1. Department of Dermatology, Yale University School of Medicine, New Haven, USA
2. SkinCare Physicians, Chestnut Hill, USA
3 Department of Medicine (Dermatology), Dartmouth Medical School, Hanover, USA

ABSTRACT

As the incidence of tattoo placement continues to increase, so does the demand for tattoo removal, with more than 10 million people in the US alone with a tattoo. Used in an appropriate clinical setting, Q-switched lasers provide relatively efficacious clearance of decorative tattoo pigment with minimal side-effects. We present our clinical experience along with literature findings on decorative tattoo removal and the important issues practitioners should consider in the management of tattoos.

Key Words:
tattoo, laser

In the United States, an estimated 7–20 million people carry at least one tattoo.¹ Recently, Laumann and Farmer conducted a random survey of 500 men and women and found a prevalence of tattooing in 26% of males and 22% of females. Of those with tattoos, 17% considered tattoo removal.² The top reasons for tattoo removal are to improve self-esteem, to remove a disliked design, and to increase credibility with friends.³

Prior to laser technology, tattoos were removed via techniques with a high likelihood of scarring, such as surgical excision and cryosurgery. Unfortunately, no one laser system can remove all available tattoo inks. This review provides our clinical experience and recommendations for decorative tattoo removal.

The Tattoo

Essentially, tattoos are exogenously placed chromophores. Amateur tattoos are less dense, placed at variable depths, and composed of carbon-based ink. Professional tattoos contain a variety of densely packed, colored pigments at a uniform depth. Once implanted, the ink particles are phagocytosed by resident dermal fibroblasts, where they permanently remain in the superficial dermis.⁴

Laser Removal

In order to selectively remove tattoo pigments placed in the dermis, pulsed lasers must meet the following criteria:

a) The laser wavelength must be well absorbed by the targeted ink.
b) The heat generated should be spatially confined to the target.
c) The energy delivered must be sufficient to cause the desired effects.⁵

Quality-switched (Q-switched) lasers (lasers with ultrashort energy pulses in the nsec domain) with wavelengths in the visible-to-near infrared range (532–1064nm), enable the deposit of energy very quickly, producing a “photoacoustic” effect. The intense heat transients cause some particles to shatter and kill the cells in which the pigment resides. The rupture of pigment-containing cells eventually triggers phagocytosis and the packaging of tattoo fragments for lymphatic drainage.⁶

Several issues are important when evaluating a tattoo for removal (Table 1).⁷ Amateur tattoos generally require fewer treatment sessions than professional tattoos. Distally located tattoos are more difficult to remove, and older tattoos may or may not be easier to remove than newer ones.⁸ Lastly, bright-colored inks may necessitate more treatment sessions.

Q-switched Laser Systems

The use of Q-switching laser pulses was first explored with the Q-switched ruby laser (QSRL) (694nm), and expanded to include the Q-switched neodymium: yttrium-aluminum-garnet (Nd:YAG) laser (532nm and 1064nm) and the Q-switched alexandrite laser (755nm).

The absorption spectrum of tattoos is unknown, with some colors responding better than others. As a result, a combination of laser systems may be used in stages for a single tattoo (Table 2).

Q-switched Ruby Laser (694nm)

The QSRL is effective for the removal of black, blue, and green inks. The laser penetrates to a depth of approximately 1mm and has spot sizes up to 6.5mm. Because this wavelength is well absorbed by melanin, caution should be used, as injury to melanocytes can lead to transient hypopigmentation and even depigmentation as well as textural change. The goal of treatment should be immediate tissue whitening (corresponding to water vapor in the skin) with minimal or no bleeding, and as with all laser treatments, no more than 10%–20% spot overlap should be employed. When compared to the other Q-switched lasers, the QSRL was shown to have the highest clearing rate after four and six treatments of blue-black tattoos. However >95% clearance was only obtained in 38% of the tattoos.⁹ For amateur tattoos, it has been reported that a mean of 4.92 treatments are needed to achieve clearance of > 90% of pigment.¹⁰ Other studies suggest only 11%–28% of professional tattoos achieve >75% clearance after more than six treatments.^11,12

Q-switched Nd:YAG Lasers (532nm and 1064nm)

The Q-switched Nd:YAG laser system overcomes the obstacle of excessive melanin absorption and is used to remove blue and black ink and tattoos in darker skin types (1064nm), or red pigment (532nm). The clinical endpoint following laser treatment is whitening of the skin with occasional mild pinpoint bleeding. Current models offer a spot size range of 1.5–8mm, which may be more appropriate for eyeliner tattoos.

