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Between seven and 20 million people in the United States, including adolescents as young as 12, are estimated to have at least one tattoo.1-3 Perhaps half later regret the decision to acquire a tattoo—for reasons ranging from an acute inflammatory reaction to the perception that having a tattoo might interfere with opportunities for professional advancement.4 The rising incidence of tattooing may be accompanied by increasing numbers of persons seeking to have decorative tattoos removed. Health care providers need to be aware of the modalities available, along with the risks and benefits of laser tattoo removal.
Tattoo types vary according to etiology, pigment, depth, and purpose. Cosmetic tattoos (“permanent makeup”) often serve to enhance physical features or mask scars; traumatic tattoos result from an injury in which foreign material is embedded in the skin. This article will focus on decorative tattoos and the clinical options for tattooed patients who regret these permanent markings and desire their removal.5
Decorative tattoos can be applied professionally or by amateurs, with pigment initially remaining in the superficial dermis; after several years, the pigment may migrate into deeper layers of the skin.6 Amateur tattoos are composed of ink or carbon; these pigments are usually less dense than those used by professionals, often making amateur tattoos easier to remove (ie, about five sessions of laser therapy for 90% clearance vs six to 10; see figures below).1,7
Professional tattoos are composed of organic pigments that vary in particle size but are applied at a uniform depth of needle penetration.5 The deposited pigment particles reside mainly in dermal fibroblasts and macrophages, although smaller collections of particles can be found within the interstitial space.
Tattoo Removal Techniques
Older techniques of tattoo removal, including surgical excision, salabrasion, dermabrasion, cryosurgery, and chemical peels, have largely been relinquished. Not only did these methods fail to yield desirable results, but they were associated with adverse effects, including hypopigmentation and scarring.5
Although continuous-wave lasers can also cause scarring, quality-switched (Q-switched) lasers have produced more favorable outcomes. The specific color and absorptive characteristics of each tattoo ink will help determine the ideal laser type to be used. In rare cases, patients may be able to contact the responsible artist and inquire about the inks used; information about the absorption spectrum of each pigment could facilitate the treatment plan. Even with this information, however, removal of intricate, colorful tattoos can be a challenge, since several different lasers, used in stages, may be needed.1,8
The patient’s skin type, too, may affect the response to treatment. Q-switched lasers are effective for all skin types, but complete pigment removal may be more difficult in lighter-skinned patients1 (ie, Fitzgerald skin types I and II). Similarly, in older tattoos, complete removal may not be possible, since some dermal pigment may have penetrated too deeply to be reached.5
Selective Photothermolysis
Laser removal of tattoos is accomplished by selective photothermolysis, a process that was first described by Anderson and Parrish in 1983.9,10 Photothermolysis targets specific microscopic sites on the skin, with effectiveness depending on the absorption spectrum of each pigment.4 The epidermis, dermis, and skin appendages are only minimally damaged in the process.6
Laser therapy modifies the optic properties of the tattoo pigments to be removed. The pigments absorb short laser pulses, which produce a high-intensity light in the pigments that is converted into heat.9 Shock waves shatter the pigment particles, achieving the selective death of the pigment-containing cells. The chemical composition of the pigment is also altered.
Lastly, the cell debris is phagocytized and transported to regional lymph nodes. Although they are hardly visible, some residual, scattered particles remain in the dermis. Only superficial pigment fragments are entirely eliminated during epidermal desquamation as repair is occurring, a development called transepidermal elimination.9
To produce the most effective treatment results, the laser wavelength must be absorbed by the ink, the heat should be confined to the target, and adequate energy must be delivered.1
Clinician–Patient Communication
Since the cosmetic outcome of laser therapy depends on both the laser wavelength and the absorption spectrum of each pigment, it is important for health care providers to understand the optimal wavelengths for each pigment type. They should be prepared to address with their patients the issues of incompatible lasers and resistance of certain pigments to treatment.11
Additionally, although Q-switched lasers are considered the gold standard for tattoo removal, realistic expectations should be established. Patients interested in treatment must be informed at the outset that complete clearance is not guaranteed and that the number of treatments and end result depend on factors that vary from patient to patient.4 Ten to 15 sessions, spaced six to eight weeks apart, may be required to achieve a desirable or even acceptable result,9 and the entire process could take a year or longer. The total cost can reach thousands of dollars.12
Before initiating laser therapy (or referring the patient for it), the primary care clinician should collect a history regarding the tattoo’s age and etiology, as well as the patient’s tanning habits, in order to recommend the best treatment. As stated earlier, professional tattoos generally require more treatments than amateur tattoos. Distally located tattoos are the most difficult to remove.1,13
Q-Switched Laser Types
The most common Q-switched lasers are:
• Q-switched ruby laser
• Q-switched Nd:YAG (neodymium:yttrium aluminum garnet) laser
• Q-switched alexandrite laser (see table1,4,6,14).
The choice of laser type is based on several factors, including the presumed absorption spectrum of the target, the desired depth of penetration, the size of the target particle, and the laser’s wavelength and pulse duration.11
Black and India inks absorb broadly across the spectrum. In the case of blue, yellow, or orange pigment, the optimal wavelength for pigment absorption is in an adjacent color. Green pigment absorption spectra vary due to the pigment’s multiple components. The spectra of white, yellow, and “flesh-colored” pigments do not have absorption peaks at the wavelengths of currently used Q-switched lasers; this explains their resistance to removal.11
Use of the Q-switched ruby laser (QSR) is indicated for the removal of black, blue-black, and dark blue pigments. Mixed results have been reported for removal of green and medium blue pigments, and poor results for red, orange, and pale blue. Six treatments at three-week intervals have been reported to yield clearance of 75% or greater in only about 25% of professional, dark-colored tattoos.1,15
Since this laser’s wavelength (694 nm) is absorbed by melanin, its use may result in transient hypopigmentation, depigmentation, and textural changes.1
The Q-switched Nd-YAG lasers (with wavelengths of 532 nm or 1064 nm) have a large spot size, concentrated energy densities, high repetition rates, and greater beam diameter, allowing for rapid, effective treatment of closely clustered and deep tattoos.6 Five treatments of red or orange tattoos may achieve 75% clearance in about 60% of patients.1
The 1064-nm Nd:YAG laser, which has the deepest penetration and carries the least risk for hypopigmentation,1 is indicated for black and dark blue pigments. It is considered the ideal choice for tattoo removal in dark-skinned patients,14,16 since its longer wavelength represents a lower affinity for melanin.4 The 532-nm Nd:YAG laser is effective for removal of red, yellow, and orange pigments.6 Ten or more treatments may be required for 75% clearance of a professional tattoo.1
Some adverse effects of Nd:YAG laser use include whitening of the skin, with occasional mild pinpoint bleeding. Use of the 532-nm model is associated with purpura, resulting from hemoglobin absorption; this may last from one week to 10 days. The 1064-nm Nd:YAG laser is the least effective for removing bright-colored pigments.1,17
The Q-switched alexandrite laser is generally used to remove black, blue, and green pigments. Typically, four to 10 sessions are required at intervals of one to two months. Transient hypopigmentation, typically lasting three to four months, occurs in about half of patients, and textural changes have been reported in about 12%.6,8
The 510-nm, pulsed-dye Q-switched alexandrite laser is reportedly effective in removing red pigment.4
Complications, Adverse Effects, and Their Management
Although Q-switched lasers appear quite effective in tattoo removal, their use is not without adverse effects.
