Non-laser treatment for tattoo removal

Tattoos are increasingly gathering attention in the young population, especially in second to fourth decade of life. With such trends, rate of its removal also has been on the rise. Treatment options for tattoo removal besides lasers are surgery, radiofrequency, infrared light, cryotherapy, dermabrasion and salabrasion. Unfortunately, none of these procedures are associated with satisfactory cosmetic results due to adverse effects such as scarring and dyspigmentation. Although laser treatment has become the gold standard for tattoo removal, it is also associated with some limitations. Some tattoo inks are resistant to laser, and multiple sessions and multiple wavelengths may be required for its complete removal. Considering these limitations, other treatment modalities for tattoo removal must be explored. This article highlights the non-laser treatment options for tattoo removal. We reviewed all published literature identified from electronic databases (MEDLINE and PubMed) till August 2021 to highlight the non-laser treatment options for tattoo removal.     

Decorative tattoos and reasons for their removal: a prospective study in 151 adults living in South of France

Background Despite increasing demands for decorative tattooing in people of all ages, occupations and social classes, little is known regarding individuals’ characteristics and behaviour with respect to tattooing. Objective The objective was to describe a large sample of French people asking for tattoo laser removal, to investigate their reasons for being tattooed and for tattoo removal, and to identify groups of subjects sharing similar characteristics. Methods A prospective exploratory study was conducted on 151 consecutive subjects asking for tattoo removal. Results The study population was composed of 65 women and 86 men, aged between 18 and 60 years. The reasons mentioned for tattoo removal included aesthetic, social, employment, family or partner pressure, change of lifestyle or partner and incompatibility with present attitudes and values. Four profiles were identified. Types 1 and 3 correspond to subjects with amateur tattoos more frequently reporting social reasons for tattoo removal, whereas types 2 and 4 correspond to subjects with studio tattoos who more frequently report aesthetic reasons. Types 1 and 4 are mainly composed of men (aged over forty and under forty, respectively), type 2 of women under thirty and type 3 of subjects of either sex aged over forty. Conclusions These profiles could be used to target information campaigns about tattooing and tattoo removal techniques to avoid unwanted tattoos, and afterwards, possible disappointment after removal, as well as to target education programs on possible health risks. Furthermore, our findings open the way to focus further studies on more homogenous group of tattooed subjects.     

Patient compliance as a major determinant of laser tattoo removal success rates: A 10-year retrospective study

Abstract

The use and success of high-energy, short-pulse, Q-switched lasers for tattoo removal has been well demonstrated. Three types of lasers are currently commercially available for tattoo removal: the Q-switched ruby laser (694 nm), the Q-switched alexandrite laser (755 nm) and the Q-switched Nd:YAG laser (532 nm and 1064 nm). Multiple parameters such as tattoo type, color, location, and patient skin type dictate which laser is optimal in each patient. Despite the demonstrated efficacy of these modalities, there are few papers that address some of the long-term issues of tattoo removal, such as patient compliance, and how these issues impact on the success rates of optimal tattoo removal treatments. In this retrospective study, 10-year data from a single center are presented. Our data include parameters such as clearance rates, number of treatments, wavelength of the utilized laser, and fluence and spot-size setting. In addition, potential complications such as scarring, hypopigmentation, and pain were analyzed. Finally, we examine the patient compliance that accompanied tattoo removal and the reasons behind the typically low success rates for total tattoo clearance.     

Paradoxical darkening and removal of pink tattoo ink

It is widely accepted that Q‐switched lasers are the gold‐standard treatment for the resolution of unwanted tattoo ink. Although much safer than other tattoo removal modalities, the treatment of tattoo ink with Q‐switched devices may be associated with long‐term adverse effects including undesired pigmentary alterations such as tattoo ink darkening. Darkening of tattoo ink is most often reported in cosmetic, flesh‐toned, white, peach, and pink tattoos. In this paper, we briefly review a case of pink tattoo ink that initially darkened paradoxically but eventually resolved with continued Q‐switched laser treatments.     

