Special Feature: Tattoo Removal

By Chloé Gronow / 03 Aug 2016

Practitioners discuss how to safely and successfully remove unwanted tattoos

Irish-American tattooist Samuel O’Reilly first patented the twin-coil electromagnetic tattoo needle in New York in 1891, paving the way for modern inking and the continued popularity of tattoos.1 In 2015 it was reported that almost one in five (19%) of the UK population now has a tattoo, however 14% of those regret getting inked.2 Based on the UK’s estimated 64.6 million population,3 these figures suggest that there are approximately 1.7 million people living in the UK who are unhappy with their tattoo.

This is not surprising, according to professionals interviewed for this article, who report seeing huge numbers of patients for tattoo removal consultations and treatments on a regular basis. Head of medical education at sk:n, which has 40 clinics nationwide, Lisa Mason, says, “I know that in a year we do about 14,000 treatments; the fact that we don’t convert all consultations to treatments suggests we probably offer around 15,000 consultations a year.” Group medical director at sk:n, consultant dermatologist Dr Firas Al-Niaimi adds that he personally sees approximately 10-20 tattoo removal requests a week, further highlighting the demand. For Juliette John, a medical micropigmentation specialist who practises in what she describes as a ‘small suburban clinic’ in Ipswich, the demand is equally as high, with 98% of the 2,800 laser tattoo removal consultations offered in her clinic in 2015 going ahead. Overseas in Israel, board-certified dermatologist and director of the Friedman Skin & Laser Center, Dr David Friedman, also reports that he conducts high numbers of tattoo removal treatments. He comments that approximately 80% of 200 consultations he conducted last year followed through to treatment; adding, “My patients pay for the consultation and are highly motivated to get treatment; they’ve thought about it, they’ve read about it and done their research. I haven’t experienced buyer’s regret where someone has said they wished they’d thought about it more.”

Reasons for tattoo removal are as expected, with practitioners reporting bad designs, an ex partner’s name and general embarrassment with the artwork of choice being the most common. Alternatively, some patients request treatment for ‘traumatic tattoos’, which are caused by the forceful penetration of the skin with particles of a foreign matter; which can include pencil led, dirt, sand, grease, paint, grass, metal, gunpowder, wood and asphalt. The skin then heals over the particles and results in what is known as a traumatic tattoo.4 So with a high and steady demand for tattoo removal in the UK, aesthetic practitioners may be tempted to add this procedure to their clinic’s treatment offering. However knowing where to start, what devices to invest in and how to safely treat patients can be a challenge; which is why, this month, Aesthetics explored these issues with leading professionals in the field.

Figure 1: Before and after three treatments and then seven treatments with the Harmony XL Pro. Images courtesy of Juliette John.

Consultation

“As with any treatment, the most important part of the consultation is setting realistic expectations,” says Dr Friedman, commenting, “People have to understand that although we can usually achieve excellent results, it’s impossible to promise exactly how much of an improvement there will be or whether they will be able to see anything afterwards.” Mason explains that the consultations for tattoo removal at sk:n are the longest of any type of treatments on offer to ensure that patients fully understand the risks, benefits, time and potential cost involved. “We would never treat a patient on the same day as a consultation; we might offer a small test patch on the tattoo on the day and then we would wait at least two weeks before treatment to give them time to think about it. This allows time to have a look at what the test patch looks like and think about the pain aspect of having their tattoo removed,” she says.

During the consultation, practitioners should take a comprehensive medical history to establish any contraindications to treatment such as, amongst others, malignancy, vitiligo, multiple sclerosis, MRSA and certain medications such as Roaccutane.5 John explains, “This drug can cause dermatitis, dryness and heightened skin fragility.” She adds, “We also don’t treat people who are taking St John’s wort for depression, as this is highly photosensitive and can cause a reaction.6 In addition, patients on blood-thinning medication should consult with their doctor before undergoing treatment.” Other risks to be aware of are discussed later in the article in more detail. John adds that, in her clinic, “After the initial consultation a cooling-off period is a must; a large amount of information has been delivered in a 30-minute consultation and patients may need to adjust to a more realistic expectation of the results that can be achieved.”