Hypopigmentation
The most common chronic adverse effect of laser treatment is hypopigmentation. The risk is high in dark-skinned patients undergoing treatment with the QSR or alexandrite lasers4 and increases in any patient according to the number of treatment sessions. Hypopigmentation occurs in more than 38% of patients treated with QSR lasers and typically lasts for two to six months.6
In a 2004 study, Gundogan et al18 attempted repigmentation with an excimer laser (Nd:YAG/potassium titanyl phosphate–Nd:YAG) in a patient with hypopigmentation following laser tattoo removal. Repigmentation required 40 treatment sessions over 15 months—not a cost-effective option.6 A better solution might be to minimize the risk for hypopigmentation by use of picosecond lasers (see “Better Options on the Horizon?”, below).8
Hyperpigmentation
Hyperpigmentation can occur as a result of melanocytes’ increased melanin production in response to laser-generated heat. This effect is usually temporary, but recovery time varies.4 The risk of hyperpigmentation depends largely on skin type, with darker-skinned patients (ie, Fitzgerald type III or IV skin) at higher risk.6,19 Patients at risk for hyperpigmentation should avoid sun exposure before and after laser treatments; UVA/UVB sun blocks are essential if sun exposure cannot be avoided.1
Hyperpigmentation can also be treated with hydroquinone or fractional photothermolysis.6
Paradoxical Darkening of the Tattoo
Paradoxical darkening occurs when the chemical composition of the ink is changed by laser treatment—for example, from rust-colored ferric oxide to jet black ferrous oxide. Similarly, titanium dioxide contained in white ink that is used to brighten other colors can be reduced to titanium oxide or blue Ti3+ in response to laser therapy.1 Darkening is often difficult to correct, requiring the use of several lasers, including Q-switched or ablative (eg, ultrapulse CO2, pulsed erbium:YAG) lasers.9
In order to avoid darkening, a spot test is recommended. The patient should return to the studio, if possible, and have a sample of the pigment to be removed tattooed in the axillary region. After a month, a laser test spot can be performed. If laser treatment fails, the test spot can be removed by surgical excision, and laser treatment abandoned.9
Blistering
Blistering can occur as a result of overaggressive laser treatment or inadvertent absorption of laser energy due to the specific pigment. Blisters may be avoided by using a tissue-cooling system, such as a contact chill tip or cryogen spray.4 To avoid adverse effects such as wheals, punctate bleeding, blisters, and crusts, a minimum of four weeks between sessions should be maintained. Topical antiseptics can be used to prevent infection.6
Allergic Reactions
Tattoos containing metal salts—mercury (red), cadmium (yellow), chrome (green), or cobalt (blue)—may be subject to a local allergic or photoallergic skin reaction.6 A preexisting local allergic reaction may be exacerbated by laser treatment, resulting in urticaria or a systemic allergic reaction. The tattoo should be treated with corticosteroids and an allergist consulted.1 Some providers recommend avoiding laser therapy altogether.
Red is the pigment most often associated with allergic reactions, resulting in nodular, scaly, pruritic areas.12 Removal of areas of red pigment with the 532-nm Nd:YAG laser can help prevent complications.9 Photoallergic reactions most commonly involve cadmium. Affected patients typically report a history of pruritus in the tattoo and raised skin after UV exposure.
Allergic reactions can also be treated with topical or intralesional corticosteroids.12
Scarring
Cobblestone texture is a sign of early scarring, usually appearing within two weeks of treatment. The risk for scarring is highest on the chest, outer upper arm, and ankle.1
The risk is especially great in laser treatment of areas that have been retattooed (ie, a second tattoo applied to cover an older tattoo) because of the high density of pigment and increased laser resistance.9 Patients should be asked about the possible presence of a cover-up tattoo, since this may not be detectable on casual inspection.
In a study of Chinese patients who underwent laser removal of professional blue-black tattoos,20 prophylactic use of a gel containing onion extract, heparin, and allantoin had no effect on pigment clearance, but it reduced the rate of scarring, compared with controls. Additional studies are needed to evaluate the gel’s effectiveness in patients with other skin types and with tattoos containing pigments of various colors.20
Topical steroids are sometimes helpful for scarring.1 More pronounced scarring resulting from laser tattoo removal can be treated with the erbium:YAG laser or pulsed CO2 laser, as well as fractional photothermolysis.6
Cutaneous Lymphoma
Two types of red azo dyes have been shown to generate toxic or carcinogenic decomposition products (eg, nitroaniline) under in vitro conditions; whether this occurs in vivo is unknown. Concern has been expressed that laser stimulation of lymphocytes or dendritic cells could lead to cutaneous lymphoma.6
Resistance
Certain pigments are resistant to laser treatment, and multicolored tattoos are difficult to treat because of the limited number of laser wavelengths.11 If a tattoo’s nonresponsive area exceeds 10% of its total area, laser treatment should be abandoned for financial reasons.9 A smaller resistant area, however, may be treated with ablative lasers (ultrapulse CO2, pulsed erbium:YAG ). This requires numerous sessions, one to three months apart. Aggressive measures, such as attempting to remove all of the pigment in one session, should be avoided, since heavy scarring can occur.9
Better Options on the Horizon?
Computer simulations have confirmed that laser tattoo removal is photoacoustic and that shorter pulses delivering the same amount of laser energy as longer pulses may be more efficient. According to Ho et al,21 the optimal pulse length is approximately 10 to 100 picoseconds. Thus, picosecond lasers (such as the 795-nm titanium:sapphire laser), which have been shown to be effective in removing traumatic tattoos, are being investigated for application in decorative tattoos.8,22,23 It is hoped that these lasers, with action that increases phagocytosis or transepidermal elimination, will achieve higher rates of clearance with fewer treatments, less collateral damage, and improved cosmetic outcomes. Currently, only prototypes of this laser are available for removal of decorative tattoos.1,24
Topical imiquimod 5% cream and tretinoin have been studied in conjunction with laser therapy to remove tattoos. In one animal study in which these agents were applied shortly after tattooing, pigments faded significantly, but inflammation and fibrosis occurred.25 In subsequent small studies in humans, imiquimod cream used in conjunction with Q-switched laser treatment yielded only slight improvements, compared with placebo-enhanced laser treatments.26,27 Larger studies of imiquimod and similar agents may be warranted.5
New tattoo pigments, with documented absorption characteristics within the treatable range of current Q-switched lasers, are in development. One permanent ink made of D&C and USP-grade ingredients, currently available only in black, is reported by the manufacturer to be more easily removed than conventional inks by laser therapy.28 Last year in the United States, only 13 tattoo studios used this novel tattooing pigment.
Tattoo inks in the United States are neither regulated nor approved by the FDA, and manufacturers are not required to monitor the composition of their pigments.11,29 Additionally, not all states require artists to report infections or other complications associated with a healing tattoo.
Conclusion
Primary care providers must be aware of the benefits and shortcomings of currently available laser treatments for removal of decorative tattoos. With an understanding of the numerous factors that influence the cosmetic outcome of these treatments, clinicians can help patients set realistic goals and avoid complications.
Collaborative efforts among clinicians, researchers, and laser manufacturers should lead to improvements in laser tattoo removal outcomes.
