Lasers Med Sci (2010) 25:619627 DOI 10.

1007/s10103-010-0800-2

REVIEW ARTICLE

Lasers for tattoo removal: a review

Sonal Choudhary & Mohamed L. Elsaie & Angel Leiva & Keyvan Nouri

Received: 8 January 2010 / Accepted: 21 May 2010 / Published online: 12 June 2010 # Springer-Verlag London Ltd 2010

Abstract Tattoos have existed and have been used as an expression of art by man for agesand so have the techniques to remove them. Lasers based on the principle of selective photothermolysis are now being used to remove black as well as colorful tattoos with varying successes. The commonly used lasers for tattoo removal are the Q-switched 694-nm ruby laser, the Q-switched 755-nm alexandrite laser, the 1,064-nm Nd:YAG laser, and the 532-nm Nd:YAG laser. Newer techniques and methods are evolving in tattoo removal with lasers. Choosing the right laser for the right tattoo color is necessary for a successful outcome. Our review aims to understand the principles of laser tattoo removal and their applications for different types and colors of tattoos. The review also highlights the complications that can occur such as dyspigmentation, allergic reactions, epidermal debris, ink darkening, and so on, in this process and how to prevent them. Keywords Lasers . Tattoos . Q-switched ruby laser . Q-switched alexandrite laser . Ink darkening

Introduction Tattoos are an ancient body art that has been practiced for ages and can be traced back to Bronze Age man whose
S. Choudhary (*) : M. L. Elsaie : A. Leiva : K. Nouri Department of Dermatology and Cutaneous Surgery, University of Miami, 1475 N.W. 12th Avenue, Suite #2175, Miami, Fl 33136, e-mail: drsonalchoudhary@gmail.com e-mail: Ext-schoudhary@med.miami.edu M. L. Elsaie Department of Dermatology and Venereology, NRC, Cairo, Egypt

body has been discovered frozen in ice with many tattoos on it [1]. Instruments from the Paleolithic period have been found which are thought to have used for tattooing [2, 3]. Egyptian mummies clearly indicate the existence of tattoos and their fondness for them. Tattoos have been used for ages to depict religious figures, names, personal ideas and feelings of happiness, belonging, frustration, identity, sexuality, anger, etc., using the body as a canvas and pigments for colors. In the United States, the prevalence among college students has been reported at 24% [4]. Tattoo removal is not an uncommon request at dermatologic surgery and cosmetic dermatology practices. There are five types of tattoos: amateur, professional, cosmetic, medicinal, and traumatic. Amateur tattoos require less treatment sessions than professional multicolored tattoos. Other factors to consider when evaluating tattoos for removal are their location on the body and the age and skin type of the patient. The physical mechanisms for lasertattoo interactions and the tattoo particle breakup process are not well understood and remain to be evaluated. Unconventional modalities of tattoo removal remain to be studied and the future could bring further developments and innovations in the removal of tattoos. Current research focus is on newer picosecond lasers as an alternative for the Q-switched systems.

Classification of tattoos & Classification on the basis of color:

Tattoos can be clearly classified on the basis of the color of pigment used to create them. The most common color is black, but over the years colorful tattoos utilizing multiple colors such as red, blue, green, brown, etc., have become

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increasingly common and popular. Often, two or more colors may be mixed to develop shades of a particular color or a new color, such as white and red mixed to make pink. & Classification on the basis of style:

are composed of a mixture of compounds, the pink, red, and flesh-colored tones often contain ferric oxide and titanium dioxide [5]. e) Traumatic tattoos Traumatic tattoos are undesirable tattoos caused by different foreign bodies such as fireworks' particles, sand, metals, glass, gunpowder, asphalt, dust, or petroleum products embedded forcefully in the dermis. Fine particles of black to blue pigments may be deeply embedded, which makes their removal extremely difficult [6, 7]. Most commonly, injuries affect the face, hands, and eyes. Traumatic tattoos require special consideration as the responsible pigment may react dangerously with laser therapy.