Mechanism of action

The two main mechanisms which have been proposed in laser tattoo removal are thermal and acoustic,7 which is further supported by a paper from Welch et al.8 GY Ho and Leok Goh outline in the Journal of Cutaneous and Aesthetic Surgery that laser tattoo removal treatment is based on the concept of selective photothermolysis, where laser light of different wavelengths is preferentially absorbed by different chromophores.9 They explain that the target chromophore is heated for no longer than its thermal relaxation time (the time required for the target to lose 50% of its heat), then selective destruction of these chromophores – which, in the case of tattoos, is the exogenous ink – can be achieved. As the tattoo pigment is very small, rapid heating with very short pulse durations – in the nanosecond or picosecond range – is required to cause photoacoustic injury and rupture the ink particles.9 The tattoo pigment is then removed in a process called phagocytosis, where the tattoo fragments are packaged for lymphatic drainage and further scavenged by dermal macrophages, fibroblasts, and mast cells, leading to lightening of the tattoo. Transepidermal elimination accounts for a small fraction of tattoo clearance too.9

Choosing a device

Safe tattoo removal with laser requires the use of a Q-switched device, of which there are three types: the Nd:YAG, ruby and alexandrite lasers which exist in three wavelengths; 532, 755 and 1064 nm. Q-switched lasers produce a very short laser pulse in the nanosecond range; which is widely reported to be a much safer method than lasers or IPL systems that emit energy in the millisecond range.10 Dr Al-Niaimi says, “I am aware of people who have used IPL or long-pulse lasers, which is very dangerous and can increase the risk of scarring, as you will deliver the heat for too long for such small ink particles, which will then diffuse to the surrounding epidermis.” This is supported in the literature, with reports of incomplete results and scarring.7,9,10,11

More recently, the introduction of picosecond technology has offered practitioners an enhanced treatment modality for tattoo removal. Ross et al8 first compared the use of nanosecond and picosecond lasers for the treatment of black tattoos, with all other parameters being equal, and reported tattoo removal to be more effective with the picosecond pulse duration. Further studies have since supported this, with research confirming the efficacy of the first commercially available picosecond laser in 2013.9 “Picosecond is the new generation because you get more photomechanical effects because the pulse duration is so short, which is much safer on the dermis and epidermis, as you’re less likely to generate lots of heat and therefore get quicker and better removal,” says Dr Al-Niaimi. Dr Friedman agrees, noting, “There’s no question in my mind that picosecond technology works magnificently; it’s more efficient [than nanosecond technology] and uses less energy for less side effects and better results.”

Figure 2: Before and after  tattoo removal treatment on Fitzpatrick skin type VI with the PicoWay. Images courtesy of Dr David Friedman.

Dr Friedman uses the PicoWay picosecond laser from Syneron Candela in his practice. He explains that the device now has fractionated capabilities, produced with the use of an add-on holographic handpiece called Resolve, which uses both 532 nm and 1064 nm wavelengths. In fact, Dr Friedman has recently had success removing a red tattoo on Fitzpatrick skin type VI with the device, which he claims has never been done before (Figure 2). Dr Al-Niaimi does note, however, that because you are shattering the ink to smaller particles more quickly than a Q-switched laser, most of the results are seen within the first three to five treatments and may begin to plateau after that.