1. Mariwalla K, Dover JS. The use of lasers for decorative tattoo removal. Skin Therapy Lett. 2006;11(5):8-11.
2. Braverman PK. Body art: piercing, tattooing, and scarification. Adolesc Med Clin. 2006; 17(3):505-519.
3. Roberts TA, Ryan SA. Tattooing and high-risk behavior in adolescents. Pediatrics. 2002; 110(6):1058-1063.
4. Burris K, Kim K. Tattoo removal. Clin Dermatol. 2007;25(4):388-392.
5. Sweeney SM. Tattoos: a review of tattoo practices and potential treatment options for removal. Curr Opin Pediatr. 2006;18(4):391-395.
6. Pfirrmann G, Karsai S, Roos S, et al. Tattoo removal: state of the art. J Dtsch Dermatol Ges. 2007;5(10):889-897.
7. Reid WH, Miller ID, Murphy MJ, et al. Q-switched ruby laser treatment of tattoos: a 9-year experience. Br J Plastic Surg. 2001;43(6): 663-669.
8. Kuperman-Meade M, Levine VJ, Ashinoff R. Laser removal of tattoos. Am J Clin Dermatol. 2001;2(1):21-25.
9. Adatto MA. Laser tattoo removal: benefits and caveats. Med Laser Appl. 2004;19:175-185.
10. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science. 1983; 220(4596):524–527.
11. Beute TC, Miller CH, Timko AL, Ross EV. In vitro spectral analysis of tattoo pigments. Dermatol Surg. 2008;34(4):508-515.
12. Bernstein EF. Laser treatment of tattoos. Clin Dermatol. 2006;24(1):43-55.
13. Prinz BM, Vavricka SR, Graf P, et al. Efficacy of laser treatment of tattoos and using lasers emitting wavelengths of 532nm, 755nm and 1064nm. Br J Dermatol. 2004;150(2):245-251.
14. Talakoub L, Wesley NO. Differences in perceptions of beauty and cosmetic procedures performed in ethnic patients. Semin Cutan Med Surg. 2009;28(2):115-129.
15. Taylor CR, Gange WR, Dover JS, et al. Treatment of tattoos by Q-switched ruby laser. Arch Dermatol. 1990;126(7):893-899.
16. Jones A, Roddey P, Orengo I, Rosen T. The Q-switched Nd:YAG laser effectively treats tattoos in darkly pigmented skin. Dermatol Surg. 1996;22(12):999-1001.
17. 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(8):971-978.
18. Gundogan C, Greve B, Hausser I, Raulin C. Repigmentation of persistent laser-induced hypopigmentation after tattoo ablation with the excimer laser [in German]. Hautarzt. 2004;55(6):549-552.
19. Rauscher GE, Maneckshana BT, Schwartz RA, Mekles TJ. Preoperative evaluation and management. http://emedicine.medscape.com/article/1127055-overview. Accessed August 18, 2010.
20. Ho WS, Ying SY, Chan PC, Chan HH. Use of onion extract, heparin, allantoin gel in prevention of scarring in Chinese patients having laser removal of tattoos: a prospective randomized controlled trial. Dermatol Surg. 2006; 32(7):891-896.
21. Ho DD, London R, Zimmerman GB, Young DA. Laser-tattoo removal: a study of the mechanism and the optimal treatment strategy via computer simulations. Lasers Surg Med. 2002;30(5):389-397.
22. Gorouhi F, Davari P, Kashani MN, Firooz A. Treatment of traumatic tattoo with the Q-switched Nd:YAG laser. J Cosmet Laser Ther. 2007;9(4):253-255.
23. Herd RM, Alora MB, Smoller B, et al. A clinical and histologic prospective controlled comparative study of the picosecond titanium:sapphire (795 nm) laser versus the Q-switched alexandrite (752 nm) laser for removing tattoo pigment. J Am Acad Dermatol. 1999;40(4):603-606.
24. Ross V, Naseef G, Lin G, et al. Comparison of responses of tattoos to picosecond and nanosecond Q-switched Neodymium:YAG lasers. Arch Dermatol. 1998;134(2):167-171.
25. Solis RR, Diven DG, Colome-Grimmer, et al. Experimental nonsurgical tattoo removal in a guinea pig model with topical imiquimod and tretinoin. Dermatol Surg. 2002;28(1):83-86.
26. Ricotti CA, Colaco SM, Shamma HN, et al. Laser-assisted tattoo removal with topical 5% imiquimod cream. Dermatol Surg. 2007;33(9): 1082-1091.
27. Elsaie ML, Nouri K, Vejjabhinanta V, et al. Topical imiquimod in conjunction with Nd:YAG laser for tattoo removal. Lasers Med Sci. 2009; 4(6):871-875.
28. Freedom 2™, Inc. InfinitInk™. www.infinitink.com/intro/intro.html. Accessed August 18, 2010.
29. Mayo Foundation for Medical Education and Research. Tattoos: understand risks and precautions (2010). www.mayoclinic.com/health/tattoos-and-piercings/MC00020. Accessed August 18, 2010.
Between seven and 20 million people in the United States, including adolescents as young as 12, are estimated to have at least one tattoo.1-3 Perhaps half later regret the decision to acquire a tattoo—for reasons ranging from an acute inflammatory reaction to the perception that having a tattoo might interfere with opportunities for professional advancement.4 The rising incidence of tattooing may be accompanied by increasing numbers of persons seeking to have decorative tattoos removed. Health care providers need to be aware of the modalities available, along with the risks and benefits of laser tattoo removal.
Tattoo types vary according to etiology, pigment, depth, and purpose. Cosmetic tattoos (“permanent makeup”) often serve to enhance physical features or mask scars; traumatic tattoos result from an injury in which foreign material is embedded in the skin. This article will focus on decorative tattoos and the clinical options for tattooed patients who regret these permanent markings and desire their removal.5
Decorative tattoos can be applied professionally or by amateurs, with pigment initially remaining in the superficial dermis; after several years, the pigment may migrate into deeper layers of the skin.6 Amateur tattoos are composed of ink or carbon; these pigments are usually less dense than those used by professionals, often making amateur tattoos easier to remove (ie, about five sessions of laser therapy for 90% clearance vs six to 10; see figures below).1,7
Professional tattoos are composed of organic pigments that vary in particle size but are applied at a uniform depth of needle penetration.5 The deposited pigment particles reside mainly in dermal fibroblasts and macrophages, although smaller collections of particles can be found within the interstitial space.
Tattoo Removal Techniques
Older techniques of tattoo removal, including surgical excision, salabrasion, dermabrasion, cryosurgery, and chemical peels, have largely been relinquished. Not only did these methods fail to yield desirable results, but they were associated with adverse effects, including hypopigmentation and scarring.5
Although continuous-wave lasers can also cause scarring, quality-switched (Q-switched) lasers have produced more favorable outcomes. The specific color and absorptive characteristics of each tattoo ink will help determine the ideal laser type to be used. In rare cases, patients may be able to contact the responsible artist and inquire about the inks used; information about the absorption spectrum of each pigment could facilitate the treatment plan. Even with this information, however, removal of intricate, colorful tattoos can be a challenge, since several different lasers, used in stages, may be needed.1,8
The patient’s skin type, too, may affect the response to treatment. Q-switched lasers are effective for all skin types, but complete pigment removal may be more difficult in lighter-skinned patients1 (ie, Fitzgerald skin types I and II). Similarly, in older tattoos, complete removal may not be possible, since some dermal pigment may have penetrated too deeply to be reached.5
Selective Photothermolysis
Laser removal of tattoos is accomplished by selective photothermolysis, a process that was first described by Anderson and Parrish in 1983.9,10 Photothermolysis targets specific microscopic sites on the skin, with effectiveness depending on the absorption spectrum of each pigment.4 The epidermis, dermis, and skin appendages are only minimally damaged in the process.6
Laser therapy modifies the optic properties of the tattoo pigments to be removed. The pigments absorb short laser pulses, which produce a high-intensity light in the pigments that is converted into heat.9 Shock waves shatter the pigment particles, achieving the selective death of the pigment-containing cells. The chemical composition of the pigment is also altered.
