Clinical Research on Laser-Assisted Tattoo Removal

Temporary tattooing using henna dye, a dark green power made from the leaves of the henna (Lawsonia inermis) plant has become very popular in recent years, both among adults and children. A recent article in the Journal of Dermatology details the case of a 9-year-old boy who developed allergic contact dermatitis after receiving a henna tattoo. Testing showed the boy had an allergy to para-phenylenediamine (PPD), the chemical often added to henna dye to make the color blacker and to speed up the dyeing process. After treatment with a cortocosteroid cream and oral antihistamines, the lesion went away, although some residual hypopigmentation remained.

Henna tattooing is not as risk-free as it seems. “The active substance from henna leaves is naphthoquinone,” the article’s authors note. “But for dying and tattooing, henna dye is usually mixed with other darkness-enhancing substances,
such as PPD or para-toluenediamine, both very potent contact allergens. Heavy metals, such as nickel, cobalt, chromium, lead and mercury, also potentially strong contact allergens, can be found in henna tattoo mixtures.”

Topical corticosteroids and oral antihistamines are usually all that’s needed to treat these allergic reactions, the authors added, although in some cases a short-term systemic corticosteroid may also be needed.

Source: Jovanovic DL, Slavkovic-Jovanovic MR. Allergic contact dermatitis from temporary henna tattooing. J Dermatol. 2009:36:63-65.

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A case study review, published in Dermatology, reports on 12 patients who came to the authors’ outpatient clinic with severe side effects after undergoing laser tattoo removal procedures performed elsewhere. All the patients had hypo- or hyper-pigmentations and scarring at the treatment site. Three had received their treatments from beauticians, the rest from physicians (dermatologists or plastic surgeons).

The authors conclude that the extensive scar formation and pigment changes that occurred in these 12 patients were most likely due to the use of improper light parameters. Two of the patients had been treated with an intense pulse light (IPL) laser, 1 with a radiofrequency device, and 9 with millisecond pulses of different laser systems.

Tattoo removal requires laser pulses of short duration (nanoseconds) and high intensities. After reviewing the treatment history of these 12 patients, the authors concluded that:

“the pulse duration of the light sources or lasers applied were considerably longer than those required by the principles of selective photothermolysis. The light intensities of those devices are normally not sufficient to destroy the pigment particles. Instead of destruction, the pigment particles in the skin are heated up and the heat is conducted to the adjacent tissue causing unspecific tissue injury. Lasers or intense pulsed light sources with millisecond pulses and low light intensities are clearly not suitable to be applied for tattoo removal.”

Source: Wenzel S, Landthaler M, Baumler W. Recurring mistakes in tattoo removal: a case series. Dermatology. 2009;218:164-167.<-->

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In a recent issue of Acta Dermato-Venereologica, French dermatologists report on a 47-year-old female patient’s unusual and severe “scleroderma-like” reaction to the red-only parts of a tattoo.

The authors of the case study point out that although other kinds of skin reactions to tattooing are common, dermal sclerosis (a hardening of the skin tissue) is rare.

The woman in this case had been tattooed three other times before experiencing any kind of severe reaction. With this fourth tattoo (a red, yellow, orange, white and black “sacred heart” on her ankle), she immediately noticed unusual swelling and intense itching, and, eventually, dermal sclerosis. She did not seek medical help, however, for 18 months, even though the symptoms interfered with her daily life and her sleep. Interestingly, the patient developed a concomitant itchy reaction on the red areas of another tattoo on her back. That tattoo had been drawn by the same tattoo artist and with the same red ink 6 months before the ankle tattoo.

The authors concluded their case study report with the following remarks:

Source:Kluger N, Mathelier-Fusade P, Moguelet P. Scleroderma-like reaction restricted to the red parts of a tattoo. Acta Derm Venereol. 2009;89:95-96.

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Researchers from the University of Maryland Department of Dermatology published a report in the Journal of Cutaneous Pathology about a case of a patient presenting a superficially invasive squamous cell carcinoma (SCC), keratoacanthoma (KA) type, of the left forearm in a 1-month-old tattoo.