Combination of CO2 and Q-switched Nd:YAG lasers is more effective than Q-switched Nd:YAG laser alone for eyebrow tattoo removal

Background: The eyebrow tattoo removal using Q-switched lasers is usually prolonged. Other modalities may be required to enhance the efficacy and shorten the treatment course. Objective: To compare the efficacy of Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser alone versus combination of Q-switched Nd:YAG and Ultrapulse CO₂ lasers for eyebrow tattoo removal after a single session. Patients and methods: After local anesthesia, the right eyebrow of 20 patients was treated with Ultrapulse CO₂ laser with the parameters of 4 J/cm² and 3.2 J/cm² for the first and the second passes. Both eyebrows were then treated with 1064-nm and 532-nm Q-switched Nd:YAG laser. The spot size and pulse duration were 3 mm and 5 nanoseconds for both wavelengths, and the fluence was 7 J/cm² for 1064 nm and 3 J/cm ² for 532 nm. Results: The side treated with combination of Q-switched Nd:YAG and CO₂ lasers improved 75–100% in 6 of 20 patients versus only 1 of 20 in the side treated with Q-switched Nd:YAG alone. Similarly, the right side in 13 of 20 patients showed more than 50% improvement with combination therapy versus the left side (the monotherapy side), where only 6 of 20 cases showed more than 50% improvement. The Mann–Whitney test was 2.85 for the right side and 1.95 for the left side (P value = 0.007). Conclusion: Using Ultra pulse CO₂ laser enhances the efficacy of Q-switched Nd:YAG laser in eyebrow tattoo removal.     

Q-开关Nd:YAG激光治疗3种文刺疗效观察

目的：评价Q-开关Nd：YAG激光治疗3种文刺的疗效。方法：采用Q-开关Nd：YAG激光治疗文眉251例、文眼线59例、文身101例，并对治疗效果作统计学分析和比较。结果：应用Q-开关Nd：YAG激光治疗3种文刺，随着治疗次数增多，疗效增加，文眉组疗效优于文眼线组，文眉、文眼线组优于文身组。结论：Q-开关Nd：YAG激光是治疗文刺的有效手段，安全可行，不良反应小，疗效与文刺的深度和染料的成分和数量有关。     

Reasons for requesting laser removal of unwanted tattoos

Laser removal of tattoos is not generally or readily available on the National Health Service and removal in privately run clinics is expensive. For those seeking removal of their tattoo this can create significant financial hardship. We investigated the psychological, social and financial impact of tattoos on the lives of those patients requesting laser removal. Sixty-eight patients with a mean age of 36 years participated. Twenty-seven (40%) had one tattoo, whereas eight (12%) possessed 10 or more; 54% had an amateur tattoo. Only 18% had received an explanation of the procedure or side-effects. The mean age at application of the first tattoo was 16 years; 48 (71%) were tattooed below the legal age limit of 18 years. Most tattoos were applied for the sake of fashion. The median duration of regret was 14 years before seeking removal. The main reasons for removal were enhancement of self-esteem and social, domestic and family reasons. In those patients attending for removal, most tattoos are applied impulsively and inexpensively in youth. They are often regretted for decades and create significant psychological, social and financial burdens.     

Combined pulsed dye laser and Q‐switched Nd:YAG laser intraumatic facial tattoo removal: A case series

Traumatic tattoos can be treated with several methods, including mechanical and chemical devices. However, they are rarely used due to the high risk of permanent side effects such as scarring and depigmentation. Recently, laser devices, especially the Q‐switched (QS) laser and the pulsed dye laser (PDL), applied in combination, have achieved complete clearance of the lesions without any risk of side effects. Herein, we reported three cases of traumatic facial tattoos successfully treated with combined PDL and QS Nd:YAG laser.     

Q‐switched Nd:YAG laser for cosmetic tattoo removal

Laser is a widely accepted tool for tattoo removal, with standardized treatment protocols. Nevertheless, cosmetic tattoo removal may be challenging, because tattoos are performed in proximity of “sensitive” areas and because the ink used in cosmetic tattoos may contain substances that are not standardized and may modify their color at a high temperature. In this case series, we aim to evaluate the effectiveness of Q‐switched (QS) Nd:YAG laser for cosmetic tattoo removal. Our study included 20 patients with cosmetic tattoos of lips, eyebrows, and eyeliners treated with QS Nd:YAG laser. Before treatment, an accurate preoperative assessment was performed, taking into account both patient and tattoo characteristics. Complete tattoo removal was obtained in all the cases and no major complications occurred. Adverse events were mild, mostly represented by erythema. All patients reported a high level of satisfaction. Selective photothermolysis enables complete tattoo removal, even in the case of cosmetic tattoos. However, cosmetic tattoos require a personalized treatment based on an accurate preoperative assessment which takes into account both patient and tattoo characteristics. QS Nd:YAG laser may be considered a good choice in the treatment of cosmetic tattoos, because it enables complete removal with acceptable secondary effects.     