Tattoos are generally defined into five categories: amateur tattoo, professional tattoo, medical tattoo, cosmetic tattoo, and even traumatic tattoos. a) Professional tattoos Professional tattoo artists are expert tattooists as they know how to make a tattoo last. This means that they will place enough ink, deep enough, and of the right composition to make it last for years or decades, resulting in dense and adequately deep ink placement. Tattoo artists also have access to certain inks, such as metal oxides, that an amateur probably would not. The more ink there is in the skin the more laser treatments that are required. Also, certain inks, such as those containing iron oxide, are harder to clear with laser tattoo removal. b) Amateur tattoos These are the next most common type of tattoos, performed by individuals who are not well versed in the process. In general, amateur tattoos can be found among teenagers and in many formations of gang activity. Amateur tattoos can be made in many ways. Someone may make a tattoo gun using a guitar string and a battery or they may simply use a needle by hand. The ink could be pen ink, charcoal, or soot. Rarely, red (mercury), yellow (cadmium), green (chromium), and blue (cobalt) pigments have elicited a persistent, localized allergic reaction or photoallergic dermatitis. It is unusual to see colors other than black in amateur tattoos. Since these tattoos are usually light and made of organic ink, they tend to be quite easy to remove. A caveat to this is that if the ink was placed extremely deeply in the skin, such as with a deeply penetrating needle, it may be below the range of the laser. However, as long as the tattoo is visible to the eye, it should also be removable with the Q-switched laser. c) Medical tattoos These are rare tattoos, placed by medical professionals for the purpose of marking body parts such as nipple re-construction in a patient with post-mastectomy breast and nipple re-construction. Also, medical tattoos are used as markers for administering radiation therapy. d) Cosmetic tattoos These tattoos are considered the latest development in the tattoo industry, used to enhance physical appearance. The advantages of permanent tattoos as make-up are that they are waterproof, time-saving, as well as being hassle free. These can be performed by both a professional tattoo artist and a dermatologist. Although cosmetic tattoos

Cutaneous lymphoid hyperplasia (CLH) CLH or pseudolymphoma comprises of a heterogeneous group of benign T- or B-cell lymphoproliferative reactions that are either idiopathic or associated with stimuli such as drugs or contact dermatitis. Approximately 20 cases of tattoo-induced CLH have been reported to date where they have occurred as asymptomatic or itchy, single or multiple, nodules or swellings [812]. It is mostly related to red color, but associations with blue and green are also known. This reaction can greatly resemble a lichenoid or granulomatous reaction [7]. The most recent report on CLH in tattoos was a case series of seven patients who developed CLH with tattoos. Their skin biopsies and contact test were performed and suggested a combined T- and B- cell response [13]. To date, only one case of lymphoma developing in CLH in a tattoo has been reported [14].

Lasers for tattoo removal The various methods of tattoo removal that have been used are excision, cryotherapy, dermabrasion, salabrasion, cauterization, infrared coagulation, and ablation with CO2 Laser. These modalities most often result in incomplete removal of the tattoos or varying degrees of scarring [15]. Surgical excision can remove tattoos in a single treatment with the possibility of leaving a linear scar, but as tattoos are commonly placed on acral locations, surgical excision can result in large scars that can spread. Surgical excision can be used for small tattoos in areas of low tension and result in easy healing. Various lasers have been tried for tattoo removal such as the argon laser and CO2 lasers. Argon lasers emit green or blue continuous laser energy at 488 nm and 514 nm, which is absorbed selectively by tattoo granules in the skin, but the heat spreads from the tattoo granules to the surrounding skin and can result in scarring. Although CO2 lasers have

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the ability to ablate more uniform and superficial layers of skin, the result once again is an incompletely removed tattoo with scarring [16, 17]. Present-day technology involves the use of lasers such as the Q-switched or quality-switched (QS) lasers. These lasers work on the principle of selective photothermolysis. This implies that the laser causes targeted destruction of the tattoo pigments by means of selectively absorbed wavelength and a pulse duration shorter than the thermal relaxation time (the time a structure needs to cool down to half the temperature to which it was heated). This would result in only minimal damage to the epidermis, dermis, and skin appendages, while selectively destroying the target pigment, which acts as the chromophore for the laser [18]. The tattoo ink is an exogenous chromophore. Q-switching is a technique that produces nanosecond laser pulses by suddenly releasing all of the excited-state energy from a laser medium. A whitening reaction occurs upon exposure to this laser. Additionally, the risk of scarring is less than 4.5% with proper use of these lasers [19, 20]. In a comparative study by Leuenberger et al., it was noted that the Q-switched laser has the highest clearance rate in blue-black tattoos; yet, it also had the highest incidence of long-lasting hypopigmentation [21]. On the other hand, the Nd:YAG laser had no incidence of hypopigmentation.