532nm

The 532nm wavelength (green light) is absorbed by hemoglobin, and as a result, purpura lasting 1 week to 10 days frequently occurs after treatment. This wavelength is also effective for red, orange, and occasionally yellow ink. In 63% of red tattoos, > 75% clearance was achieved after one to five treatments at 2.5 J/cm2. In this same study, only two of eight yellow tattoos faded.¹³

Some reports have detailed the paradoxical darkening of red tattoo pigment as well as other skin-toned, yellow, and pink tattoos.^14,15 This occurs as the laser pulse reduces ink from rust-colored ferric oxide (Fe2O3) to jet black ferrous oxide (FeO).¹⁶ Similarly, bright colors may contain white ink made up of titanium dioxide (TiO2, T4+) that is reduced to TiO2 or blue Ti3+ upon laser treatment.

1064nm

The long 1064nm wavelength has the deepest penetration and carries the least risk of hypopigmentation; however, it is also the least effective in removing brightly colored pigments. Of all the laser systems, it is the one we recommend for use in darker skin types. This wavelength may also be useful when residual, more deeply placed ink particles are all that remain, as well as in the treatment of eyeliner tattoos, because it is less likely to damage the hair follicle.

Ferguson and August found that 79% of amateur black tattoos were >75% clear after one to five treatments at 1064nm, and 74% of professional tattoos achieved similar clearance but required up to 11 treatments (average 6.3).¹³

Q-switched Alexandrite Laser (755nm)

Although this laser system has the least amount of tissue splatter owing to its slightly longer pulse duration of approximately 50nsec (compared to 5– 15nsec for the Nd:YAG and 15–40nsec for the ruby laser) it is not as successful as the other models. Similar to the QSRL, the alexandrite is most effective for removing black, blue, and green inks. As with the other lasers, the clinical endpoint is tissue whitening. In a study by Stafford, et al., an average of 11.6 treatments was required to completely remove professional blue-black tattoos, compared with 10.3 treatments for the same results in subjects with amateur tattoos. Hypopigmentation occurred in 80% of treated subjects, which resolved within 3–4 months of treatment.¹⁷

Further Research

As noted, the data available for solid colors have been mixed and may not be adequate for patient satisfaction. As a result, picosecond lasers such as the titanium:sapphire (795nm) laser are being compared to current Q-switched technology. It is theorized that by confining thermal and photomechanical damage to the target particle more effectively, these lasers may optimize tattoo removal either by increased phagocytosis or through transepidermal elimination. Initial animal studies¹⁸ have been promising, as was a study in human subjects that showed a higher success rate of tattoo clearing with fewer laser treatments.¹⁹ To date, however, only prototypes of this laser are available.

Conclusion

While no single laser system holds the answer for tattoo removal, Q-switched lasers can successfully fade most tattoos with minimal adverse effects. In understanding the capabilities and limits of current laser technology, practitioners can set realistic goals
with their patients. Complete clearance of all treated tattoos is rare. At best, depending on the color, practitioners can expect 75% clearance in half the cases they treat. As the demand for tattoo placement increases, research continues to perfect tattoo removal with the development of picosecond and femtosecond laser systems.

