive a poorly defined assessment of the number of treatments and often engage in the process without full awareness of the potential success. In the Kirby-Desai scale, numerical values are assigned to six parameters: skin type, location, color, amount of ink, scarring or tissue change, and layering. Parameter scores are then added to yield a combined score that will show the estimated number of treatments needed for successful tattoo removal. Tattoos scoring greater than 15 points may be difficult to remove and should be assessed by the physician to decide whether laser removal is the method of choice for the patient. The Kirby-Desai scale is the first proposed scale, to our knowledge, that enables physicians to have a thorough laser-removal assessment and hopefully aids in defining a more accurate treatment plan and improve patient satisfaction.     

Successful Treatment of a Cosmetic Tattoo Using a Combination of Lasers

BACKGROUND: Cosmetic tattoos are becoming more popular and are often composed of several colors. Tattoo pigments containing ferric oxide and titanium dioxide can change to a blue-black color after exposure to Q-switched lasers that can be permanent. OBJECTIVE: Using a patient who presented with rouge tattoos on the cheeks as an example, we describe a useful approach to laser treatment of cosmetic tattoos. METHODS: Test areas were done with the Q-switched Nd:YAG at both 532 and 1064 nm and with the pulsed-dye laser at 595 nm. RESULTS: Although an immediate blue-black color change occurred after treatment with the Nd:YAG at 532 and 1064 nm, sequential treatments at 1064 nm produced a near complete clearance of the tattoos. The pulsed-dye laser was used to remove subtle pink tones. CONCLUSION: Performing small test areas before complete treatment and using several laser wavelengths throughout the course of therapy are essential to the successful treatment of cosmetic tattoos.