Tattoo Removal: 5 Things to Know

Nazanin Saedi, MD

Disclosures

March 12, 2020

Nazanin Saedi, MD

To say that the number of people getting tattoos has increased is a huge understatement. A 2019 survey found that almost 30% of Americans reported having at least one tattoo, and that percentage was higher among younger individuals. Although the vast majority—92%—reported that they had no regrets, the growing numbers of people getting tattoos means we're all likely to encounter a patient in that 8% asking about removing their body art.

Nazanin Saedi, MD, director of the Laser Surgery and Cosmetic Dermatology Center at Jefferson University Hospitals in Philadelphia, discusses five things to know that will help you answer your patients' questions.

1. Are All Tattoos the Same?

No. There are five different subtypes of tattoos, and the likelihood of successfully treating—or "removing," in lay terminology—them varies by type. There are:

Professional tattoos: Professional tattoos are placed by professional tattoo artists, typically using a vibrating needle. The pigment tends to be deposited more deeply than is the case with amateur tattoos. This deeper pigment often makes them more challenging to remove.

Amateur tattoos: Amateur tattoos are placed by nonprofessionals, often by hand or with a needle. They are usually black in color. Because other chemicals are often mixed into these inks, not all are "pure" ink, and those other products affect how successful removal of these tattoos will be.

Traumatic tattoos: Traumatic tattoos are caused by a foreign substance entering the skin. This is often something like gunpowder or residual from the road (dirt, gravel, asphalt). These injuries are treated—with varying success—using the same modalities as those used to remove other types of tattoos.

Medical tattoos: Medical tattoos can be placed to identify sites for radiation therapy but can also be placed after reconstructive surgery, such as an areolar tattoo. Whereas some patients choose to keep these visible reminders of medical treatment to memorialize their struggle, others want to forget about it. A national philanthropic campaign supported by the American Society for Laser Medicine & Surgery, called New Beginnings, provides free radiation mark removal for patients with cancer.

Cosmetic tattoos: Cosmetic tattoos are placed as permanent makeup (eyebrows, lip margins). These, too, are sometimes removed at the request of a patient not happy with this decision.

2. Are All Lasers the Same?

In a word, no. Two types of lasers are used to treat tattoos:

QS lasers generate nanosecond bursts of laser light that break apart tattoo pigment in the dermis. This results in very rapid heating and causes shattering of tattoo particles. The shattered pigment fragments either remain in the dermis, where they are slowly resorbed, or are removed by the lymphatic system. Tattoo fragments removed lymphatically are then sequestered in lymph nodes and subsequently cleared.

Picosecond lasers have pulse durations in the picosecond range (one trillionth of a second). Picosecond laser treatments cause significant photomechanical effects that lead to mechanical breakup of the pigment particles. These particles are smaller than those produced by QS lasers and are easier for the body to clear.

Although it was initially thought that picosecond lasers would replace QS lasers, there is currently no good evidence that picosecond lasers are significantly better. Lasers with longer pulse durations, or lasers that emit their energy over a longer period, can cause scarring to the area and should not be used. Because of the myriad factors that can affect the success of tattoo treatment, trials directly comparing different lasers are difficult to conduct and the results often cannot be widely applied to other populations.

3. When Is the Best Time to Remove a Tattoo?

Sometimes people decide that they want to be rid of an impulsively acquired tattoo almost immediately. Unfortunately, it's not that simple or quick. Typically, I suggest to my patients that it is best to wait at least 6-8 weeks before beginning tattoo treatment. Tattoos that have been present for longer than 3 years, which allows more time for the pigment to settle deeper into the dermis, as well as those placed on extremities can be harder to treat. In my experience, most people will need more than six to eight treatments spaced 6-8 weeks apart. It's important to be sure that patients understand that this will be neither a quick nor a painless process. Even though the area being treated is anesthetized with topical or injectable agents before beginning treatment, removing a tattoo hurts! Patients can ice the treated area afterward or take over-the-counter medications such as acetaminophen.

4. Are All Colors Treated the Same?

No. The theory of selective photothermolysis teaches us that different colors in the tattoo pigment require different wavelengths. The best outcome occurs with use of wavelength that is preferentially absorbed by the color of the tattoo pigment.

Laser devices for tattoo removal deliver energy in four different wavelengths. Different colors in the tattoo require different wavelengths for the most effective outcome.

The 1064-nm Nd:YAG laser is ideal for treating black, dark blue, and brown tattoos, whereas the 532-nm laser can treat brown, orange, red, yellow, and rose colors. The 694-nm ruby laser is effective at treating tattoo pigments that are black, blue, green, and purple. The 755-nm alexandrite laser can be used to remove black, blue, and green tattoos.

Usually, more than one laser is needed for optimal treatment of multicolored tattoos, making them more challenging to treat.

5. And the Big Question: How Successful Is Tattoo Treatment?

Many factors affect how completely a tattoo can be removed. The patient's own skin color, how long the tattoo has been in place, where on the body the tattoo is found, and the colors and chemicals of the ink used can all affect success. Even when a tattoo has been successfully treated and all of the ink is cleared, most patients are left with some degree of residual hypopigmentation in the area. In a lighter-skinned patient, that may not be particularly noticeable. However, in darker-skinned patients, the contrast is more noticeable.

Treating light-colored (pink, tan, blush, white) tattoos with a QS or picosecond laser can cause paradoxical darkening. This happens after the initial pulse and is caused as the dye shifts from an oxidized state to a reduced state. Titanium dioxide or iron oxide, commonly found in red pigments, are more likely to cause this reaction.

The frequency of specific adverse events varies depending on the type of laser used in treatment. The most common adverse effects of both QS and picosecond laser treatments are bleeding, blister formation, and infection. These all typically resolve fairly quickly and without sequelae. The risk for scarring is generally quite low. Often, posttreatment scarring can be attributed to energy levels that are too high, causing hotspots within the beam, or abnormal healing after treatment. Local or widespread allergic reactions are infrequent adverse events but more commonly occur when treating tattoos using red inks. All of these reactions are treated using the same conventional therapies used for burns or secondary infections arising from any other cause.

As noted above, dyspigmentation (whether hypopigmentation or hyperpigmentation) is a potential risk that is most likely to occur in patients with darker skin (Fitzpatrick skin types V and VI). The 1064-nm QS Nd:YAG laser has reduced the risk for dyspigmentation compared with other lasers in those with dark skin. It has traditionally been considered the laser of choice for darker skin types. Its picosecond counterpart can also be safely used to treat darkly pigmented tattoos in darker skin types. It is important to discuss sun avoidance pre- and post-treatment to minimize risk for dyspigmentation.

Nazanin Saedi, MD, is the director of Laser Surgery and Cosmetic Dermatology Center at Jefferson University Hospitals. She is a board-certified and fellowship-trained dermatologist specializing in dermatologic surgery and cosmetic dermatology.

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