The evolution of picosecond lasers does not mean Q-switched lasers are outdated; Dr Al-Niaimi says that he has a Q-switched Nd:YAG 532 nm to treat red tattoos, a Q-switched 1064 for black tattoos, a Q-switched ruby for green tattoos and picosecond laser for resistant tattoos or those that aren’t fading fast with the Q-switched. John stocks a similar range of Q-switched lasers, preferring to use the Harmony XL Pro platform from ABC Lasers. She says, “The high power Q-switched Nd:YAG 1064 nanometre (nm) laser is great for treating blue-black tattoo inks and micropigmentation pigment, while the 532 nm wavelength is more effective on red, orange and red/brown ink and pigments.” John also advocates using the Er:YAG 2940 nm in combination with her Q-switched laser as she claims it boosts pigment clearance, shortens recovery time, helps the skin to repair and evens out texture.

Treating colour

As already mentioned, the chromophore that is targeted by the laser is the exogenously-placed ink of a tattoo. Successful destruction of the ink will depend upon the application of the correct wavelength, which is chosen based on the colour of the tattoo, as certain colours have complementary colours that they absorb. “For example,” explains Dr Al-Niaimi, “green light is best absorbed by red colour, which is why the best wavelength to treat a red tattoo is a Q-switched 532 nm.” He continues, “We know black absorbs all light so, effectively, any of the wavelengths in the visible spectrum will work. But, because you want to minimise damage to the epidermis you try to use a wavelength that is the least absorbed by the epidermis – this is why we prefer the 1064 nm.” All practitioners interviewed agree that yellow is the most difficult colour to treat, with Mason noting that patients may end up with a patchy tattoo if the yellow can’t be entirely removed.

Mason notes that practitioners should be aware that patients could have had cover-up tattoos over other tattoos so there may be competing colours. She says, “You have to remember that you don’t always know what colours are making up that ink so if you’re not getting anywhere with that wavelength then you can test patch on another area to see how that goes.” She adds, “You should also be aware that every colour has a different shade which may effect results; some blues can be a dark blue or have a bit of a green tinge, or be more turquoise.”

Which wavelength for which colour?12

1064 nm
 black inks 
12694 nm or 755 nm
blue and green inks 
532 nm
 red and warm-toned inks (i.e. browns, oranges, yellows)

Treatment

Each practitioner interviewed agrees that the first thing to do prior to treatment is examine the patient’s Fitzpatrick skin type and check it is free from infection and inflammation. Although not a contraindication, darker skin should be treated with particular care, as it is more likely to encounter pigment changes. “One of the complications is hypopigmentation,” says Mason, who explains that this is often referred to as ‘ghosting’ because, while the ink may have been removed, the patient is left with a faint outline of the shape. This will of course become more prominent when a patient tans. Dr Friedman then says he decides upon the appropriate pain relief options for the patient, which ranges from cold air to direct intralesional injection with lidocaine. Tattoo removal is notoriously painful, with patients anecdotally reporting it as equal to or sometimes more painful than having the tattoo itself. Dr Friedman comments, “I’d say 80% of people get by with just cold air, 15% use topical anesthetic and 5% get injected.”

Practitioners then choose the appropriate wavelength for the colour of the pigment, as well as a suitable spot size, and then safely begin treatment. Choosing a spot size is important, explains Dr Al-Niaimi, noting that if you use a small spot size, you will generate a lot of concentration of light high in the epidermis, which can increase the risk of epidermal injury. “Therefore, in darker skin, it’s advisable to use a larger spot size,” he says. Dr Friedman agrees, explaining, in general, “If you use a larger spot size you get greater penetration of the skin using less energy, which is more efficient and more effective.”

Figure 3: Before and after 12 treatments with the RevLite. Images courtesy of sk:n.

Following the first session, John explains that she recommends that patients apply an ice pack to the treatment site in order to minimise the risk of blistering and scabbing. She also advises patients to avoid smoking, as it may inhibit results,13 and to stay out of the sun as it may influence pigmentation changes.10

The amount of treatments needed varies based on a number of factors, mainly the size of the tattoo, the colour(s) of the tattoo and the level of professionalism as to how it was applied. “The more professional a tattoo, the more difficult it is to remove,” says Dr Friedman, while Dr Al-Niaimi adds that, if professionally applied with a specific machine like a gun, the tattoo may be placed more deeply and have many colours that are densely packed so, more difficult to treat. Mason comments that practitioners at sk:n usually advise, “Professional tattoos typically need between eight and twelve treatments, depending on the size and colour, however they can take up to 20 sessions.” For amateur tattoos or traumatic tattoos, Mason notes that she has seen these removed in as little as four to six sessions.

