Special Feature: Tattoo Removal

Some do it to emulate celebrity icons; others, to pay indelible tributes to loved ones. Love them or hate them, tattoos have become a representation of western culture. 

Around one fifth of British adults reportedly have tattoos, with the number rising to 29% among those aged 16 to 44.¹ Americans have a similar penchant for getting ‘inked’, with one in five US adults having at least one tattoo, according to a Harris poll.²

What is perhaps surprising – and somewhat worrying – is that there are no national standards in England and Wales requiring qualifications and training of tattooists. As long as premises are registered, anyone can wield a tattoo gun and permanently mark someone’s skin with ink. Lack of regulation of course means the risk of life-threatening infection cannot be properly mitigated. But in the shorter term, it also means there’s a greater chance of someone walking out of a parlour with an unprofessional and poor-quality tattoo. In addition, certain careers – such as those in the services and the police force, or as a flight attendant – prohibit visible tattoos.

Tattoo regret

It’s little wonder, then, that so many people live to regret having it done. A 2012 study released by the British Association of Dermatologists revealed that one third of tattooed adults regretted their tattoo.³ Accordingly, as quickly as tattoos themselves are on the rise, so are procedures to remove them, say practitioners.

John Sheffield, manager and laser protection supervisor at Royal Tunbridge Wells Skin and Laser Clinic (RTW), has been doing laser tattoo removal for nine years and says there has been a steady rise in people requesting the procedure. Currently, he says, there are around 700 patients on RTW’s books who are undergoing treatment. According to Sheffield, people who have the procedure can be split into four groups: “There are the young females who have had a tattoo they immediately regret, then you have middle-aged ladies who have put up with bad tattoos for a long time and have recently become both aware and financially able to invest in having them removed,” he explains. “The next group is people who are applying for jobs, where they have visible tattoos they need to have removed before they can even get an interview; and finally, there’s older people, who have had tattoos for many years, and have decided they just want to get rid of it.”

Evolving technology

Gone are the days when dermabrasion, salabrasion, chemical destruction or cryotherapy were the most readily available options for removing tattoos. Lasers are now the recognised gold standard for tattoo removal, and they work by reacting with the ink in the tattoo and breaking it down into tiny particles, which are then absorbed into the body and excreted as waste products. For the last 10 years or so, the device favoured by most has been the Q-switched laser, which uses selective photothermolysis – targeting a specific area with a wavelength of light, which turns into heat energy sufficient to break down the pigment with minimal damage to the surrounding skin. 

Two of the most commonly used types are the Nd:Yag and the ruby laser. All tattoo pigments have a specific spectrum of light absorption so different light wavelengths are needed to target different colours. The Nd:Yag uses neodymium-doped yttrium aluminium garnet crystal (hence its name) as its medium, to produce pulses of 1064 nanometres (nm), which effectively targets black, dark blue and dark brown. Its high-intensity pulse can be doubled to generate laser light at 532nm – the wavelength needed for red, yellow and purple inks. Light blue and green inks are broken down by 694nm, the pulse wavelength provided by synthetic ruby crystal – or ruby – laser.⁴ These lasers typically transmit pulses at the speed of nanoseconds (ns), although more recently, a new generation of lasers has come to market that deliver shots in the range of picoseconds – one trillionth of a second.

Dr Klaus Hoffman, from Katholisches Klikikum Bochum in Germany, explains how the new technology improves the experience for patients. “When you want to test if an iron is hot, you wet your finger and put it very quickly onto the iron plate. If you leave the finger for long on the iron it will burn,” he comments. “The same thing happens with light – because laser is nothing more than light – if you shoot on the skin with the long-shot laser, you transfer light energy into thermal energy, which more or less cooks the pigment in the depth of the skin. This harms the skin. With picosecond lasers, you give an extremely shortened light pulse that still gives very high energy of 280 megawatts. This blows the pigment in the depth of the skin rather than cooking it.”

