What Dermatologists Need to Know about Laser Removal of Tattoos

What Dermatologists Need to Know about Laser Removal of Tattoos

The dermatologic laser surgeon’s ability to treat tattoos continues to improve. Lasers and their protocols have changed dramatically from the days when my personal dermatologist and the “father of Dermatologic Lasers,” Dr. Leon Goldman, was working with the Q-switched ruby laser for tattoo removal. There are now a number of laser choices to consider, each with its own positives and negatives.
(See table below).

Type of Laser
Q-Switched
Ruby Laser 694 nm
Q-Switched
Nd:YAG 532 nm Pulsed Dye 540
Q-Switched
Nd:YAG 1064 nm
Q-Switched
Alexandrite 755 nm
Pigment Response to Lasers
Good Fair Poor
Green
Black
Blue Red Yellow
Red-Excellent
Orange
Purple Black Yellow
Blue
Black Green Yellow
Green
Blue
Black Red Yellow

When trying to decide which laser to use, remember:
Flesh toned/tan, brown or rust and white tattoos often darken with Q-switched lasers.
Q-switched lasers can also darken tattoos after the ingestion of oral gold.
If your patient has ever had an allergic reaction to tattoo pigments, the laser treatment could potentially set off another.
In one study, 33% of patients with tattoos had hepatitis C. Therefore get a careful history, and if a patient is positive for this disease, wear a face mask and use a smoke evacuator because aerosolization of the tattoo during treatment can occur.
Laser of the Future
As dermatologists and laser surgeons, we wish lasers could treat tattoos in fewer visits. It would also be helpful if a new specific wavelength or shorter pulse width was available that did not allow competition with melanocytes. Therefore, it could decrease or eliminate the most common risks associated with laser treatment of tattoos – namely post-inflammatory (hypo or hyper) pigmentation, blistering, textural changes and scarring.

We’ve been waiting for one versatile laser for all tattoos for years, and we may be closer to it than ever before. The Versapulse laser, which has three Q-switched lasers in it, Nd:YAG 532 nm, and the 1064 nm alexandrite. In addition, hand pieces utilizing polymer dye technology are now used with the Nd:YAC lasers (e.g. Medlite 2) for the purpose of treating different colors that don’t respond particularly well to the 532 nm or 1064 nm. Perhaps a color meter or photographic image would inform you of the proper wavelength and appropriate treatment protocol. Already, computer simulations help us better understand the mechanism of removal as well as optimize treatment parameters. As we approach the future, we could imagine a truly tunable excimer diode or alternate laser type that could be “dialed up” depending on the color.

Tidbits to Remember For Tattoo Removal
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, (eg 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/Retin A) 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.