Lastly, the cell debris is phagocytized and transported to regional lymph nodes. Although they are hardly visible, some residual, scattered particles remain in the dermis. Only superficial pigment fragments are entirely eliminated during epidermal desquamation as repair is occurring, a development called transepidermal elimination.9
To produce the most effective treatment results, the laser wavelength must be absorbed by the ink, the heat should be confined to the target, and adequate energy must be delivered.1
Clinician–Patient Communication
Since the cosmetic outcome of laser therapy depends on both the laser wavelength and the absorption spectrum of each pigment, it is important for health care providers to understand the optimal wavelengths for each pigment type. They should be prepared to address with their patients the issues of incompatible lasers and resistance of certain pigments to treatment.11
Additionally, although Q-switched lasers are considered the gold standard for tattoo removal, realistic expectations should be established. Patients interested in treatment must be informed at the outset that complete clearance is not guaranteed and that the number of treatments and end result depend on factors that vary from patient to patient.4 Ten to 15 sessions, spaced six to eight weeks apart, may be required to achieve a desirable or even acceptable result,9 and the entire process could take a year or longer. The total cost can reach thousands of dollars.12
Before initiating laser therapy (or referring the patient for it), the primary care clinician should collect a history regarding the tattoo’s age and etiology, as well as the patient’s tanning habits, in order to recommend the best treatment. As stated earlier, professional tattoos generally require more treatments than amateur tattoos. Distally located tattoos are the most difficult to remove.1,13
Q-Switched Laser Types
The most common Q-switched lasers are:
• Q-switched ruby laser
• Q-switched Nd:YAG (neodymium:yttrium aluminum garnet) laser
• Q-switched alexandrite laser (see table1,4,6,14).
The choice of laser type is based on several factors, including the presumed absorption spectrum of the target, the desired depth of penetration, the size of the target particle, and the laser’s wavelength and pulse duration.11
Black and India inks absorb broadly across the spectrum. In the case of blue, yellow, or orange pigment, the optimal wavelength for pigment absorption is in an adjacent color. Green pigment absorption spectra vary due to the pigment’s multiple components. The spectra of white, yellow, and “flesh-colored” pigments do not have absorption peaks at the wavelengths of currently used Q-switched lasers; this explains their resistance to removal.11
Use of the Q-switched ruby laser (QSR) is indicated for the removal of black, blue-black, and dark blue pigments. Mixed results have been reported for removal of green and medium blue pigments, and poor results for red, orange, and pale blue. Six treatments at three-week intervals have been reported to yield clearance of 75% or greater in only about 25% of professional, dark-colored tattoos.1,15
Since this laser’s wavelength (694 nm) is absorbed by melanin, its use may result in transient hypopigmentation, depigmentation, and textural changes.1
The Q-switched Nd-YAG lasers (with wavelengths of 532 nm or 1064 nm) have a large spot size, concentrated energy densities, high repetition rates, and greater beam diameter, allowing for rapid, effective treatment of closely clustered and deep tattoos.6 Five treatments of red or orange tattoos may achieve 75% clearance in about 60% of patients.1
The 1064-nm Nd:YAG laser, which has the deepest penetration and carries the least risk for hypopigmentation,1 is indicated for black and dark blue pigments. It is considered the ideal choice for tattoo removal in dark-skinned patients,14,16 since its longer wavelength represents a lower affinity for melanin.4 The 532-nm Nd:YAG laser is effective for removal of red, yellow, and orange pigments.6 Ten or more treatments may be required for 75% clearance of a professional tattoo.1
Some adverse effects of Nd:YAG laser use include whitening of the skin, with occasional mild pinpoint bleeding. Use of the 532-nm model is associated with purpura, resulting from hemoglobin absorption; this may last from one week to 10 days. The 1064-nm Nd:YAG laser is the least effective for removing bright-colored pigments.1,17
The Q-switched alexandrite laser is generally used to remove black, blue, and green pigments. Typically, four to 10 sessions are required at intervals of one to two months. Transient hypopigmentation, typically lasting three to four months, occurs in about half of patients, and textural changes have been reported in about 12%.6,8
The 510-nm, pulsed-dye Q-switched alexandrite laser is reportedly effective in removing red pigment.4
Complications, Adverse Effects, and Their Management
Although Q-switched lasers appear quite effective in tattoo removal, their use is not without adverse effects.
Hypopigmentation
The most common chronic adverse effect of laser treatment is hypopigmentation. The risk is high in dark-skinned patients undergoing treatment with the QSR or alexandrite lasers4 and increases in any patient according to the number of treatment sessions. Hypopigmentation occurs in more than 38% of patients treated with QSR lasers and typically lasts for two to six months.6
In a 2004 study, Gundogan et al18 attempted repigmentation with an excimer laser (Nd:YAG/potassium titanyl phosphate–Nd:YAG) in a patient with hypopigmentation following laser tattoo removal. Repigmentation required 40 treatment sessions over 15 months—not a cost-effective option.6 A better solution might be to minimize the risk for hypopigmentation by use of picosecond lasers (see “Better Options on the Horizon?”, below).8
Hyperpigmentation
Hyperpigmentation can occur as a result of melanocytes’ increased melanin production in response to laser-generated heat. This effect is usually temporary, but recovery time varies.4 The risk of hyperpigmentation depends largely on skin type, with darker-skinned patients (ie, Fitzgerald type III or IV skin) at higher risk.6,19 Patients at risk for hyperpigmentation should avoid sun exposure before and after laser treatments; UVA/UVB sun blocks are essential if sun exposure cannot be avoided.1
Hyperpigmentation can also be treated with hydroquinone or fractional photothermolysis.6
Paradoxical Darkening of the Tattoo
Paradoxical darkening occurs when the chemical composition of the ink is changed by laser treatment—for example, from rust-colored ferric oxide to jet black ferrous oxide. Similarly, titanium dioxide contained in white ink that is used to brighten other colors can be reduced to titanium oxide or blue Ti3+ in response to laser therapy.1 Darkening is often difficult to correct, requiring the use of several lasers, including Q-switched or ablative (eg, ultrapulse CO2, pulsed erbium:YAG) lasers.9
In order to avoid darkening, a spot test is recommended. The patient should return to the studio, if possible, and have a sample of the pigment to be removed tattooed in the axillary region. After a month, a laser test spot can be performed. If laser treatment fails, the test spot can be removed by surgical excision, and laser treatment abandoned.9
Blistering
Blistering can occur as a result of overaggressive laser treatment or inadvertent absorption of laser energy due to the specific pigment. Blisters may be avoided by using a tissue-cooling system, such as a contact chill tip or cryogen spray.4 To avoid adverse effects such as wheals, punctate bleeding, blisters, and crusts, a minimum of four weeks between sessions should be maintained. Topical antiseptics can be used to prevent infection.6
Allergic Reactions
Tattoos containing metal salts—mercury (red), cadmium (yellow), chrome (green), or cobalt (blue)—may be subject to a local allergic or photoallergic skin reaction.6 A preexisting local allergic reaction may be exacerbated by laser treatment, resulting in urticaria or a systemic allergic reaction. The tattoo should be treated with corticosteroids and an allergist consulted.1 Some providers recommend avoiding laser therapy altogether.