References

1. Anderson RR. Tattooing should be regulated. N Engl J Med 326(3):207 (1992 Jan).
2. Laumann AE, Farmer AJ. Tattoo and body piercings in the United States: a national data set. J Amer Acad Derm (in press).
3. Armstrong ML, Stuppy DJ, Gabriel DC et al. Motivation for tattoo removal. Arch Dermatol 132(4):412-6 (1996 Apr).
4. Lea PJ, Pawlowski A. Electron microscope assessment of epidermis, epidermal-dermal junction, and dermis. Int J Dermatol 26(7):453-8 (1996 Apr).
5. Kilmer SL. Laser treatment of tattoos. Dermatol Clin 15(3):407-17 (1997 Jul).
6. Kuperman-Beade M, Levine VJ, Ashinoff R. Laser removal of tattoos. Am J Clin Dermatol 2(1):21-5 (2001).
7. Kilmer SL. Laser eradication of pigmented lesions and tattoos. Dermatol Clin 20(1):37-53 (2002 Jan).
8. Prinz BM, Vavricka SR, Graf P, Burg G, Dummer, R. Efficacy of laser treatment of tattoos and using lasers emitting wavelengths of 532nm, 755nm and 1064nm. Br J of Dermatol 150(2):245-51 (2004 Feb).
9. Leuenberger ML, Mulas MW, Hata TR, Goldman, MP, Fitzpatrick RE, Grevelink JM. Comparison of the Q-switched alexandrite, ND:YAG, and ruby lasers in treating blue-black tattoos. Dermatol Surg 25(1):10-14 (1999 Jan).
10. Reid WH, Miller ID, Murphy MJ, Paul JP, Evans JH. Q-switched ruby laser treatment of tattoos; a 9-year experience. Br J Plastic Surg 43(6):663-9 (1990 Nov).
11. Kilmer SL, Lee MS, Grevelink JM, Flotte TJ, Anderson RR. The Q-switched Nd:YAG laser effectively treats tattoos. A controlled, doseresponse study. Arch Dermatol 129(8):971-8 (1993 Aug).
12. Taylor CR, Gange WR, Dover JS, et al. Treatment of tattoos by Q-switched ruby laser. Arch Dermatol 126(7):893-9 (1990 Jul).
13. Ferguson JE, August PJ. Evaluation of the Nd:YAG laser for treatment of amateur and professional tattoos. Br J Dermatol 135(4):586-91 (1996 Oct).
14. Anderson RR, Geronemus R, Kilmer SL, Farinelli W, Fitzpatrick RE. Cosmetic tattoo ink darkening. A complication of Q-switched and pulsed-laser treatment. Arch Dermatol 129(8):1010-4 (1993 Aug).
15. Varma S, Swanson NA, Lee KK. Tattoo ink darkening of a yellow tattoo after Q-switched laser treatment. Clin and Exp Dermatol 27(6):461-3 (2002 Sep).
16. Baumler W, Eibler ET, Hohenleutner U, Sens B, Suer J, Landthaler M. Q-switch laser and
    tattoo pigments: first results of the chemical and photophysical analysis of 41 compounds. Lasers Surg Med 26(1):13-21 (2000).
17. Stafford TJ, Lizek R, Tian Tan O. Role of the alexandrite laser for removal of tattoos. Lasers Surg Med 17(1):32-8 (1995).
18. Herd RM, Alora MB, Smoller B, Arndt KA, Dover JS. A clinical and histologic prospective controlled comparative study of the picosecond titanium: sapphire (795nm) laser versus the Q-switched alexandrite (752nm) laser for removing tattoo pigment. J Amer Acad Dermatol 40(4):603-6 (1999 Apr).
19. Ross V, Naseef G, Lin G, et al. Comparison of responses of tattoos to picosecond and nanosecond Q-switched Neodymium:YAG lasers. Arch Dermatol 134(2):167-71 (1998 Feb).

¹Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
²Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA
³SkinCare Physicians of Chestnut Hill, Chestnut Hill, MA, USA
⁴Department of Medicine (Dermatology), Dartmouth Medical School, Hanover, NH, USA

ABSTRACT

Over the past 2 decades, there have been numerous advances in laser therapy of birthmarks in the pediatric population. Concerns regarding efficacy, overall benefit, and side-effects linger. We present our opinion, based upon decades of clinical experience, on the role of lasers to treat port wine stains, superficial hemangiomas, and café au lait macules in children.