Treatment of traumatic tattoo with the Q‐switched Nd:YAG laser

Traumatic tattoos are undesirable tattoos caused by different foreign bodies such as fireworks' particles, sand, metals, glass, gunpowder, asphalt, dust, or petroleum products embedded forcefully in the dermis. We report the case of a 54‐year‐old man who presented with sand and asphalt tattooing on his face following a bomb explosion 15 years ago. Q‐switched Nd:YAG laser at a wavelength of 1064?nm with a spot size of 4?mm and a fluence of 7.96?J/cm² were applied to treat the patient. The patient tolerated the treatment very well. Most of the blue dots became whitened immediately after the procedure and remained almost clear after a 6‐month follow‐up.     

Laser hair removal

The extended theory of selective photothermolysis enables the laser surgeon to target and destroy hair follicles, thereby leading to hair removal. Today, laser hair removal (LHR) is the most commonly requested cosmetic procedure in the world and is routinely performed by dermatologists, other physicians, and non-physician personnel with variable efficacy. The ideal candidate for LHR is fair skinned with dark terminal hair; however, LHR can today be successfully performed in all skin types. Knowledge of hair follicle anatomy and physiology, proper patient selection and preoperative preparation, principles of laser safety, familiarity with the various laser/light devices, and a thorough understanding of laser-tissue interactions are vital to optimizing treatment efficacy while minimizing complications and side effects.     

Erbium:Yag laser therapy of lichenoid red tattoo reaction

Delayed reactions caused by red tattoo pigments are often difficult to treat. We report a 31-year-old female patient with a lichenoid reaction to a red tattoo on the right ankle who was successfully treated with five sessions of a surgical Erbium:Yag laser, using several passes in each session. Our work leads us to consider that Er:Yag laser therapy may be an effective and safe treatment for these therapeutically challenging reactions.     

A rapid tattoo removal technique using a combination of pulsed Er:YAG and Q-Switched Nd:YAG in a split lesion protocol

Background: Tattoo removal has evolved over the years and though Q-switched laser is the ‘workhorse’ laser, it invariably requires multiple sittings, which are dependent on numerous factors, including the skin colour, location of the tattoo, age of the tattoo, colour of pigment used, associated fibrosis and the kind of tattoo treated. Though ablative lasers, both pulsed CO2 and Er:YAG, have been used for recalcitrant tattoos, very few studies have been done comparing them with pigment-specific lasers. Our study was based on the premise that ablating the epidermis overlying the tattoo pigment with Er:YAG could help in gaining better access to the pigment which would enable the Q-switched laser to work effectively with less beam scattering. Objective: A study of rapid tattoo removal (RTR) technique using a combination of pulsed Er:YAG and Q-Switched Nd:YAG in a split lesion protocol. Materials and methods: This prospective study was undertaken during 2010–13 at a laser Clinic in the Maulana Azad Medical College, New Delhi. A total of 10 patients were recruited, 5 of amateur tattoo and 5 of professional tattoo. After informed consent each tattoo was arbitrarily ‘split’ into two parts. One part was treated with QS Nd:YAG laser(1064 nm) and the other part with Er:YAG laser immediately followed by the QS Nd:YAG. The laser treatments were repeated at 6-week intervals until the tattoo pigment had cleared. On the combination side in subsequent sittings only the QS Nd:YAG was used, to minimize repetitive ablation. To ensure consistency in the intervention methods a trained dermatologist who was independent of the treatment delivery randomly rated 10% of the procedures. Results: The mean improvement achieved by the Q-switched laser (2.93) was less than the combination laser (3.85) side (p = 0.001) and needed more sessions (3.8 vs. 1.6; p = 0.001). There was a statistically significant difference in the improvement on the combination side till the second session. On the combination side patients required a maximum of 2 sessions, while the Q-switched laser required 3–5 sessions for appreciable lightening. Conclusion: From our study it was concluded that use of a pulsed ablative laser may help in rapid removal of tattoos in conjunction with QS lasers with minimal side effects and can be used as a RTR.     

Comment on: Tattooing of skin results in transportation and light-induced decomposition of tattoo pigments

Abstract:  Decorative tattoos have become a common feature of many societies. Their popularity appears mainly driven by fashion, and scant attention has been paid to any associated risk. The risks can be associated either with the tattooees' proclivity for risk taking in general, or with the substances used in the tattoos.
It is well established that tattoo pigments wander widely in the body after they have been injected, and research now suggests that azo pigments may become mutagenic after exposure to either natural light or laser light. This may not only affect the risk profile of tattoos themselves, but also tattoo removal using lasers.     