Red is the pigment most often associated with allergic reactions, resulting in nodular, scaly, pruritic areas.12 Removal of areas of red pigment with the 532-nm Nd:YAG laser can help prevent complications.9 Photoallergic reactions most commonly involve cadmium. Affected patients typically report a history of pruritus in the tattoo and raised skin after UV exposure.
Allergic reactions can also be treated with topical or intralesional corticosteroids.12
Scarring
Cobblestone texture is a sign of early scarring, usually appearing within two weeks of treatment. The risk for scarring is highest on the chest, outer upper arm, and ankle.1
The risk is especially great in laser treatment of areas that have been retattooed (ie, a second tattoo applied to cover an older tattoo) because of the high density of pigment and increased laser resistance.9 Patients should be asked about the possible presence of a cover-up tattoo, since this may not be detectable on casual inspection.
In a study of Chinese patients who underwent laser removal of professional blue-black tattoos,20 prophylactic use of a gel containing onion extract, heparin, and allantoin had no effect on pigment clearance, but it reduced the rate of scarring, compared with controls. Additional studies are needed to evaluate the gel’s effectiveness in patients with other skin types and with tattoos containing pigments of various colors.20
Topical steroids are sometimes helpful for scarring.1 More pronounced scarring resulting from laser tattoo removal can be treated with the erbium:YAG laser or pulsed CO2 laser, as well as fractional photothermolysis.6
Cutaneous Lymphoma
Two types of red azo dyes have been shown to generate toxic or carcinogenic decomposition products (eg, nitroaniline) under in vitro conditions; whether this occurs in vivo is unknown. Concern has been expressed that laser stimulation of lymphocytes or dendritic cells could lead to cutaneous lymphoma.6
Resistance
Certain pigments are resistant to laser treatment, and multicolored tattoos are difficult to treat because of the limited number of laser wavelengths.11 If a tattoo’s nonresponsive area exceeds 10% of its total area, laser treatment should be abandoned for financial reasons.9 A smaller resistant area, however, may be treated with ablative lasers (ultrapulse CO2, pulsed erbium:YAG ). This requires numerous sessions, one to three months apart. Aggressive measures, such as attempting to remove all of the pigment in one session, should be avoided, since heavy scarring can occur.9
Better Options on the Horizon?
Computer simulations have confirmed that laser tattoo removal is photoacoustic and that shorter pulses delivering the same amount of laser energy as longer pulses may be more efficient. According to Ho et al,21 the optimal pulse length is approximately 10 to 100 picoseconds. Thus, picosecond lasers (such as the 795-nm titanium:sapphire laser), which have been shown to be effective in removing traumatic tattoos, are being investigated for application in decorative tattoos.8,22,23 It is hoped that these lasers, with action that increases phagocytosis or transepidermal elimination, will achieve higher rates of clearance with fewer treatments, less collateral damage, and improved cosmetic outcomes. Currently, only prototypes of this laser are available for removal of decorative tattoos.1,24
Topical imiquimod 5% cream and tretinoin have been studied in conjunction with laser therapy to remove tattoos. In one animal study in which these agents were applied shortly after tattooing, pigments faded significantly, but inflammation and fibrosis occurred.25 In subsequent small studies in humans, imiquimod cream used in conjunction with Q-switched laser treatment yielded only slight improvements, compared with placebo-enhanced laser treatments.26,27 Larger studies of imiquimod and similar agents may be warranted.5
New tattoo pigments, with documented absorption characteristics within the treatable range of current Q-switched lasers, are in development. One permanent ink made of D&C and USP-grade ingredients, currently available only in black, is reported by the manufacturer to be more easily removed than conventional inks by laser therapy.28 Last year in the United States, only 13 tattoo studios used this novel tattooing pigment.
Tattoo inks in the United States are neither regulated nor approved by the FDA, and manufacturers are not required to monitor the composition of their pigments.11,29 Additionally, not all states require artists to report infections or other complications associated with a healing tattoo.
Conclusion
Primary care providers must be aware of the benefits and shortcomings of currently available laser treatments for removal of decorative tattoos. With an understanding of the numerous factors that influence the cosmetic outcome of these treatments, clinicians can help patients set realistic goals and avoid complications.
Collaborative efforts among clinicians, researchers, and laser manufacturers should lead to improvements in laser tattoo removal outcomes.
Between seven and 20 million people in the United States, including adolescents as young as 12, are estimated to have at least one tattoo.1-3 Perhaps half later regret the decision to acquire a tattoo—for reasons ranging from an acute inflammatory reaction to the perception that having a tattoo might interfere with opportunities for professional advancement.4 The rising incidence of tattooing may be accompanied by increasing numbers of persons seeking to have decorative tattoos removed. Health care providers need to be aware of the modalities available, along with the risks and benefits of laser tattoo removal.
Tattoo types vary according to etiology, pigment, depth, and purpose. Cosmetic tattoos (“permanent makeup”) often serve to enhance physical features or mask scars; traumatic tattoos result from an injury in which foreign material is embedded in the skin. This article will focus on decorative tattoos and the clinical options for tattooed patients who regret these permanent markings and desire their removal.5
Decorative tattoos can be applied professionally or by amateurs, with pigment initially remaining in the superficial dermis; after several years, the pigment may migrate into deeper layers of the skin.6 Amateur tattoos are composed of ink or carbon; these pigments are usually less dense than those used by professionals, often making amateur tattoos easier to remove (ie, about five sessions of laser therapy for 90% clearance vs six to 10; see figures below).1,7
Professional tattoos are composed of organic pigments that vary in particle size but are applied at a uniform depth of needle penetration.5 The deposited pigment particles reside mainly in dermal fibroblasts and macrophages, although smaller collections of particles can be found within the interstitial space.
Tattoo Removal Techniques
Older techniques of tattoo removal, including surgical excision, salabrasion, dermabrasion, cryosurgery, and chemical peels, have largely been relinquished. Not only did these methods fail to yield desirable results, but they were associated with adverse effects, including hypopigmentation and scarring.5
Although continuous-wave lasers can also cause scarring, quality-switched (Q-switched) lasers have produced more favorable outcomes. The specific color and absorptive characteristics of each tattoo ink will help determine the ideal laser type to be used. In rare cases, patients may be able to contact the responsible artist and inquire about the inks used; information about the absorption spectrum of each pigment could facilitate the treatment plan. Even with this information, however, removal of intricate, colorful tattoos can be a challenge, since several different lasers, used in stages, may be needed.1,8
The patient’s skin type, too, may affect the response to treatment. Q-switched lasers are effective for all skin types, but complete pigment removal may be more difficult in lighter-skinned patients1 (ie, Fitzgerald skin types I and II). Similarly, in older tattoos, complete removal may not be possible, since some dermal pigment may have penetrated too deeply to be reached.5
Selective Photothermolysis
Laser removal of tattoos is accomplished by selective photothermolysis, a process that was first described by Anderson and Parrish in 1983.9,10 Photothermolysis targets specific microscopic sites on the skin, with effectiveness depending on the absorption spectrum of each pigment.4 The epidermis, dermis, and skin appendages are only minimally damaged in the process.6
Laser therapy modifies the optic properties of the tattoo pigments to be removed. The pigments absorb short laser pulses, which produce a high-intensity light in the pigments that is converted into heat.9 Shock waves shatter the pigment particles, achieving the selective death of the pigment-containing cells. The chemical composition of the pigment is also altered.
