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.     

Transient immunoreactivity after laser tattoo removal: report of two cases

BACKGROUND AND OBJECTIVE: Laser tattoo removal is one of most commonly used indications for medical lasers. Professional tattoos contain a multitude of potentially immunogenic chemicals that are released or modified by laser treatment. We studied potential immunologic reactions following laser tattoo removal. STUDY DESIGN/PATIENTS AND METHODS: Case report of two patients with immunologic reactions after laser tattoo removal. RESULTS: Two patients developed transient immunoreactivity that presented as regional lymphadenopathy after laser tattoo removal of professional black and blue-green tattoos. These reactions resolved without any complications. CONCLUSIONS: Tattoo pigments released or modified by laser therapy may trigger transient immunoreactivity in susceptible individuals.     

Treatment of Large Bulla Formation after Tattoo Removal with a Q-Switched Laser

Widely considered the gold standard treatment option for tattoo removal, the use of Q-switched lasers may very rarely result in the formation of large bulla. While very disconcerting to patients, these lesions are easily managed and, with proper care, heal quickly with no long-term consequences. The authors present three cases of patients who had bullous reactions shortly after receiving Q-switched laser treatment of tattoo ink. Bullous formation in all three patients was treated successfully.It is well established that Q-switched lasers are the gold-standard treatment for tattoo ink removal.^1,2 While some unwanted side effects may be associated with the treatment, it is important to distinguish between transient adverse events and true treatment complications. In this article, the authors present three patients who had bullous reactions shortly after receiving Q-switched laser treatment of tattoo ink. All three patients experienced an excellent, nonscarring recovery.     

An Internet-based survey on characteristics of laser tattoo removal and associated side effects

Tattoo removal by laser therapy is a frequently performed procedure in dermatological practices. Quality-switched ruby, alexandrite, or Nd:YAG lasers are the most suitable treatment devices. Although these techniques are regarded as safe, both temporary and permanent side effects might occur. Little has been published on the frequency of complications associated with laser tattoo removal. We performed an Internet survey in German-speaking countries on characteristics of laser tattoo removal and associated side effects. A total number of 157 questionnaires entered the final analysis. Motivations for laser tattoo removal were mainly considering the tattoo as youthful folly (29 %), esthetic reasons (28 %), and 6 % indicated medical problems. One third of participants were unsatisfied with the result of laser tattoo removal, and a complete removal of the tattoo pigment was obtained in 38 % only. Local transient side effects occurred in nearly all participants, but an important rate of slightly visible scars (24 %) or even important scarring (8 %) was reported. Every fourth participant described mild or intense tan when the laser treatment was performed, and the same number of people indicated UV exposure following laser therapy, which should normally be avoided in these circumstances. As reported in the literature, nearly half of the participants experienced hypopigmentation in the treated area. Our results show that from the patients’ point of view there is an important rate of side effects occurring after laser tattoo removal. Appropriate pretreatment counseling with regard to realistic expectations, possible side effects, and the application of test spots is mandatory to ensure patient satisfaction. Laser treatment should be performed by appropriately trained personnel only.     

