Tattoo removal has historically been scarring and painful, but modern methods are reducing those concerns
Tattooing is an ancient art whose origins have been traced as far back as the Stone Age (12,000 bce).1 Primitive people slashed their skin during bereavement ceremonies and rubbed ash into the cuts as a sign of grief. Decorative tattooing has been traced to the Bronze Age (8000 bce) through circumstantial evidence of crude needles and pigment bowls found in caves in France, Spain, and Portugal.2
People of this age decorated animal skins worn for warmth with ochre and plant pigments. This may have led to decorative tattooing of their own skin. Mummies dating from 4000 bce also had crude tattoos.3
Today, tattooing continues to thrive as an art form. The mid-1980s began a surge in tattooing popularity in the United States, and surveys in the past 5 years have found that 3% to 8% of the general population have tattoos.4–7 The Table shows the percentages of people who have tattoos by age group.
Significantly, smokers are almost 3 times more likely than nonsmokers to have tattoos, and slightly more women than men on college campuses and entering military service have tattoos.4,6,7 In a recent survey of professional women with tattoos, 94% said they were pleased with their tattoos,8 although a potential bias exists because those who were pleased may have been more likely to respond. Of the women who were pleased with their tattoos, 55% had friends with tattoos—a known influential factor.
Tattoos are increasingly featured in the media and advertisements. Tattooing-inspired television series such as Inked and Miami Ink have gained popularity within this past year.
The average age of acquisition of a professional tattoo is 18 years,9 and that of a self-inflicted amateur tattoo is 14 years.10–12 However, an individual’s quest for identity at age 14 to 18 is often irrelevant or embarrassing at age 30 or 40; in that age range, 50% or more people regret having tattoos.13,14
As a consequence of the increasing numbers of tattoos Americans are receiving, the demand for tattoo removal is rising as well. Among professional persons with tattoos, 38% report significant problems with having a tattoo and 28% consider tattoo removal.
The motivation for tattoo removal may encompass not only internal regret and desire for a more mature identity and method of self-expression, but may be driven by external societal pressure. In general, tattoos are not well received by the public, and tattooed individuals may be perceived as antisocial, aggressive, or immature and unable to accept controls and authority. Tattoos may become a significant barrier to employment, social status, or religious acceptance.15,16 Because most people live in the present rather than in anticipation of future endeavors, however, tattoos remain popular.9
Tattoo Removal Through the Ages
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With the advent of Q-switched lasers operating in the nanosecond range, and the ongoing development of picosecond lasers, the promise of scarless tattoo removal has become reality. But first, a little history: Egyptian mummies dating to 4000 bce show evidence of attempts at tattoo removal.17 The earliest documented report of tattoo removal was by Aetius, a Greek physician, who described salabrasion in 543 ce.12 In general, older tattoo-removal techniques involved destroying or removing the outer skin layers by mechanical, chemical, or thermal means, accompanied by inflammation.
Transepidermal elimination of pigment occurred through denuded skin18–21 and via an exudative phase that allowed tattoo pigment to migrate to the wound surface to be absorbed into the dressing. The inflammatory response may have promoted macrophage activity and increased phagocytosis, enabling additional pigment loss during the healing phase.
The primary disadvantage of all these mechanical destructive modalities is the high risk of scarring. Hypertrophic scars are very common when the removal of tissue is performed deeply in an attempt to remove all tattoo pigment. In addition, the procedure can be exquisitely painful, residual tattoo pigment is common, and postoperative pain can also be significant.
Surgical excision of skin containing tattoo pigment often results in incomplete tattoo removal, tissue distortion, and scarring because of limitations in wound closure and healing. Thermal injury, via fire, hot coals, or cigarettes, has also been used for centuries to attempt to remove unwanted tattoos—again, usually with significant scarring.
Chemical Removal
More recent advances in tattoo removal have focused on nonsurgical methods of enhancing macrophage activity and pigment clearance without causing inflammation—hence, reducing the potential for scarring while increasing removal efficiency. In 1888, Variot first described the use of caustic chemicals (tannic acid and silver nitrate) after disruption of the skin surface with punctures and incisions.22 This technique, known as the French method, left variable amounts of residual tattoo and also resulted in hypertrophic scarring in 34% of patients.23
Phenol solution, used in the same manner as for facial peels,24 and trichloroacetic acid (TCA) used in a 95% solution25,26 have been used to remove tattoos, but resulted in hypopigmented scars. Repeat application was hazardous and could result in a full-thickness burn that required skin grafting.