A retrospective analysis of the influencing factors and complications of Q-switched lasers in tattoo removal in China

Background and objective: Q-switched (QS) lasers are the gold standard for tattoo removal. The purpose of the present study was to gain a more comprehensive understanding of the factors that influence the efficacy of QS lasers and their associated complications in the removal of tattoos in China. Patients and methods: Clinical data of 266 patients were analyzed retrospectively. The tattoo clearance rate was evaluated using the 4-point scale. The Cox regression model was applied to analyze the factors that affected the efficacy of QS lasers in tattoo removal. In addition, treatment-related adverse reactions were analyzed. Results: The results showed that several variables had a statistically significant effect (p < 0.05) on the efficacy of QS laser-mediated tattoo removal treatment, including the patients’ age, the tattoo’s age, type, color, or ink density and the number of treatments. A variety of adverse responses occurred during the laser treatment. The overall incidence of adverse responses was approximately 24.06%, including pigmentation, hypopigmentation, bulla formation, allergic reactions, and skin texture changes or hypertrophic scarring. Conclusion: Some factors may influence the efficacy of QS lasers in the treatment of tattoos and certain adverse reactions may occur during this process.     

Red ink tattoo reactions: successful treatment with the Q-switched 532 nm Nd:YAG laser

BACKGROUND: In the South-west Thames region there were an unprecedented number of lichenoid tattoo reactions to red ink in patients who had visited a local tattoo parlour. The red ink was found to contain mercuric sulphide, a compound known to cause allergic reactions. Topical Dermovate (clobetasol propionate 0.05%, GlaxoWellcome) ointment alone had little impact. OBJECTIVES: To investigate whether the Q-switched 532 nm Nd:YAG laser could produce permanent flattening of the reaction. METHODS: This was an open nonrandomized clinical trial. Biopsies were taken from the lichenoid areas within the tattoos. Subjects were patch tested to 1% ammoniated mercury in petrolatum prior to treatment with the Q-switched 532 nm Nd:YAG laser. Laser treatments were delivered at 6-weekly intervals by a single operator. Patients also applied topical Dermovate between treatments. Therapy was discontinued when the lesions flattened. Clinical photographs were assessed at baseline and prior to each laser treatment. RESULTS: Seven patients with Fitzpatrick skin types I-III were enrolled in the study (four females, three males, mean age 39 years). All patients completed the trial. Patch testing to mercury was universally negative at 48 and 96 h. Substantial flattening and depigmentation of the red ink within the tattoos was noted after six laser treatments. No adverse effects were recorded. CONCLUSIONS: The Q-switched 532 nm Nd:YAG laser in combination with topical Dermovate ointment is a safe and effective method of treating red ink tattoo reactions.     

Laser complications: Hair removal

The increasing use of laser and light source‐based hair removal techniques has led to not only an increased incidence of reported complications, but also to a better understanding of the cause of such complications. The objective of this article was to provide an understanding of the incidence and the etiology of complications following laser/light‐based hair removal. In conclusion, almost all complications following laser/light‐based hair removal techniques can be prevented with a thorough understanding of the thermally induced effect of such treatment on the hair follicle and epidermal melanin. Some newly described complications may have a variety of etiologic factors.     

Cutaneous lymphoid hyperplasia (pseudolymphoma) in tattoos: a case series of seven patients

Background Cutaneous lymphoid hyperplasia (CLH or pseudolymphoma) is considered a rare complication occurring in tattoos. We analysed the demographics, clinical features, histological aspects, allergy tests, outcome and therapeutic data of CLH in tattoos performed by a professional in a series of patients. Methods We conducted a retrospective chart review of seven patients managed in private practice of dermatology all over France from 2001 to 2007. Results Reactions occurred within 2 years after tattooing, were non‐specific (pruritus, swelling, infiltration) and mainly restricted to red. Photosensitivity was noted in two cases. Histology was characteristic of pseudolymphoma with a T‐cell predominance in all cases. Surgery (2 cases) and laser removal (2 cases, CO2 and QS‐532 nm) were efficient, while local corticosteroids were not. One patient had spontaneous clinical remission after 2 years of evolution. Conclusions This is the largest series of CLH occurring in tattoos. This delayed hypersensitivity reaction may be underestimated and triggered by a specific immunogenic compound of the ink. Its management remains difficult.