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By Joshua L. Fox, M.D
Make sure your patient has realistic expectations and understands the number of treatments, healing time, percent improvement expected, cost, risk, benefit, alternate treatments, etc. Photographs and consent forms are strongly advised.
Patients with Fitzpatrick types V and VI can now be treated effectively, albeit with extra precautions and protocols. Aggressive use of Hydroquinone or one of the newer Hydroquinone compounds together with sunscreens and pre-and post-treatment sun avoidance lessens the risk of post-inflammatory pigmentation.
Surprisingly, some tattoos, like eyebrow or eyelid liner, blue or black tattoo from radiation therapy, or dirt tattoos, may completely respond after just one or two treatments.
Amateur, cosmetic, traumatic and medical tattoos, older tattoos or those with thin, narrow markings respond in fewer treatments than denser, deeper placed professional tattoos with mixed colors. Yellow, flesh-toned and newer fluorescent mixed colors often made from organometallic dyes are often poor responders.
While I believe lasers are the best tools for removing tattoos, don’t forget about flash lamp intense light sources, excision, (e.g. if very small or resistant color) tattooing over the lesion or possibly even use of one of the older techniques like salabrasion, cryosurgery, chemical peeling (e.g. trichlorite acid), and dermabrasion in the appropriate patient.
Certain skin diseases like sarcoidosis, lichen planus and psoriasis may be localized to tattoos.
Use as much anesthesia, topical and also local, to prevent pain. There’s no reason for a patient to suffer at all.
Detailed pre-laser (e.g. avoid sun/RetinA) and post-laser treatment protocols (good wound healing and sun avoidance) lessen risk and side effects and improve on results with faster healing.
We often find it helpful to treat the tattoos with multiple wavelengths, occasionally using two or three lasers on the same visit for a portion of a tattoo. We also test spot sections of the tattoo to different wavelengths. Sometimes the laser you might expect to give the best results is not the most commonly recommended one. It’s especially important to spot test unusual colors. Only rarely nowadays might one use CO2, or erbium:YAG as ablative lasers or argon or tunable dye lasers for difficult-to-remove pigment.