The Laser: Milder and Safer
The advent of lasers offered promise for a precise means of inducing predictable thermal necrosis to tattoo-containing tissue in a manner that would reduce scarring. In the 1980s, 50% urea paste was used to improve the results of laser tattoo removal.27,28 After laser treatment, a generous application of 50% urea in hydrophilic ointment was applied to the wound and covered with a nonstick dressing. The dressing was changed daily with reapplication of the urea ointment for 1 to 2 weeks, until tattoo pigment was no longer seen on the bandage.
Modern research focuses on combining milder and safer chemicals with Q-switched laser treatments to enhance the efficacy of the laser without increasing inflammation or the potential for scarring. McNichols et al tested methods of reducing the attenuation coefficient of the dermis and epidermis with glycerol, leading to improved laser tattoo removal by providing increased efficiency of laser delivery to embedded ink particles and enabling the use of shorter-wavelength visible lasers that are more effective on certain inks.29
Intradermal and transdermal applications of glycerol on a hairless guinea pig tattoo model were tested, using visual inspection, spectral analysis, and optical coherence tomography techniques to assess effectiveness. The outcomes of single laser-treatment sessions for both cleared and uncleared tattoo sites using Q-switched 755- and 532-nm lasers on three different inks showed that intradermal injection of clearing agents induced dermal clearing but resulted in necrosis and scar.
On the other hand, transdermal application of clearing agents resulted in moderate reversible clearing, localized to the superficial layers of the skin, without complications. Statistically significant differences in laser-treatment outcome were observed relative to a number of treatment parameters, including the treatment of certain tattoos by short-wavelength lasers.29
As Cohen and Goldman first hypothesized in 1994, macrophage-stimulating factors can be used for adjuvant therapy with laser tattoo removal.30 With the advent of imiquimod, the first of a new class of topical immune-response–modifier drugs, such adjuvant therapy is readily accomplished. Nonsurgical tattoo removal in animal models has been demonstrated using topical imiquimod cream.31–33
Solis et al compared the efficacy of topical imiquimod and tretinoin for the removal of fresh tattoos in a guinea pig model.32 Guinea pigs were tattooed with black, red, green, and yellow inks. Begin-ning 6 hours after tattooing, comparison groups received no treatment, treatment with petrolatum, imiquimod cream alternating with tretinoin gel, imiquimod cream alone, or tretinoin gel alone for a period of 7 days. Biopsies of the tattoos were also described.
The control had normal-appearing tattoos with consistent histopathology on day 28. The subject treated with imiquimod cream clinically had no visible tattoo, consistent with greatly diminished or no dye evident on histopathology. Subjects treated with tretinoin gel and the combination of tretinoin gel and imiquimod cream had faded tattoos and moderate clearance of pigment on histopathology. These treatment regimens were associated with some degree of fibrosis and the loss of dermal appendages.
A Tattoo Experiment
One of my patients who volunteered for a trial of imiquimod cream in conjunction with Q-switched laser tattoo removal agreed to treat separate portions of his tattoos for comparison. As a teenager, he had a small blue-black tattoo of a bird placed on his forearm that was later covered with a second, larger, blue-black tattoo of another bird (Figure 1A). Within the next few years, he had an orange-brown lion’s head tattooed on his upper arm. As an adult, he tired of his tattoos and presented for tattoo removal.
At the first treatment session, the forearm tattoo was divided into three sections (Figure 1B). The first section was treated with a Q-switched alexandrite laser followed by imiquimod cream, the second section was pretreated with imiquimod cream prior to the laser (without subsequent imiquimod cream), and the third section was treated with imiquimod cream alone (without laser treatment).
For the section treated with laser followed by imiquimod cream, imiquimod was started once all crusting had resolved, approximately 10 days after the laser session, and was applied overnight Monday through Friday for the following 3 weeks. Pretreatment with imiquimod cream at the corresponding section was initiated 5 days prior to laser treatment, and was last applied the evening prior to the treatment session. Imiquimod cream was applied overnight Monday through Friday for 6 weeks altogether to the section treated with imiquimod alone.
The 6-week follow-up photograph (Figure 1C, page 38) demonstrates that the section treated with the laser followed by imiquimod cream cleared more than the section treated with imiquimod followed by laser, whereas the imiquimod-cream-alone section did not clear significantly. Following this initial test period, the entire tattoo was treated with the laser followed by the imiquimod-cream regimen; and after two Q-switched alexandrite and four Q-switched ruby laser sessions, the overlaid tattoo was completely removed and only the older, underlying tattoo still remains (Figure 1D, page 38).