They took an initial biopsy and in the time following, he developed four more additional lesions. In the area of the lesions the patient had recently received a multicolored tattoo. Here is an excerpt from their report:

On physical examination, the patient had a large, multicolor tattoo on his left forearm, a well-healed surgical biopsy site and four erythematous hyperkeratotic papules within differently pigmented areas of the patient’s tattoo. Histopathological examination showed KA and tattoo pigment. Based on the eruptive nature of these lesions, their clinical presentation and the histopathological changes, we report this as the first case of eruptive KA arising in a multicolor tattoo.

Has anyone else heard or seen of a similar case?

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A new French study published this month describes some potentially lethal allergic reactions patients have had following Henna tattoos received on vacation. Henna tattoos are the temporary tattoos common in India and other Eastern nations which many Westerners will receive while visiting on vacation. They are especially popular among children and young adults.

The inks used to perform the tattooing include a powerful allergen, Para-phenylenediamine (PPD), which is responsible for the majority of complications which arise from Henna tattoos. Typically Henna tattoo side effects are localized contact dermatitis, keloid or hypertrophic scarring, temporary or sometimes permanent hyper and hypo pigmentation.

The study also reports cases of type I hypersensitivity reactions (urticaria, angioedema, or anaphylaxis) with potentially lethal outcomes.

The researchers recommend the greater education of Western consumers about the risks involved in Henna tattooing.

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A new study by Mass General researchers Drs. Rox Anderson, Avram and Izikson have shown two patients who’ve had an immunologic reaction following laser tattoo removal. There have been reports of patients who are undergoing an allergic reaction to a tattoo ink who, upon receiving laser tattoo removal, have gone into full body anaphylactic shock. This may potentially be life threatening in some cases.

This is, however, rare. The purpose of the study done by Anderson et al was to study the potential immunologic reactions following laser tattoo removal.

As laser tattoo removal is one of most commonly used indications for medical lasers the concern is obvious, will patients be at risk for some unwanted complication due to the inks?

Anderson et al report that:

Two patients developed transient immunoreactivity that presented as regional lymphadenopathy after laser tattoo removal of professional black and blue-green tattoos. These reactions resolved without any complications.

CONCLUSIONS: Tattoo pigments released or modified by laser therapy may trigger transient immunoreactivity in susceptible individuals.

Clearly there is some potential complication to laser assited tattoo removal, but given how often it is performed with few reported complications, the risk is low.

More information about the use of laser to remove unwanted tattoos

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A new study published by leading dermatologist Dr. Edward Ross at the Naval Medical Center in San Diego looked at the absorption spectra of various tattoo inks and found some interesting results.

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How tattoo inks absorb various laser light is an important question as it may determine the success of the removal of a tattoo. Here Dr. Ross et al report on their results:

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�Absorption spectra of common tattoo pigments, their reaction to irradiation at 532 and 752 nm, and correlation with their titanium and iron component are important to the selection of an optimal laser device.

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OBJECTIVE The objectives were (1) to establish the absorption spectra of common tattoo pigments and India ink and (2) to determine their response to laser irradiation at 532 and 752 nm and correlate this to their composition.

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MATERIALS AND METHODS Samples of 28 tattoo pigments and India ink were mixed in agar and analyzed with a spectrophotometer. These agar plates were irradiated with Q-switched wavelengths of 532 and 752 nm.

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RESULTS The highest absorbance of red was in the complementary spectrum, while blue, yellow, and orange had peaks in the adjacent portion of the visible light spectrum. There is great variability in the absorbance of green tattoo material. Pigment darkening was noted at both wavelengths in all iron-containing pigments except black. It was variable in those containing titanium. Pigments tested responded with either clearance or darkening at 532 nm; however, response at 752 nm was more limited.

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CONCLUSION (1) Tattoo pigment absorption spectra can explain why some colors are more resistant to removal. (2) Pigment darkening is a complex process.�

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Does anyone have any comments/questions on this?

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A fascinating case has been reported in the November 2007 Journal of Cutaneous Pathology. French dermatologists at the University of Montpellier have reported a case of Keratoacanthoma (KA), a common keratinizing squamous cell neoplasm of unknown origin characterized by rapid growth and spontaneous involution, apparently brought on as a complication of red tattoo dye.