The upshot is that the quicker the beam, the smaller the particles it can break the tattoo down into, meaning more of the tattoo can be effectively removed with fewer treatments. “Think of the particles of the tattoo colours as rocks underneath the skin,” says Reset Room’s laser practitioner Wayne Joyce. “The old machines would break the rocks down into pebbles, but some of the pebbles were still too big for your body to break down so a lot of the tattoo remained. The new ones break the particles into little pieces of sand, making it easier for your immune system to get rid of them.”

Dr Arielle Kauvar, director of NY Laser and Skin Care, concurs that the new technology is providing an attractive treatment option for patients looking to remove unwanted tattoos. “Tattoo ink clears approximately twice as fast as with Q-switched/nanosecond domain lasers, and we can safely treat at intervals as short as two weeks,” she says. Dr Harryono Judodihardjo, a dermatologist and medical director of Cellite Clinic, predicts that the efficacy of the procedure will improve with smarter technology, too. “The colours break up more with each treatment, and currently with a black tattoo, patients can expect about 80-90% clearance,” he says. “In the future, however, the timing of the beams will get shorter and shorter and they’ll be able to break up smaller particles, so the chance of getting 100% clearance will be higher.”

Images courtesy of Dr Rox Anderson and Dr Suzanne Kilmer

Patient selection

Whatever the choice of laser, a test patch several weeks in advance is essential. Practitioners must also fully consult with patients before beginning a course of treatments. Most important is taking a full medical history, to exclude any medical contraindications. “We don’t treat people who are taking St John’s wort, which some people take for depression, because it’s highly photosensitive and can cause a reaction,” says Lauren Sibley, clinic manager and lead aesthetic practitioner at Juvea Aesthetics. “Certain other medications can also affect the treatment, including Roaccutane, which is used to treat acne.” This drug can cause exfoliation, dermatitis, dryness and heightened skin fragility⁵, so the skin would be more easily damaged by laser treatments. Patients on blood-thinning medication such as warfarin should consult with their doctor before undergoing treatment.

Also important is the patient’s general health, that the skin is free from infection and inflammation, and generally in good condition. The patient’s skin type is assessed, as it’s a good predictor of how effective the removal procedure will be. “Paler skin responds better, because the laser ‘sees’ the tattoo so much more easily when it’s a dark pigment on a light skin,” Sibley adds. “But we use Nd:Yag 1064nm to treat skin types four to six, lowering the settings and using extra cooling to take the heat out of the skin.” The added risk for darker-skinned patients is that, as well as removing pigments from the tattoo, the laser can cause loss of pigmentation in the skin itself, “Which sometimes comes back after a long time, but not always,” advises Sheffield.

Thereafter, there are five main considerations a practitioner should take into account: the tattoo’s size, how old it is, the colours used, whether it was done professionally and its position on the body. Taken together, these factors will determine how many treatments will be needed, over how long, and how successful the outcome should be. As a rule of thumb, yellow, green and blue inks are trickier to remove, whilst black responds best, and the length of each treatment will vary from 10 minutes to up to an hour, depending on the size and the colours used. Becky Crozier, aesthetician at Wilmslow’s Courthouse Clinic, suggests that, “The best results come from the worst-quality tattoos. The easiest ones to get rid of are homemade tattoos that use Indian ink. The higher the quality, the finer the lines and the harder it is to remove,” she says.

According to Sibley, the tattoo’s age is a significant factor, with older inks that have become blurry and faded over time responding well. She adds that the closer the tattoo is to the heart, the better the results tend to be. “It’s to do with circulation; how well your body can break it down. Ankles and feet are usually more difficult – you need more treatments and you see more blistering,” she says. “Upper body tattoos respond very well, especially the neck, the upper arms and chest.” The number and frequency of treatments needed varies greatly, with practitioners reporting as few as five or six, and up to 15 treatment sessions, with intersession intervals of somewhere between two weeks and three months. The choice of equipment is also crucial, says Joyce. “The new [picosecond] machines reduce the number of sessions by about half because you’re getting the equivalent of three to four treatments in one go. Treatments are more expensive, but patients will end up spending the same, if not more, with the older technology, over a longer period of time with more sessions, more down time and more detriment to the skin.”