Six weeks after an initial treatment with Q-switched ruby laser alone, the orange-brown upper-arm tattoo did not clear significantly (Figure 2A). The next three Q-switched ruby laser treatments were followed by the above regimen of imiquimod cream to the entire upper-arm tattoo surface; and 6 weeks after the fourth laser treatment session, the orange-brown areas of the upper arm tattoo were nearly resolved (Figure 2B). The remaining small blue-black areas are being treated with a Q-switched alexandrite laser followed by the imiquimod-cream regimen.
In my clinical experience, tattoos treated with the Q-switched laser in conjunction with at-home imiquimod therapy during the interval between laser sessions yields more rapid visible clearance of the tattoo than laser or imiquimod treatment alone. Newer topical immune-response–modifier molecules are under development, and optimal therapeutic parameters for this class of adjuvant therapy are yet to be defined.
New Lasers, No Scars
With the advent of new Q-switched lasers that operate in the nanosecond range and the further development of picosecond lasers, the discharge of nonspecific thermal energy or heat is minimized, and “burn-free” scarless tattoo removal has become a reality.
Newer Q-switched lasers with shorter pulse durations (approximately 25 nanoseconds), higher fluences (8 to 10 joules per square centimeter), and better beam quality more rapidly clear tattoos.34,35 The Q-switched ruby laser, the Q-switched Nd:YAG laser, and the Q-switched alexandrite laser are all remarkably effective for removing tattoos with minimal scarring, although multiple treatment sessions are necessary and transient or permanent hypopigmentation is common.36
New research has found that repigmentation of persistent pigment-laser–induced hypopigmentation can be achieved using the excimer laser or other UV-range lasers.37 Gundogan et al describe successful repigmentation of hypopigmentation that developed following tattoo removal with the Q-switched Nd:YAG laser had remained unchanged for more than 4 years. The use of the 308-nm xenon chloride excimer laser induced a significant repigmentation in 40 sessions over 14 months. The excimer laser has the potential to influence the reduced activity of the melanocytes, as demonstrated by electron microscopy.
Postlaser hyperpigmentation, however, is related primarily to the patient’s skin type. Those with darker skin are more prone to hyperpigmentation no matter which wavelength laser is used. Treatment with hydroquinone and broad-spectrum sunscreens will resolve the hyperpigmentation within a few months, although in some patients it can be more prolonged. Textural changes or scars are, luckily, very rare.
Allergies and Toxicity
Allergic reactions to tattoo pigment after Q-switched laser treatment are possible.38 Unlike the destructive modalities previously described, Q-switched lasers mobilize the ink and may generate a systemic allergic response. If an allergic reaction to the ink has been noted, Q-switched laser treatment is not advised.
There is no evidence to date of systemic-toxicity reactions in vivo following laser treatment of tattoos. However chemical and photophysical analysis studies do find some evidence that potentially hazardous compounds can be liberated from the laser treatment of tattoo pigment in vitro.39,40
Vasold et al state that most tattoo colorants are industrial pigments that chemical industries never intended for human use, but rather for staining consumer goods. Based on a recent analysis of tattoo pigments, two widely used azo compounds were irradiated in suspension with a laser and subsequently analyzed by using quantitative high-performance liquid chromatography and mass spectrometry.
The high laser intensities cleaved the azo compounds, leading to an increase of decomposition products such as 2-methyl-5-nitroaniline, 2-5-dichloroaniline, and 4-nitrotoluene, which are toxic or even carcinogenic compounds. Moreover, the results of the chemical analysis show that the tattoo colorants already contain such compounds before laser irradiation.41
The last, but certainly not least, important area of development in tattoo removal has been anesthesia. Most tattoo-removal patients are not shy about saying that removing the tattoo is far more painful than receiving the tattoo in the first place. Topical or local anesthetics may be used for small-surface-area tattoos. For larger tattoos, this may not be feasible due to the relative toxicity of large doses of anesthetics.
As an alternative to general anesthesia—or, worse, no anesthesia—nerve-distraction techniques such as vibration may be used as a mode of cutaneous anesthesia. Smith et al propose vibration anesthesia, that is, the use of vibration delivered with commercially available inexpensive massagers to reduce discomfort in dermatologic procedures.42
The analgesic effect of vibration may be helpful for minimizing pain in patients who are undergoing a variety of aesthetic procedures, including Q-switched laser treatment of tattoos, as well as for facilitating anesthetic injections for needle-phobic patients. Although the use of vibration anesthesia generally does not eliminate pain completely, it can serve to make the injection or procedure much more tolerable. PSP
Michelle Ehrlich, MD, is a board-certified dermatologist and fellowship-trained aesthetic plastic surgeon in private practice in Los Angeles. She can be reached at [email protected].
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