The location of the tattoo can also be a factor. John says, “Tattoos on the torso respond well to removal, whereas those on the ankles or feet can be more difficult to treat.” It has been suggested that this may be because these areas have a lower vascular supply than other parts of the body.17

In her practice, John uses the Kirby Desai scale to help determine how many sessions a removal will take, which aims to provide a good assessment of the anticipated number of treatments needed, based on the patient’s skin type, the location of the tattoo, the colours, amount of ink, scarring and tissue change, and layered tattoos.11

All practitioners interviewed agree that the interval between treatments is ideally relatively long compared to many other treatments, as you rely on the macrophage clearance, which can take many weeks. “There is evidence to suggest that leaving a longer time between treatments is more effective, as the ink continues to be broken down and absorbed during that time,”9 says Mason, adding, “anecdotally, if you leave at least eight to twelve weeks between treatments you still see fading in that time.” Dr Al-Niaimi adds, “Two to four weeks is too short so it’s not advisable.”

Risks and side effects

As with all laser procedures, there is a significant risk of side effects and complications occurring during and after treatment. Most commonly, side effects can include pain, itching, swelling and some bleeding. More serious complications include blistering and crusting, which can lead to dispigmentation and scarring.10 As such, Dr Al-Niaimi highlights the importance of taking into consideration the depth of penetration of the laser wavelength and the interaction of other chromophores, namely, the melanin in the surface of the skin. He explains, “You want to try and minimise absorption of the laser light by the melanin in the epidermis because, if that happens, you will heat the epidermis and influence the occurrence of crusting, scabbing or blistering, which can lead to secondary infection with subsequent scarring.” Dr Friedman notes that scarring is not only unsightly, but it can also impede further improvement in the laser removal. Practitioners explain that this unintentional collateral damage to the surrounding skin can also influence pigmentation changes, which are highlighted as a predominant concern. They emphasise that understanding how different Fitzpatrick skin types will respond to wavelengths and how to safely treat is therefore imperative to successful results. For patients who are likely to tan in between treatments, for example, if they are going on holiday, the treatment area should be entirely covered with a good dressing. “If we don’t think there is any change of colour when they return, we would treat them,” says Mason. Another complication that can occur is swelling, which could happen, for example, if a practitioner attempts to treat the whole circumference of a full-arm sleeve tattoo. “This is a complete no-no,” says Mason, explaining, “you can get so much swelling it almost acts as a tourniquet around the arm so it’s not advisable to treat large tattoos like that in one session.” Another complication, which Mason says is not as common, is that the tattoo becomes blurred following treatment, as though someone has smudged it. She explains, “We think it’s because, rather than being shattered, the ink particles move deeper into the dermis. You can usually remove it but it does become more challenging to treat.” Mason adds that practitioners should also find out if the patient had an allergic reaction to ink when they had the tattoo, as they may have another reaction as the ink is broken up. She explains, “We don’t know what the tattooist may have put in their ink – most aren’t FDA-approved or approved by any organisation – some inks contain cadmium sulfide [added to help brighten tattoos] or cinnabar [used in greens], which can cause reactions.”18

Figure 4: Before and after eight tattoo removal sessions, eight weeks apart, with the Harmony XL Pro. 
Images courtesy of Juliette John.