Key Words:
hemangioma, café au lait macules, pediatrics

Port Wine Stains

Port wine stains (PWSs) are congenital vascular malformations composed of ectatic capillary-like vessels in the papillary dermis that occur in 0.3% of newborns. They
can vary in size (millimeters to >50% body surface area) and color (flat pink patches to “cobblestoned” purple plaques) as the patient ages. Children with PWSs should be treated
early to prevent adverse sequelae to their psychological development.

Observable reduction in PWS size and color is achieved through laser therapy by selective vascular damage. The pulsed dye laser (PDL) is the laser of choice due to its low risk of scarring or pigmentary alteration^1,2 and relatively high rates of clearing.

Which Laser Is Best for Children?

In one study, use of the 595nm PDL with 1.5msec pulse width and fluences up to 11-12J/cm2 with a dynamic cooling spray resulted in >75% clearance of PWSs in 63% of patients under the age of 12 months, after four treatments.³ Lack of controlled trials with single parameter variation make it difficult to ascertain optimal settings in this area. The addition of a dynamic cryogen cooling device (DCD) has advanced the treatment of PWSs by allowing for epidermal protection via surface cooling and resultant heat accumulation in vessels. Recently Bernstein and Brown, using the 585nm PDL with DCD at a 1.5msec
pulse duration, demonstrated an average 68% subjective and 69% objective improvement in 83 previously untreated PWSs after approximately four treatments.⁴ Additional devices,
including the 1064nm Nd:YAG are now also being tested for PWS combination treatment.⁵

We routinely start with the largest available spot size (10mm), a pulse duration of 1.5msec, and fluence of 7.5J/cm2 with the V-Beam laser (Candela) and then, depending on the
outcome, we may reduce the spot size to 7.0mm and vary the fluence from 9-14J/cm2 or 6-8.5J/cm2 with the V-Star laser (Cynosure). Treated tissue should appear dark purple
but not assume a grayish hue, which may indicate potential overtreatment. This temporary purpura may last 7-10 days.

Will It Work?

Certain favorable prognostic features are known about PWSs. We advocate early treatment; success is likely due to thinner skin in infants, as well as smaller and more superficial vessels leading to improved clearance in fewer treatment sessions.⁶ Based on current studies, >50% improvement has been reported after an average of four treatments per patient.^3,4,7

Red lesions appear to clear more with the PDL than pink or purple lesions and lesions on the head and neck respond more favorably than those on the trunk and lower extremities. Furthermore, the midline facial area responds better than the lateral face and neck.

PWSs rarely clear completely even with a series of treatments, but optimal improvement is usually achieved with repeat sessions every 4-8 weeks. PWSs may respond, (to a lesser degree) in skin types IV and V with lower fluences and multiple treatments, though the risk of pigmentary alteration is more common than that in lighter skin tones (see Table 1).

Superficial Hemangiomas

Superficial hemangiomas are benign proliferations of endothelial tissue with an incidence of almost 10% by the age of 1 year. They are frequently located on the head or neck and if not present at birth, usually appear shortly thereafter, showing a female-to-male predominance. The natural history of these hemangiomas has two phases, proliferating (marked by significant growth during the first 7 months of life) and involuting (pallor within the lesion followed by involution and residual atrophic telangiectatic skin with fibrofatty tissue in some cases). Complications such as ulceration, obstruction of vital structures, and recurrent bleeding can occur. Laser therapy can prevent such complications and provide psychological relief for pediatric patients and their parents during the first few years of life. Early treatment reduces the chance that the lesion will reach its full size and minimizes the risk of fibrofatty tissue development.

Which Laser Is Best for Children?

The short-pulsed (0.45-1.5msec) PDL (either 585nm or 595nm) with dynamic or air cooling is the treatment of choice for hemangiomas comprised mostly of superficial vessels.⁹ Since the depth of selective photothermolysis with the 585nm PDL is 1.2mm, deeper components of hemangiomas may progress. Better results are often achieved with larger spot sizes (7mm, 10mm).10 Newer long-pulsed Nd:YAG lasers may be more effective but further study is necessary.