A 41 year old woman came to the department with no history of medical problems (other than hereditary spider veins) and presented a growing nodule confined to the red part of a tattoo on the scapula. According to the their report:

Histology showed a keratin-filled cuplike crater with an epithelial proliferation (hyperkeratosis, parakeratosis, no keratinocyte atypia). An inflammatory infiltrate in the dermis composed of lymphocytes and histiocytes intermixed with red ink-related exogenous pigments was noted. Lack of papillomatosis and viral inclusions ruled out the diagnosis of viral wart, absence of granulomatous reaction ruled out deep fungal or mycobacterial infection and lack of cytological atypia and frank architectural abnormalities did not favour a squamous cell carcinoma.

As a result of this case, the report concludes that KA should be included in the list of cutaneous complications related to tattooing. The diagnosis of such complications, however, may be challenging as differential diagnoses include pseudoepitheliomatous hyperplasia and squamous cell carcinoma. The report urges removal of the entire area, thorough histological examination and careful follow up as mandatory.

Does anyone have any experience with such a case? Or complications arising from red dye?

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Leading researchers published a study in the Dermatologic Surgery Journal which evaluated the efficacy of S-Caine peels for the induction of local anesthesia for laser-assisted tattoo removal. The study, headed up by researchers at the University of Louisville Department of Dermatology, involved multiple centers and was a randomized, double-blind, placebo-controlled study.

The researchers enrolled thirty adult patients undergoing laser tattoo removal. Each patient received both an S-Caine Peel and placebo simultaneously for sixty minutes. The primary efficacy parameter used in the study was a 100 mm visual analog scale (VAS) for patient self-assessment. In addition, secondary efficacy assessments were utilized including both the investigator�s and an independent observer�s evaluation of the subject�s pain. Each used a categorical four-point scale (no pain to severe).

The results were significant. The study reports:

Mean VAS scores were 42 mm for the S-Caine Peel and 66 mm for placebo treatment sites (p=.001). Patients received adequate pain relief in 50% of S-Caine Peel sites versus 7% of placebo sites (p=.002). The percentage of those who would like to use the S-Caine Peel again were 43% for the S-Caine Peel compared with 7% for placebo (p=.005). Investigators’ evaluations revealed that 70% of patients had less pain at S-Caine Peel treatment sites compared with 10% with less pain at placebo sites (p<.001), and 70% of the S-Caine Peel-treated sites achieved adequate anesthesia versus 10% of placebo sites (p<.001). The independent witness assessed less pain in 67% of S-Caine Peel-treated sites versus 10% of the placebo sites (p=.002). One occurrence of moderate to severe erythema was noted at both an S-Caine Peel and a placebo treatment site on removal of the S-Caine Peel after 60 minutes, which self-resolved quickly. There was no statistical difference between the two groups. Other side effects were limited to local mild, transient erythema at the application sites. CONCLUSION: Administration of the S-Caine Peel for 60 minutes prior to laser-assisted tattoo removal was effective in significantly reducing pain levels associated with the procedure.

The researchers concluded that the administration of the S-Caine peel for sixty minutes prior to the treatment session was indeed effective in significantly reducing pain levels. This is a great report and we are excited to hear thoughts on this.

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A study by researchers at the University of Miami Miller School tested the effects of imiquimod, an immune response modifier, on laser tattoo removal. The study had a primary efficacy parameter which tested the tattoo clearance on a five point scale (poor through complete), and a secondary efficacy scale measuring textural changes, also on a five point scale.

Twenty subjects were enrolled in the study, each of whom had similar tattoos. The study was randomized and double-blinded. Subjects were either given daily applications of imiquimod or placebo, with laser therapy in four to six week intervals. There were a total of six laser treatment sessions.

Nineteen subjects completed the study. The study published by the researchers reports that:

The mean score for tattoo clearance with imiquimod versus placebo was 3.2 versus 2.9 and, for textural changes, was 1.37 versus 1.21 (differences not statistically significant). There was no difference in subjective pain during and between laser sessions and no undesirable pigment alterations were reported. Adverse reactions were more frequent with imiquimod compared to placebo. CONCLUSION: Topical imiquimod is an ineffective adjunct to laser-assisted tattoo removal.

The results with imiquimod as an adjunct to laser tattoo removal were insignificant. Hopefully we can find more comments on this study.

The information found on this website is not designed to replace the patient/physician relationship.