Lastly, the cell debris is phagocytized and transported to regional lymph nodes. Although they are hardly visible, some residual, scattered particles remain in the dermis. Only superficial pigment fragments are entirely eliminated during epidermal desquamation as repair is occurring, a development called transepidermal elimination.9
To produce the most effective treatment results, the laser wavelength must be absorbed by the ink, the heat should be confined to the target, and adequate energy must be delivered.1
Clinician–Patient Communication
Since the cosmetic outcome of laser therapy depends on both the laser wavelength and the absorption spectrum of each pigment, it is important for health care providers to understand the optimal wavelengths for each pigment type. They should be prepared to address with their patients the issues of incompatible lasers and resistance of certain pigments to treatment.11
Additionally, although Q-switched lasers are considered the gold standard for tattoo removal, realistic expectations should be established. Patients interested in treatment must be informed at the outset that complete clearance is not guaranteed and that the number of treatments and end result depend on factors that vary from patient to patient.4 Ten to 15 sessions, spaced six to eight weeks apart, may be required to achieve a desirable or even acceptable result,9 and the entire process could take a year or longer. The total cost can reach thousands of dollars.12
Before initiating laser therapy (or referring the patient for it), the primary care clinician should collect a history regarding the tattoo’s age and etiology, as well as the patient’s tanning habits, in order to recommend the best treatment. As stated earlier, professional tattoos generally require more treatments than amateur tattoos. Distally located tattoos are the most difficult to remove.1,13
Q-Switched Laser Types
The most common Q-switched lasers are:
• Q-switched ruby laser
• Q-switched Nd:YAG (neodymium:yttrium aluminum garnet) laser
• Q-switched alexandrite laser (see table1,4,6,14).
The choice of laser type is based on several factors, including the presumed absorption spectrum of the target, the desired depth of penetration, the size of the target particle, and the laser’s wavelength and pulse duration.11
Black and India inks absorb broadly across the spectrum. In the case of blue, yellow, or orange pigment, the optimal wavelength for pigment absorption is in an adjacent color. Green pigment absorption spectra vary due to the pigment’s multiple components. The spectra of white, yellow, and “flesh-colored” pigments do not have absorption peaks at the wavelengths of currently used Q-switched lasers; this explains their resistance to removal.11
Use of the Q-switched ruby laser (QSR) is indicated for the removal of black, blue-black, and dark blue pigments. Mixed results have been reported for removal of green and medium blue pigments, and poor results for red, orange, and pale blue. Six treatments at three-week intervals have been reported to yield clearance of 75% or greater in only about 25% of professional, dark-colored tattoos.1,15
Since this laser’s wavelength (694 nm) is absorbed by melanin, its use may result in transient hypopigmentation, depigmentation, and textural changes.1
The Q-switched Nd-YAG lasers (with wavelengths of 532 nm or 1064 nm) have a large spot size, concentrated energy densities, high repetition rates, and greater beam diameter, allowing for rapid, effective treatment of closely clustered and deep tattoos.6 Five treatments of red or orange tattoos may achieve 75% clearance in about 60% of patients.1
The 1064-nm Nd:YAG laser, which has the deepest penetration and carries the least risk for hypopigmentation,1 is indicated for black and dark blue pigments. It is considered the ideal choice for tattoo removal in dark-skinned patients,14,16 since its longer wavelength represents a lower affinity for melanin.4 The 532-nm Nd:YAG laser is effective for removal of red, yellow, and orange pigments.6 Ten or more treatments may be required for 75% clearance of a professional tattoo.1
Some adverse effects of Nd:YAG laser use include whitening of the skin, with occasional mild pinpoint bleeding. Use of the 532-nm model is associated with purpura, resulting from hemoglobin absorption; this may last from one week to 10 days. The 1064-nm Nd:YAG laser is the least effective for removing bright-colored pigments.1,17
The Q-switched alexandrite laser is generally used to remove black, blue, and green pigments. Typically, four to 10 sessions are required at intervals of one to two months. Transient hypopigmentation, typically lasting three to four months, occurs in about half of patients, and textural changes have been reported in about 12%.6,8
The 510-nm, pulsed-dye Q-switched alexandrite laser is reportedly effective in removing red pigment.4
Complications, Adverse Effects, and Their Management
Although Q-switched lasers appear quite effective in tattoo removal, their use is not without adverse effects.
Hypopigmentation
The most common chronic adverse effect of laser treatment is hypopigmentation. The risk is high in dark-skinned patients undergoing treatment with the QSR or alexandrite lasers4 and increases in any patient according to the number of treatment sessions. Hypopigmentation occurs in more than 38% of patients treated with QSR lasers and typically lasts for two to six months.6
In a 2004 study, Gundogan et al18 attempted repigmentation with an excimer laser (Nd:YAG/potassium titanyl phosphate–Nd:YAG) in a patient with hypopigmentation following laser tattoo removal. Repigmentation required 40 treatment sessions over 15 months—not a cost-effective option.6 A better solution might be to minimize the risk for hypopigmentation by use of picosecond lasers (see “Better Options on the Horizon?”, below).8
Hyperpigmentation
Hyperpigmentation can occur as a result of melanocytes’ increased melanin production in response to laser-generated heat. This effect is usually temporary, but recovery time varies.4 The risk of hyperpigmentation depends largely on skin type, with darker-skinned patients (ie, Fitzgerald type III or IV skin) at higher risk.6,19 Patients at risk for hyperpigmentation should avoid sun exposure before and after laser treatments; UVA/UVB sun blocks are essential if sun exposure cannot be avoided.1
Hyperpigmentation can also be treated with hydroquinone or fractional photothermolysis.6
Paradoxical Darkening of the Tattoo
Paradoxical darkening occurs when the chemical composition of the ink is changed by laser treatment—for example, from rust-colored ferric oxide to jet black ferrous oxide. Similarly, titanium dioxide contained in white ink that is used to brighten other colors can be reduced to titanium oxide or blue Ti3+ in response to laser therapy.1 Darkening is often difficult to correct, requiring the use of several lasers, including Q-switched or ablative (eg, ultrapulse CO2, pulsed erbium:YAG) lasers.9
In order to avoid darkening, a spot test is recommended. The patient should return to the studio, if possible, and have a sample of the pigment to be removed tattooed in the axillary region. After a month, a laser test spot can be performed. If laser treatment fails, the test spot can be removed by surgical excision, and laser treatment abandoned.9
Blistering
Blistering can occur as a result of overaggressive laser treatment or inadvertent absorption of laser energy due to the specific pigment. Blisters may be avoided by using a tissue-cooling system, such as a contact chill tip or cryogen spray.4 To avoid adverse effects such as wheals, punctate bleeding, blisters, and crusts, a minimum of four weeks between sessions should be maintained. Topical antiseptics can be used to prevent infection.6
Allergic Reactions
Tattoos containing metal salts—mercury (red), cadmium (yellow), chrome (green), or cobalt (blue)—may be subject to a local allergic or photoallergic skin reaction.6 A preexisting local allergic reaction may be exacerbated by laser treatment, resulting in urticaria or a systemic allergic reaction. The tattoo should be treated with corticosteroids and an allergist consulted.1 Some providers recommend avoiding laser therapy altogether.