Will It Work?

Although opinions differ regarding the treatment of hemangiomas in patients younger than 4 months old¹¹ (as hemangiomas may spontaneously resolve within the first year of life), long-term studies have not been carried out using objective observers nor have data regarding significant improvement vs. clearance been reported. We advocate early intervention given the minimal risks associated with laser therapy and the notion that the most effective time for treatment is during the proliferation phase. Some evidence
suggests lesions less than 3mm may resolve better than thicker lesions.¹² As in treatment of PWSs, the basic principles of depth and size apply to efficacy of laser therapy. Multiple treatments may be needed to achieve maximal clearing and are recommended to begin during the rapid proliferating phase in 2-3 week intervals. During the involuting phase, treatments can be spread out to every 1-2 months.

Ulceration and subsequent pain is a frequent complication in 5%-14% of all infantile hemangiomas and though compelling data do not exist to support the use of a single therapy,¹³ faster rates of resolution may occur with the PDL^14,15 than with Nd:YAG lasers, potentially due to increasing rates of reepithelialization. In our practice, we always start with biologic dressings and add PDL if this fails.

Café au Lait Macules

Café au lait macules (CALMs) are benign hyperpigmented areas, present at birth in 2% of all newborns (up to 1/3 of black neonates).¹⁶ While they can be markers for underlying disease such as neurofibromatosis, isolated CALMs are recognized as a common finding in many infants and may increase in size over time. The exact etiology of the macules is unknown. Cosmetic improvement can be achieved by use of any of the short-pulsed lasers which selectively destroy melanosomes.

Which Laser Is Best for Children?

Laser therapy for CALMs is considered safe but there is no data to suggest that treatment of CALMs in infancy is required. The best choice is the Q-switched pigment-specific laser. Efficacy studies on the Q-switched Nd:YAG lasers (532nm or 1064nm), the Q-switched alexandrite (755nm), and the Q-switched ruby laser (694nm) show that each of these lasers works with varying degrees of efficacy;¹⁷ to date no study comparing the Q-switched lasers has been carried out. Wheeland and Schmults¹⁸ recommend the Q-switched 532nm Nd:YAG laser, though it is worth mentioning that the risk of purpura and postoperative abradement of the treated area may be unacceptable to parents of pediatric patients.

Will It Work?

Clinical experience with repeated Q-switched laser treatments has been inconsistent, with total clearing occurring in approximately 50% of patients and recurrence and patchy pigmentation occurring in the other half.¹⁹ The risk of repigmentation exists for all CALMs though the mechanism behind this is unknown. It appears that if total clearing is achieved repigmentation is rare, though an exact percentage has not been uniformly reported. The key to successful treatment is to use relatively low fluences and perform multiple treatment sessions 6-8 weeks apart. It is generally agreed that results seen at 12 months after the last treatment are usually lasting.^20,21 Given the risk of pigmentary alteration, skin types IV-VI should generally not be treated, as CALMs are often less apparent and the risk of pigment change outweighs cosmesis. In all skin types, the risk of postinflammatory hypopigmentation exists, and if this occurs, a delay in further treatments until the pigmentation normalizes is recommended (see Table 2).

Conclusion

While additional long-term studies may be needed to assess the efficacy of laser therapy in the pediatric population, our experience suggests that laser use in children for the treatment of port wine stains, superficial hemangiomas, and café au lait macules has not only been well tolerated by patients but also successful with minimal side-effects.