Topical imiquimod in conjunction with Nd:YAG laser for tattoo removal

The purpose of this study is to evaluate the efficacy of tattoo removal using topical imiquimod 5% cream in conjunction with the 1,064-nm Nd:YAG laser. This procedure for tattoo removal will be compared to laser treatment alone, which is the standard for cosmetic removal of tattoos. Previous studies have linked partial tattoo removal to imiquimod application in a guinea pig model. Methods: This was a small-sized, double-blinded, placebo-controlled trial with patients with Fitzpatrick skin types I-IV (light skin) who were 18–65 years of age. The patients were required to have had two tattoos of similar age and dark blue or black in color in areas that can be covered by clothing. There were four visits in total, with laser treatment and photography being performed on the first visit. Laser settings were with 1,064-nm Nd:YAG with a 10-ns pulse, 3-mm spot size, and 4 J of energy, a standard laser used for tattoo removal. During the second visit, tattoos were randomized and chosen to receive either the laser-imiquimod treatment course or laser-vehicle cream treatment. The patients returned 1 month after the completion of cream application (week #10) and 2 months after the completion of treatment with cream (week #14) for final evaluation and photographing. Results: Three patients were enrolled in this study. All of them are Fitzpatrick skin type IV. All of the patients were compliant with the drug application and have good tolerability with only mild pruritus without changing of vascularity or pigmentation. None of the patients had ulceration or scar development during the cream application. Conclusions: imiquimod plus laser therapy demonstrated a more favorable outcome when evaluated by the investigators or subjects. The mean scores for tattoo clearance from baseline to 2 months after completion of treatment with 5% imiquimod cream versus placebo cream were 4.3 versus 2.7 as rated by investigators and 4.7 versus 2.3 as rated by subjects. No textural changes were observed after therapy and were not shown to be different between the two groups. Further large-scale studies are important in developing a role for the use of imiqumod in laser-assisted tattoo removal.     

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.     

Histologic Evaluation of a Q-Switched Nd:YAG Laser in the Nonablative Treatment of Wrinkles

BACKGROUND: A variety of nonablative dermal remodeling techniques are currently available. The Q-switched Nd:YAG laser, in addition to its role in tattoo removal, hair removal, and vascular and pigmented lesion treatment, may also play a role in dermal remodeling for the treatment of wrinkles. The histologic changes seen in human skin after Q-switched Nd:YAG laser exposure have yet to be evaluated. OBJECTIVE: To study histologic changes after the use of a Q-switched Nd:YAG laser in the nonablative treatment of photoaged skin. METHODS: Sun-damaged infrauricular skin from six female subjects was exposed to a Q-switched Nd:YAG laser at fluences of 7 J/cm2 with two laser passes. Histologic examinations were performed before laser treatment and 3 months later. RESULTS: Biopsy specimens showed slight fibrosis in the superficial papillary dermis with unremarkable epidermal changes. CONCLUSION: The Q-switched Nd:YAG laser produced morphologic changes similar to, but lesser in degree, than those seen with both CO2 and Er:YAG laser resurfacing.     

Destruction of tattoo by ruby laser]

The originality of tattoo destruction by ruby laser is to selectively treat the tattooed areas without injuring the surrounding normal cells, in order to obtain better healing. Therefore, we selected a red laser (ruby, emitting at 694.3 nm), with very short flashes (100 ns with self Q switched ruby laser). Ruby laser spots of about 1 cm diameter are delivered to on the area to be treated. As the black particles of the tattoo absorb more laser energy than the surrounding pale-pink skin (140 Mw/cm2, i.e. 14 j/cm2), we can obtain quite localized destruction and better healing. The beam is focussed on one point of the tattoo with a sighting neon-helium laser. In view of the very short impact, the energy absorbed by the pigmented particles diffuses minimally to adjacent tissues. After the crust falls, carrying away some tattoo pigment on its deeper surface, a pale-pink scar forms, then gradually fades in several months. With thick tattoos, it is necessary to proceed in layers and to plan a course of several treatments about one month apart. Compared with the other methods of tattoo removal (dermabrasion, salt, CO2 laser), ruby laser gives the best cosmetic results, even in keloid prone areas.     

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.     

Q开关Nd:YAG激光治疗不良眼线疗效评价

目的：评价Ｑ开关Ｎｄ：ＹＡＧ激光对不理想眼线文饰的疗效。方法：以质量分数描述疗前疗后不理想眼线文饰的表现，以积分下降比率确定疗效。结果：８２例求治者治疗前总积分（３６７分）与治疗一次后总积分（２０８分）８２例最后痊愈：２３例，显效：５１例，无效：８例。经统计学处理，差异有显著性意义（ｔ＝３．６５ Ｐ〈０．００１）。激光能量大小的选择、接受治疗次数与眼线的颜色有关。结论：Ｑ开关Ｎｄ：ＹＡＧ激光对去除     

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.     