Duty of care

A practitioner’s job at the consultation stage is to educate patients about these variables, to make sure they’re fully prepared for the journey ahead of them. Part of this, says Sheffield, is to consider whether they have the requisite financial resources. “It’s going to cost someone the thick end of £1,000 to get rid of a large tattoo, so you have to look at whether they can afford to fulfil the course of treatment to the bitter end,” he adds. “The minute you do the first treatment, the tattoo looks less attractive than it did before, so you could end up with a nasty splodge in its place if you give up after three or four treatments.”
The psychological impact of what can be a very long-term, and potentially painful process should also be taken into account. “Some people just aren’t ready for the commitment, and with all patients, you have to make sure they’re doing it for the right reasons,” Sheffield continues.

While the development of technology means fewer, less intense side effects, some complications can still arise with even the most advanced lasers. “Immediately after the procedure we get a frosting appearance, so the tattoo goes white,” explains Sibley. “That’s an indication that the laser is being attracted to the pigment and is breaking it down. It’s very common to see slight oedema in the area too; we like to see some swelling because, again, that’s an indication that the particles are being broken down.” It’s also common for the skin to become inflamed and blistered, and to scab over. Some scarring can occur, but this is reduced if the patient does not pick at the scabs. For the practitioner’s part, they can minimise the risks of scarring by keeping the settings low to begin with, and increasing them with each session, taking care not to overlap the laser’s shots. “It’s important to make sure the shots are next to each other and not overlapping,” says Crozier. Patients should be advised to keep the area covered and to moisturise, for example with aloe vera or Bio-Oil, in between applying fresh dressings.

Tattoo pigments break down over time, with the colours fading gradually over a period of several weeks – so patients should be fully aware of the timescales involved. “Every time the patient comes back for their next treatment, we like to see some improvement in the appearance of the tattoo,” says Sibley. Pain can be reduced by using a topical anaesthetic before each procedure, such as a preparation of lidocaine, with prilocaine (as in Emla cream) or with tetracaine (as in Pliaglis).

A business opportunity

The use of lasers for cosmetic purposes was deregulated in England in 2010, so anyone can use them. This has led to a boom in the number of clinics and practitioners offering tattoo removal, and there is certainly demand, both here and internationally. “In my experience it seems as though a huge segment of the population are unhappy with their tattoos. There has definitely been a greater demand for tattoo removal throughout the past five years,” says Dr Kauvar. The advanced picosecond laser technology makes tattoo removal more accessible, she adds. “Knowing that you can remove your tattoo in five to six treatments over a three to four month period, rather than 15 or more sessions over one to two years, makes tattoo removal a realistic possibility for so many people who previously would not consider this option.” Dr Hoffman confirms that the commercial gains are high, too. “We see about 10 to 20 patients a day so we are overbooked for a year. It’s a good business and the return on investment is high,” he adds.

Last year, the British Medical Laser Association (BMLA) and the British Association of Aesthetic Plastic Surgeons (BAAPS), called for tighter regulation of the industry and rules governing who can buy and use lasers.⁶ Responsible practitioners would no doubt support such an action, but notwithstanding, anyone carrying laser tattoo removal should be suitably trained, says Sheffield. As well as educating practitioners how to properly use the equipment, Sheffield suggests that clinic leaders should also train staff to not give in to pressure from patients to increase power or take short cuts, because it almost always causes problems. “Like all medical procedures, you have to deal with your patient selection carefully,” he says. “Otherwise, you’re making a rod for your back and you’ll end up with an unhappy patient.”