References

1. Levine VJ, Geronemus RG. Adverse effects associated with the 577- and 585-nanometer pulsed dye laser in the treatment of cutaneous vascular lesions: a study of 500 patients. J Am Acad Dermatol 32(4):613-7 (1995 Apr).
2. Kim KH, Rohrer TE, Geronemus RG. Vascular lesions. In: Dover JS, Goldberg DJ, editors. Procedures in Cosmetic Dermatology, Laser and Lights. Volume 1. China: Elsevier Saunders p11-27 (2005).
3. Geronemus RG, Quintana AT, Lou WW, Kauvar AN. High-fluence modified pulsed dye laser photocoagulation with dynamic cooling of port wine stains in infancy. Arch Dermatol 136(7):942-3 (2000 Jul).
4. Bernstein EF, Brown DB. Efficacy of the 1.5 millisecond pulse-duration, 585nm, pulsed-dye laser for treating portwine stains. Lasers Surg Med 36(5):341-6 (2005 Jun).
5. Ahcan U, Zorman P, Recek D, Ralca S, Majaron B. Port wine stain treatment with a dual-wavelength Nd:YAG laser and cryogen spray cooling: a pilot study. Lasers Surg Med 34(2):164-7 (2004).
6. Lanigan SW, Taibjee SM. Recent advances in laser treatment of port-wine stains. Br J Dermatol 151(3):527-33 (2004 Sep).
7. Kelly KM, Nanda VS, Nelson JS. Treatment of port wine stain birthmarks using the 1.5-msec pulsed dye laser at high fluences in conjunction with cryogen spray cooling. Dermatol Surg 28(4):309-13 (2002 Apr).
8. Lam SM, Williams EF 3rd. Practical considerations in the treatment of capillary vascular malformations, or port wine stains. Facial Plast Surg 20(1):71-6 (2004 Feb).
9. Ashinoff R, Geronemus RG. Capillary hemangiomas and treatment with the flash lamp-pumped pulsed dye laser. Arch Dermatol 127(2):202-5 (1991 Feb).
10. Selecting a laser to treat vascular lesions. In: Dover JS, Arndt KA, Geronemus RG, Alora MB, editors. Illustrated Cutaneous & Aesthetic Laser Surgery. Second Edition. Stamford: Appleton & Lange. p231-40 (2000).
11. Batta K, Goodyear HM, Moss C, Williams HC, Hiller L, Waters R. Randomised controlled study of early pulsed dye laser treatment of uncomplicated childhood haemangiomas: results of a 1-year analysis. Lancet 360(9332):521-7 (2002 Aug 17).
12. Garden JM, Bakus AD, Paller AS. Treatment of cutaneous hemangiomas by the flashlamp-pumped pulsed dye laser: prospective analysis. J Pediatr 120(4 Pt 1):555-60 (1992 Apr).
13. Kim HJ, Colombo M, Frieden IJ. Ulcerated hemangiomas: clinical characteristics and response to therapy. J Am Acad Dermatol 44(6):962-72 (2001 Jun).
14. Morelli JG, Tan OT, Weston WL. Treatment of ulcerated hemangiomas with the pulsed tunable dye laser. Am J Dis Child 145(9):1062-4 (1991 Sep).
15. Scheepers JH, Quaba AA. Does the pulsed tunable dye laser have a role in the management of infantile hemangiomas? Observations based on 3 years’ experience. Plast Reconstr Surg 95(2):305-12 (1995 Feb).
16. Chang MW, Levine N, Trout C. Disorders of hyperpigmentation. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. Volume 1. Spain: Mosby p975-1004 (2003).
17. Grossman MC, Anderson RR, Farinelli W, Flotte TJ, Grevelink JM. Treatment of café au lait macules with lasers. A clinicopathologic correlation. Arch Dermatol 131(12):1416-20 (1995 Dec).
18. Wheeland R, Schmults C. Pigmented lesions and tattoos. In: Dover JS, Goldberg DJ, editors. Procedures in Cosmetic Dermatology, Laser and Lights. Volume 1. China: Elsevier Saunders p41-66 (2005).
19. Stratigos AJ, Dover JS, Arndt KA. Laser treatment of pigmented lesions – 2000: how far have we gone? Arch Dermatol 136(7):915-21 (2000 Jul).
20. Alster RS. Complete elimination of large café au lait birthmarks by the 510 nm pulsed dye laser. Plast Reconstr Surg 96:1660-4 (1995).
21. Levy JL, Mordon S, Pizzi-Anselme M. Treatment of individual café au lait macules with the Q-switched Nd: YAG: a clinicopathologic correlation. J Cutan Laser Ther 1(4):217-23 (1999 Dec).