Laser-Assisted Tattoo Removal with Topical 5% Imiquimod Cream

BACKGROUND: Laser-assisted tattoo removal is effective but can be costly and time-consuming and can result in disfiguring scars and pigment alterations. Imiquimod, an immune response modifier, may play a role in tattoo removal. OBJECTIVE: The objective was to evaluate the safety and efficacy of topical 5% imiquimod cream used daily in conjunction with laser therapy to remove unwanted tattoos. MATERIALS AND METHODS: Twenty subjects with two similar tattoos were enrolled in this randomized, prospective, double-blinded, case-controlled study. Tattoos were treated with either imiquimod or placebo daily and laser therapy every 4 to 6 weeks for a total of six sessions. The primary efficacy parameter was tattoo clearance (5-point scale, poor through complete). Secondary efficacy parameters included textural changes (5-point scale, minimal through severe), pain during and between laser procedures, and undesirable pigment alterations. RESULTS: Nineteen subjects completed the study. The mean score for tattoo clearance with imiquimod versus placebo was 3.2 versus 2.9 and, for textural changes, was 1.37 versus 1.21 (differences not statistically significant). There was no difference in subjective pain during and between laser sessions and no undesirable pigment alterations were reported. Adverse reactions were more frequent with imiquimod compared to placebo. CONCLUSION: Topical imiquimod is an ineffective adjunct to laser-assisted tattoo removal.     

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.     

Tattoo removal by grafting enzymatically separated epidermis

A novel method of tattoo removal in which the enzymatically separated epidermis of an excised tattoo was grafted in situ was applied to 3 patients. Unlike the conventional skin-grafting procedure, this method resulted in the complete obliteration of the tattoos without donor site scars. In 1990, Hosokawa and colleagues first reported a technique similar to the one described, but the enzymatic process required surgery to be performed over two consecutive days and, thus, it did not become an established procedure. A modification of Hosokawa's method enabled the authors to reduce the enzymatic processing time to an hour using Dispase. The thinning of the tattooed skin using a Paget's-type dermatome before its exposure to an enzymatic solution facilitated the enzyme's infiltration of the basal layer of the epidermis. Hence, the time taken for the epidermis to separate from the tattooed skin was markedly shortened. Although laser removal continues to be the optimal treatment method, skin grafting or other abrasive procedures, including dermabrasion and cryosurgery, are still necessary for those patients who want complete tattoo obliteration over a shorter time frame and at less expense. In these patients the authors recommend that their procedure be offered as an alternative treatment to laser removal.     

The "chemo-laser" technique for the treatment of decorative tattoos: a more complete dye-removal procedure

A technique embodying the use of chemical agents and the argon laser was developed in the 1981-1982 that provides for a more complete removal of tattoo dye with one treatment. The number of visits for the laser treatment to the patient is reduced to two or three treatment sessions, compared to five to eight visits previously required. The area of "chemo-laser" approximated the normal skin without hypertrophic scar tissue more than the areas of multiple or heavy laser treatment.     

A novel titanium sapphire picosecond‐domain laser safely and effectively removes purple,blue, and green tattoo inks

Background

Green, blue, and purple tattoo pigments are often the colors most resistant to laser removal. Recently, the first ever production picosecond‐domain laser with a 785 nm wavelength was developed to improve the rate of clearance of green, blue, and purple tattoo inks.

Methods

Twenty‐two tattoos from 15 subjects with skin phototypes II–IV were enrolled in the study. A total of four treatments were administered using a single 785 nm picosecond‐domain laser wavelength. Blinded assessment of digital, cross‐polarized photographs taken approximately 8 weeks following the last treatment was performed using an 11‐point clearance scale.

Results

Fourteen subjects with 21 tattoos completed all study visits. The 21 tattoos contained the following pigments: black (n = 15), green (n = 13), blue (n = 8), yellow (n = 5), purple (n = 4), and red (n = 3). Treatments were performed with a 2‐4‐mm beam diameter and fluences ranging from 1.1 to 3.1 J/cm². Blinded assessment of photographs found 85%, 81%, 74%, 61%, 11%, and 5% clearance from baseline photos for purple, blue, green, black, red, and yellow pigments, respectively. Treatments were well tolerated with typical erythema, edema and one case of pinpoint bleeding. No scarring was noted.