Practitioners should also be aware of the risk of paradoxical darkening. Dr Al-Niaimi explains that cosmetic tattoos, such as eyebrow and lip liner tattoos, tend to have iron or titanium in them, which can oxidise when heated and therefore darken. He says, “You need to do a test spot prior to treatment and gain experience in treating cosmetic tattoos. They can still be treated but should be done so by someone experienced.” Finally, there is of course a risk that results are unsuccessful. “My advice would be, if you’re not seeing any improvement at all, you need to stop and rethink what you’re doing,” says Mason. She adds, “You need to say to the patient, ‘I don’t think we’re getting anywhere with this’ rather than keep going and getting nowhere.” She also emphasises the importance of documenting the conversation you have during the consultation, so you can ensure the patient has been told that there are people who do not respond to treatment. In such cases where patients don’t respond, Mason suggests they can opt for surgical removal, however this is not always appropriate, depending on the location of the tattoo, and is likely to result in a scar.

Plexr: an alternative tattoo removal treatment

While the use of laser is regarded as the most common method of removing unwanted tattoos, a new treatment modality has recently emerged. The Plexr ‘soft surgery’ system utilises the plasma energy generated from the ionisation of atmospheric gas between the Plexr probe and the skin.19 Dr David Jack, who offers Plexr treatments for facial rejuvenation and tattoo removal to his patients, explains that this injures the skin, creating access to the dermis where the tattoo ink is located. A hypertonic dressing is then applied over the tattoo, which influences an osmotic response that aims to soak up the pigment and remove the tattoo. Patients can go home with the dressing and are advised to change it every 24 hours for approximately two days. Dr Jack explains that the benefit of this treatment method over laser is that it can remove any colour of tattoo. He says,“Because you’re not targeting the pigment by virtue of colour, like you are with laser which is targeting a chromophore, any colour of tattoo ink can be removed with Plexr.” He does note, however, that if the pigment has been injected very deep into the skin, it makes it a lot more difficult to remove and laser may be more effective. Treatment usually lasts 30 to 40 minutes and, as with laser removal, repeat Plexr treatments are necessary. Dr Jack explains that between six and eight treatments are usually needed, with results reviewed monthly, however this varies depending on the size of the tattoo and the patient’s satisfaction with results. He adds that, anecdotally, the procedure is relatively painless with the use of local anaesthetic blocks, although it may be slightly sore with topical anaesthetic. According to Dr Jack, prolonged redness is the main side effect that can occur with Plexr treatment. He says, “Although it may not be too much of an issue for tattoo removal patients until most of the ink has been removed, it is important to be aware of prolonged redness, which is fairly persistent in a small proportion of patients.” Dr Jack also adds that it is essential to undergo thorough Plexr training before offering treatment.

Figure 5: Before and after treatment with Plexr. Images courtesy of Fusion GT.

Adding laser tattoo removal to your clinic offering

Before offering laser tattoo removal to patients, practitioners need to ensure they are competent to treat and have completed their Core of Knowledge training, in line with the Medicines and Healthcare products Regulatory Agency’s syllabus.16 Practitioners should also ensure they meet the requirements set out by Health Education England on qualifications and training, which recommends that practitioners offering tattoo removal treatment with lasers (excluding treatments within the periorbital rim) should meet the Level 5 requirements, equivalent to a foundation degree level.17 Mason says that practitioners should have a really good understanding of laser-light tissue interaction, commenting, “If you don’t have that basic knowledge then you don’t have the insight into getting the best results and managing complications.” To conclude, Dr Friedman warns practitioners to ensure they are using the most appropriate device for the tattoo they are treating. He adds, “You need to understand which inks respond to which wavelengths as well as under promise and over deliver to manage patients’ expectations.” Mason adds that practitioners can get really good job satisfaction from removing tattoos, especially if the tattoo may be causing psychological distress to the patient. Considering the continued popularity in people having tattoos, there is a very strong likelihood that there will also be a continued increase in demand for tattoo removal in the UK. And with advancements in laser technology progressing steadily, tattoo removal is certainly an interesting skill to consider adding to your repertoire.

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