Red is the pigment most often associated with allergic reactions, resulting in nodular, scaly, pruritic areas.12 Removal of areas of red pigment with the 532-nm Nd:YAG laser can help prevent complications.9 Photoallergic reactions most commonly involve cadmium. Affected patients typically report a history of pruritus in the tattoo and raised skin after UV exposure.
Allergic reactions can also be treated with topical or intralesional corticosteroids.12
Scarring
Cobblestone texture is a sign of early scarring, usually appearing within two weeks of treatment. The risk for scarring is highest on the chest, outer upper arm, and ankle.1
The risk is especially great in laser treatment of areas that have been retattooed (ie, a second tattoo applied to cover an older tattoo) because of the high density of pigment and increased laser resistance.9 Patients should be asked about the possible presence of a cover-up tattoo, since this may not be detectable on casual inspection.
In a study of Chinese patients who underwent laser removal of professional blue-black tattoos,20 prophylactic use of a gel containing onion extract, heparin, and allantoin had no effect on pigment clearance, but it reduced the rate of scarring, compared with controls. Additional studies are needed to evaluate the gel’s effectiveness in patients with other skin types and with tattoos containing pigments of various colors.20
Topical steroids are sometimes helpful for scarring.1 More pronounced scarring resulting from laser tattoo removal can be treated with the erbium:YAG laser or pulsed CO2 laser, as well as fractional photothermolysis.6
Cutaneous Lymphoma
Two types of red azo dyes have been shown to generate toxic or carcinogenic decomposition products (eg, nitroaniline) under in vitro conditions; whether this occurs in vivo is unknown. Concern has been expressed that laser stimulation of lymphocytes or dendritic cells could lead to cutaneous lymphoma.6
Resistance
Certain pigments are resistant to laser treatment, and multicolored tattoos are difficult to treat because of the limited number of laser wavelengths.11 If a tattoo’s nonresponsive area exceeds 10% of its total area, laser treatment should be abandoned for financial reasons.9 A smaller resistant area, however, may be treated with ablative lasers (ultrapulse CO2, pulsed erbium:YAG ). This requires numerous sessions, one to three months apart. Aggressive measures, such as attempting to remove all of the pigment in one session, should be avoided, since heavy scarring can occur.9
Better Options on the Horizon?
Computer simulations have confirmed that laser tattoo removal is photoacoustic and that shorter pulses delivering the same amount of laser energy as longer pulses may be more efficient. According to Ho et al,21 the optimal pulse length is approximately 10 to 100 picoseconds. Thus, picosecond lasers (such as the 795-nm titanium:sapphire laser), which have been shown to be effective in removing traumatic tattoos, are being investigated for application in decorative tattoos.8,22,23 It is hoped that these lasers, with action that increases phagocytosis or transepidermal elimination, will achieve higher rates of clearance with fewer treatments, less collateral damage, and improved cosmetic outcomes. Currently, only prototypes of this laser are available for removal of decorative tattoos.1,24
Topical imiquimod 5% cream and tretinoin have been studied in conjunction with laser therapy to remove tattoos. In one animal study in which these agents were applied shortly after tattooing, pigments faded significantly, but inflammation and fibrosis occurred.25 In subsequent small studies in humans, imiquimod cream used in conjunction with Q-switched laser treatment yielded only slight improvements, compared with placebo-enhanced laser treatments.26,27 Larger studies of imiquimod and similar agents may be warranted.5
New tattoo pigments, with documented absorption characteristics within the treatable range of current Q-switched lasers, are in development. One permanent ink made of D&C and USP-grade ingredients, currently available only in black, is reported by the manufacturer to be more easily removed than conventional inks by laser therapy.28 Last year in the United States, only 13 tattoo studios used this novel tattooing pigment.
Tattoo inks in the United States are neither regulated nor approved by the FDA, and manufacturers are not required to monitor the composition of their pigments.11,29 Additionally, not all states require artists to report infections or other complications associated with a healing tattoo.
Conclusion
Primary care providers must be aware of the benefits and shortcomings of currently available laser treatments for removal of decorative tattoos. With an understanding of the numerous factors that influence the cosmetic outcome of these treatments, clinicians can help patients set realistic goals and avoid complications.
Collaborative efforts among clinicians, researchers, and laser manufacturers should lead to improvements in laser tattoo removal outcomes.
1. Mariwalla K, Dover JS. The use of lasers for decorative tattoo removal. Skin Therapy Lett. 2006;11(5):8-11.
2. Braverman PK. Body art: piercing, tattooing, and scarification. Adolesc Med Clin. 2006; 17(3):505-519.
3. Roberts TA, Ryan SA. Tattooing and high-risk behavior in adolescents. Pediatrics. 2002; 110(6):1058-1063.
4. Burris K, Kim K. Tattoo removal. Clin Dermatol. 2007;25(4):388-392.
5. Sweeney SM. Tattoos: a review of tattoo practices and potential treatment options for removal. Curr Opin Pediatr. 2006;18(4):391-395.
6. Pfirrmann G, Karsai S, Roos S, et al. Tattoo removal: state of the art. J Dtsch Dermatol Ges. 2007;5(10):889-897.
7. Reid WH, Miller ID, Murphy MJ, et al. Q-switched ruby laser treatment of tattoos: a 9-year experience. Br J Plastic Surg. 2001;43(6): 663-669.
8. Kuperman-Meade M, Levine VJ, Ashinoff R. Laser removal of tattoos. Am J Clin Dermatol. 2001;2(1):21-25.
9. Adatto MA. Laser tattoo removal: benefits and caveats. Med Laser Appl. 2004;19:175-185.
10. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science. 1983; 220(4596):524–527.
11. Beute TC, Miller CH, Timko AL, Ross EV. In vitro spectral analysis of tattoo pigments. Dermatol Surg. 2008;34(4):508-515.
12. Bernstein EF. Laser treatment of tattoos. Clin Dermatol. 2006;24(1):43-55.
13. Prinz BM, Vavricka SR, Graf P, et al. Efficacy of laser treatment of tattoos and using lasers emitting wavelengths of 532nm, 755nm and 1064nm. Br J Dermatol. 2004;150(2):245-251.
14. Talakoub L, Wesley NO. Differences in perceptions of beauty and cosmetic procedures performed in ethnic patients. Semin Cutan Med Surg. 2009;28(2):115-129.
15. Taylor CR, Gange WR, Dover JS, et al. Treatment of tattoos by Q-switched ruby laser. Arch Dermatol. 1990;126(7):893-899.
16. Jones A, Roddey P, Orengo I, Rosen T. The Q-switched Nd:YAG laser effectively treats tattoos in darkly pigmented skin. Dermatol Surg. 1996;22(12):999-1001.
17. 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(8):971-978.
18. Gundogan C, Greve B, Hausser I, Raulin C. Repigmentation of persistent laser-induced hypopigmentation after tattoo ablation with the excimer laser [in German]. Hautarzt. 2004;55(6):549-552.