Conclusion

This first study of a new 785 nm picosecond‐domain laser demonstrates safe and effective removal of multicolor tattoos. Although clearance was shown for a multitude of colors including black, the 785 nm laser wavelength has special affinity to purple, blue and green tattoo pigments. Lasers Surg. Med. 50:704–710, 2018. © 2018 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.     

CO2 Laser Treatment of Epidermal Nevi: Long-Term Success

BACKGROUND: Epidermal nevi have been notoriously difficult to treat due to their large size and often conspicuous location. Variable results have been obtained with different laser treatments, and scarring and/or incomplete removal is typical after excisional or other destructive modalities. OBJECTIVE: To outline the successful use of a short-pulsed CO2 laser in the long-term eradication of epidermal nevi in three patients. METHODS: Three females (ages 15-19) presented with extensive grouped verrucous papules and plaques on the face, trunk, and extremities. A pulsed CO2 laser was used to vaporize the lesions using a 500 mJ pulse energy, 3 mm spotsize, and 7 watts of power. RESULTS: All lesions healed without incident. No lesional recurrence was observed 10 to 13 months after treatment except in one small area on the ankle in one patient. CONCLUSIONS: Carbon dioxide laser vaporization of epidermal nevi provides good clinical effect and offers unique advantages for the treatment of these lesions, including effective intraoperative hemostasis with excellent lesional visualization. It is also possible to treat widespread areas in one laser treatment session. While the results of this series clearly show the benefit of CO2 laser treatment, epidermal nevi may not always respond so favorably, due in part to the variability in their depths of involvement.     

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.     

Temporary dermal scatter reduction: quantitative assessment and implications for improved laser tattoo removal

BACKGROUND AND OBJECTIVES: Temporary dermal clearing, i.e., reduction in the attenuation coefficient of the dermis and epidermis, may lead to improved laser tattoo removal by providing increased efficiency of laser delivery to embedded ink particles and enabling the use of shorter wavelength visible lasers more effective on certain inks. STUDY DESIGNS/MATERIALS AND METHODS: In a hairless guinea pig model of human tattoo, we tested both intradermal and transdermal application of glycerol, using visual inspection, spectral analysis, and optical coherence tomography techniques to assess effectiveness. In controlled experiments, we compared the outcomes of single laser treatment sessions for both cleared and uncleared tattoo sites using Q-switched 755 and 532 nm lasers on three different inks. RESULTS: Intradermal injection of clearing agents induced dermal clearing but resulted in necrosis and scar. Transdermal application of clearing agents resulted in moderate reversible clearing, which was localized to the superficial layers of the skin and did not result in complications. Statistically significant differences in laser treatment outcome were observed relative to a number of treatment parameters including the treatment of certain tattoos by short wavelength lasers. CONCLUSIONS: Temporary clearing of superficial skin layers may be performed in an apparently safe and reliable manner. Clearing should lead to increased penetration of laser light to tattoos and should, therefore, increase treatment efficiency. Further study is needed to determine the degree to which this change is of clinical value.     

Using a Side Effect to Therapeutic Advantage: The Darkening of Red Eyebrow Tattoo Pigment Following Q-Switched Laser Treatment

BACKGROUND: Q-switched lasers are commonly used to achieve tattoo removal, utilizing the principle of selective photothermolysis. However, certain tattoo pigments may darken following laser pulsing. OBJECTIVE: To determine whether this side effect can be used to therapeutic advantage in a woman who previously had her eyebrows enhanced with a dark tattoo that spontaneously changed to a reddish hue over time. METHOD: The woman's eyebrows were pulsed with the Q-switched Nd:YAG laser at both 532 nm and 1064 nm. RESULTS: The test areas pulsed with the 1064 nm laser revealed partial clearing. However, 532 nm Q-switched Nd:YAG pulses produced darkening of tattoo pigment both at the test sites and in the subsequent treatment. CONCLUSION: Q-switched lasers can produce darkening of red tattoo pigment. In some cases this side effect can be used to therapeutic advantage.