19. Rauscher GE, Maneckshana BT, Schwartz RA, Mekles TJ. Preoperative evaluation and management. http://emedicine.medscape.com/article/1127055-overview. Accessed August 18, 2010.
20. Ho WS, Ying SY, Chan PC, Chan HH. Use of onion extract, heparin, allantoin gel in prevention of scarring in Chinese patients having laser removal of tattoos: a prospective randomized controlled trial. Dermatol Surg. 2006; 32(7):891-896.
21. Ho DD, London R, Zimmerman GB, Young DA. Laser-tattoo removal: a study of the mechanism and the optimal treatment strategy via computer simulations. Lasers Surg Med. 2002;30(5):389-397.
22. Gorouhi F, Davari P, Kashani MN, Firooz A. Treatment of traumatic tattoo with the Q-switched Nd:YAG laser. J Cosmet Laser Ther. 2007;9(4):253-255.
23. Herd RM, Alora MB, Smoller B, et al. A clinical and histologic prospective controlled comparative study of the picosecond titanium:sapphire (795 nm) laser versus the Q-switched alexandrite (752 nm) laser for removing tattoo pigment. J Am Acad Dermatol. 1999;40(4):603-606.
24. Ross V, Naseef G, Lin G, et al. Comparison of responses of tattoos to picosecond and nanosecond Q-switched Neodymium:YAG lasers. Arch Dermatol. 1998;134(2):167-171.
25. Solis RR, Diven DG, Colome-Grimmer, et al. Experimental nonsurgical tattoo removal in a guinea pig model with topical imiquimod and tretinoin. Dermatol Surg. 2002;28(1):83-86.
26. Ricotti CA, Colaco SM, Shamma HN, et al. Laser-assisted tattoo removal with topical 5% imiquimod cream. Dermatol Surg. 2007;33(9): 1082-1091.
27. Elsaie ML, Nouri K, Vejjabhinanta V, et al. Topical imiquimod in conjunction with Nd:YAG laser for tattoo removal. Lasers Med Sci. 2009; 4(6):871-875.
28. Freedom 2™, Inc. InfinitInk™. www.infinitink.com/intro/intro.html. Accessed August 18, 2010.
29. Mayo Foundation for Medical Education and Research. Tattoos: understand risks and precautions (2010). www.mayoclinic.com/health/tattoos-and-piercings/MC00020. Accessed August 18, 2010.
1. Mariwalla K, Dover JS. The use of lasers for decorative tattoo removal. Skin Therapy Lett. 2006;11(5):8-11.
2. Braverman PK. Body art: piercing, tattooing, and scarification. Adolesc Med Clin. 2006; 17(3):505-519.
3. Roberts TA, Ryan SA. Tattooing and high-risk behavior in adolescents. Pediatrics. 2002; 110(6):1058-1063.
4. Burris K, Kim K. Tattoo removal. Clin Dermatol. 2007;25(4):388-392.
5. Sweeney SM. Tattoos: a review of tattoo practices and potential treatment options for removal. Curr Opin Pediatr. 2006;18(4):391-395.
6. Pfirrmann G, Karsai S, Roos S, et al. Tattoo removal: state of the art. J Dtsch Dermatol Ges. 2007;5(10):889-897.
7. Reid WH, Miller ID, Murphy MJ, et al. Q-switched ruby laser treatment of tattoos: a 9-year experience. Br J Plastic Surg. 2001;43(6): 663-669.
8. Kuperman-Meade M, Levine VJ, Ashinoff R. Laser removal of tattoos. Am J Clin Dermatol. 2001;2(1):21-25.
9. Adatto MA. Laser tattoo removal: benefits and caveats. Med Laser Appl. 2004;19:175-185.
10. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science. 1983; 220(4596):524–527.
11. Beute TC, Miller CH, Timko AL, Ross EV. In vitro spectral analysis of tattoo pigments. Dermatol Surg. 2008;34(4):508-515.
12. Bernstein EF. Laser treatment of tattoos. Clin Dermatol. 2006;24(1):43-55.
13. Prinz BM, Vavricka SR, Graf P, et al. Efficacy of laser treatment of tattoos and using lasers emitting wavelengths of 532nm, 755nm and 1064nm. Br J Dermatol. 2004;150(2):245-251.
14. Talakoub L, Wesley NO. Differences in perceptions of beauty and cosmetic procedures performed in ethnic patients. Semin Cutan Med Surg. 2009;28(2):115-129.
15. Taylor CR, Gange WR, Dover JS, et al. Treatment of tattoos by Q-switched ruby laser. Arch Dermatol. 1990;126(7):893-899.
16. Jones A, Roddey P, Orengo I, Rosen T. The Q-switched Nd:YAG laser effectively treats tattoos in darkly pigmented skin. Dermatol Surg. 1996;22(12):999-1001.
17. 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(8):971-978.
18. Gundogan C, Greve B, Hausser I, Raulin C. Repigmentation of persistent laser-induced hypopigmentation after tattoo ablation with the excimer laser [in German]. Hautarzt. 2004;55(6):549-552.
19. Rauscher GE, Maneckshana BT, Schwartz RA, Mekles TJ. Preoperative evaluation and management. http://emedicine.medscape.com/article/1127055-overview. Accessed August 18, 2010.
20. Ho WS, Ying SY, Chan PC, Chan HH. Use of onion extract, heparin, allantoin gel in prevention of scarring in Chinese patients having laser removal of tattoos: a prospective randomized controlled trial. Dermatol Surg. 2006; 32(7):891-896.
21. Ho DD, London R, Zimmerman GB, Young DA. Laser-tattoo removal: a study of the mechanism and the optimal treatment strategy via computer simulations. Lasers Surg Med. 2002;30(5):389-397.
22. Gorouhi F, Davari P, Kashani MN, Firooz A. Treatment of traumatic tattoo with the Q-switched Nd:YAG laser. J Cosmet Laser Ther. 2007;9(4):253-255.
23. Herd RM, Alora MB, Smoller B, et al. A clinical and histologic prospective controlled comparative study of the picosecond titanium:sapphire (795 nm) laser versus the Q-switched alexandrite (752 nm) laser for removing tattoo pigment. J Am Acad Dermatol. 1999;40(4):603-606.
24. Ross V, Naseef G, Lin G, et al. Comparison of responses of tattoos to picosecond and nanosecond Q-switched Neodymium:YAG lasers. Arch Dermatol. 1998;134(2):167-171.
25. Solis RR, Diven DG, Colome-Grimmer, et al. Experimental nonsurgical tattoo removal in a guinea pig model with topical imiquimod and tretinoin. Dermatol Surg. 2002;28(1):83-86.
26. Ricotti CA, Colaco SM, Shamma HN, et al. Laser-assisted tattoo removal with topical 5% imiquimod cream. Dermatol Surg. 2007;33(9): 1082-1091.
27. Elsaie ML, Nouri K, Vejjabhinanta V, et al. Topical imiquimod in conjunction with Nd:YAG laser for tattoo removal. Lasers Med Sci. 2009; 4(6):871-875.
28. Freedom 2™, Inc. InfinitInk™. www.infinitink.com/intro/intro.html. Accessed August 18, 2010.
29. Mayo Foundation for Medical Education and Research. Tattoos: understand risks and precautions (2010). www.mayoclinic.com/health/tattoos-and-piercings/MC00020. Accessed August 18, 2010.