d) Any of the lasers can be used for treating black tattoos because black absorbs virtually every wavelength of light. The laser that would emit light in the wavelength corresponding to the color of the tattoo cannot be used for the removal of the same colored tattoo. e) The exact mechanism of tattoo removal/lightening is unknown, but it appears that laser treatment leads to instant alteration of optic properties of the tattoo pigments, partly by destruction and partly by thermal, photochemical (cleavage of pigment molecules by laser irradiation and oxidation), or photoacoustic (fracturing molecules by virtue of acoustic or pressure waves) means [23]. Histologic and electron microscopic analyses of biopsies indicate disintegration of pigments into smaller fragments which were then phagocytosed by macrophages or carried away via the lymphatic system [24]. There are also structural changes noted in the pigment particles. Depending on the dosage, temporary whitening may occur during the treatment. Whitening is caused by rapid local heating of the pigment leading to gas or plasma formation and subsequent dermal and epidermal vacuolization. The whitening reaction appears immediately with the use of the laser and is replaced by a scab in 25 days. A test spot with the laser provides an opportunity to test the suitability of a particular laser for a skin phototype or tattoo response to laser treatment. The small test area can then be reevaluated in 1 month. Post-procedure patients must be instructed to apply a petrolatum-based emollient on the treated area until the scab falls off [25]. & Q-switched 532-nm Nd:YAG laser:

The fundamentals of tattoo-removing lasers a) The first basic concept is that the lasers are absorbed by the tattoo pigments, and since these pigments come in a variety of colors, multiple wavelengths of laser lights may be needed to remove the tattoo. Often, a given laser removes most of the pigment that is seen by the laser and/or alters the remaining pigment, such that the initial laser is no longer effective in removing this pigment. This results in tattoos becoming refractory to treatment. b) Longer wavelengths penetrate deeper into the skin and are less scattered. Besides wavelength, spot size determines the depth of penetration of the laser light [22]. Light scatters at the edge of the field, so a small spot size will result in a greater proportion of the light being scattered and not reaching significant depths in the skin. Therefore, the largest available spot size capable of delivering clinically relevant fluences should be used instead of increasing the fluence in refractory tattoos. The latter would result in more energy being placed in the superficial layer, and hence more damage and scarring. c) When a given laser no longer results in effective treatment of a tattoo, another device should be considered.

The Nd:YAG Laser (1,064-nm) can be passed through an optical crystal (potassium titanyl phosphate-KTP) that doubles the frequency and halves the wavelengths to yield green light with a wavelength of 532 nm. Besides being useful in the removal of red, orange, and purple-colored tattoos, the Q-switched 532-nm Nd:YAG laser has been found to be a safe and effective method of treatment for red ink tattoo reactions in combination with topical Dermovate [26]. Special handpieces can be used to convert 532-nm wavelength to 585 nm for sky-blue ink and 650 nm for green ink. & Q-switched 694-nm ruby laser:

The Q-switched ruby laser (QSRL) for tattoo removal was first demonstrated by Goldman who demonstrated that the Q-switched ruby laser using nanosecond pulses interacted with and removed dark tattoo pigments without causing a scar, but millisecond pulses resulted in thermal damage to the treated area [27, 28]. There was an

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incomplete resolution of tattoos, so this attempt of Goldman was deemed to be a failure. Three years later, other investigators demonstrated successful removal of the blue and black tattoo pigment with QSRL without tissue damage, and biopsies were performed 3 months later to show the absence of tattoo pigment and absence of any thermal damage [29]. The concept of selective photothermolysis was explained by Anderson and Parrish as the ability to remove target tissues in skin without causing any damage to the surrounding tissues, by a given wavelength of laser light [30]. On the contrary, devices using millisecond pulses, such as intense pulse light, result in incomplete tattoo removal and cause substantial scarring. Taylor et al. demonstrated clearing of tattoos, both amateur and professional, using QSRL using 40- and 80-ns pulse durations ranging between 1.58 J/cm2. It was found that higher fluences resulted in better tattoo clearance and 48 J/cm2 was the optimal fluence range. In all, 78% of amateur tattoos and 23% of professional tattoos showed the best results. Scarring was observed in only one out of 57 tattoos that were treated [31]. In another study by Schiebner et al. [32], QSRL was used for treating 163 tattoos (101 amateur and 62 professional), using 5- to 8-mm spot size and 2 to 4 J/cm2 fluence range. Each tattoo underwent an average of three treatments. Amateur tattoos were once again seen to respond better to treatment than the professional tattoos and among the professional tattoos, the red, yellow, and green colors faded less than the black pigment. No scarring was seen in any of these patients. It was shown by Kilmer and Anderson [33] that QSRL is effective for removing blue, black, and green pigments, though some authors describe different experiences in their practice [25]. In a case report by Sayed et al. [34], it was suggested that the QSRL can be an excellent choice for the treatment of traumatic tattoos secondary to explosive trauma if two conditions are respected, the low fluence and the pretreatment test zone. The apprehension in treating such tattoos is that the rapid transfer of high-energy pulses to powder particles can create microexplosions of these fragments, resulting in cavitation and provoking transepidermal holes and subsequent pox-like scars [35, 36]. & Q-switched 755 nm alexandrite laser:

amateur and professional tattoos and demonstrated 95% removal of tattoo pigment using an average of 8.9 treatment sessions [37]. This showed the efficacy and safety of alexandrite lasers for blue and black tattoo removal. In another study on alexandrite lasers for the removal of 24 professional and 18 amateur tattoos, the former (8.5) was shown to require more treatment sessions than the latter (4.6) [38]. Zelickson et al. [39] have studied the clinical, histopathological, and ultrastructural effects of the three types (ruby, alexandrite, and Nd:YAG) of Q-switched lasers and concluded that red, brown, and orange pigments responded best to the Nd:YAG laser, the alexandrite laser was most effective in removing blue and green pigments, and the Q-switched ruby laser was most effective in removing purple and violet pigments. The 532-nm wavelength of the Nd:YAG laser was best for removing red pigment. All lasers were found to be equivalent in removing black tattoo pigment. & Q-switched 1,064-nm Nd:YAG laser:

The Q-switched 755-nm alexandrite laser has a pulse duration of 100 ns, a spot size of 3 mm, and a repetition rate of 1 Hz. Therefore it offers advantages over earlier ruby lasers in terms of reliability, speed, and repetition rates. It has been used for the removal of green, blue, and black tattoos, and is considered the treatment of choice for the removal of green-colored tattoos. In a study by Fitzpatrick and Goldman, 25 patients were treated for

The Q-switched Nd:YAG laser can emit two wavelengths of light, 1,064 nm and 532 nm. This property can be used to treat dark tattoo pigments using 1,064-nm wavelength and removal of red and orange pigments can be brought about by using the 532-nm wavelength. Kilmer et al. treated 39 tattoos using a Q-switched Nd: YAG laser with fluences from 6 to 12 J/cm2, demonstrating more than 75% of pigment removal in 77% of the black tattoos and more than 95% of the black ink cleared in 28% of the tattoos at 10 to 12 J/cm2 after four treatment sessions [40]. It has been seen in practice that multiple treatments of resistant tattoos often result in fibrosis and visible textural changes that lessen response to subsequent treatments. In a study by Karsai et al. to evaluate the influence of beam profile and spot size on clearance rates and side-effects in the setting of resistant tattoos, 36 professional black tattoos in 32 patients were treated unsuccessfully with a Q-switched Nd: YAG laser (MedLite C3, HoyaConBio Inc., Fremont, CA). Due to therapy resistance, all tattoos were re-treated using a new-generation Nd:YAG laser (MedLite C6, HoyaConBio Inc.). The investigators were able to document for the first time that 1,064-nm Nd:YAG laser (having a more homogenous beam profile and a larger spot size) could achieve clearance of resistant tattoos with a low incidence of side-effects [41]. Lapidoth and Aharonowitz studied tattoo removal in 404 subjects of Ethiopian origin with skin types V and VI. All tattoos were blue/black and had been made by injecting charcoal into the skin and underwent three to six laser treatments with the Q-switched Nd:YAG (380 patients) or ruby (24 patients) laser at intervals of at least 8 weeks. At

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the last follow-up, a clearance of 75100% was achieved in 92% of the patients. Transient (24 months) mild hyperpigmentation was noted in 44% of the patients, and mild textural changes in two. There were no cases of scarring or permanent pigmentary changes [42]. Dark tattoo pigments effectively absorb the relatively long 1,064-nm wavelength, which is less well absorbed by epidermal melanin pigment. This enables effective treatment of dark tattoo pigments such as black and dark blue using the 1064-nm wavelength, as well as removal of red and orange pigments using the 532-nm wavelength. This enables effective treatment of darkly pigmented individuals with less risk of affecting epidermal melanin pigment with shorter wavelengths. In a study on 15 tattoos treated with the Q-switched Nd: YAG laser in patients with Fitzpatrick skin type VI, more than half of the treated tattoos had 7595% clearance after three or four treatments. This can be attributed to the fact that in darkly pigmented individuals, 1064 nm wavelength laser has low absorption in epidermal melanin. The newer Nd:YAG lasers offer very fast repetition rates of up to 10 pulses per second and high peak powers. An evidence-based table (Table 1) indicating the latest studies in the field of lasers for tattoo removal has been compiled below (also see Table 2). & Pigmented dye laser:

of penetration of tattoo lasers into the skin. Topical solutions that decrease dermal scattering, make tattoo pigments easy to see, and also enable a larger proportion of the administered laser energy to reach the dermal tattoo pigment are also being developed [45]. Freedom-2 solution These are microsphere-encapsulated bioresorbable pigments. The microspheres contain discrete pigment that can be targeted by a specific laser wavelength. The laser treatment during the tattoo removal would cause the capsule to break, exposing the pigment. The pigment is then resorbed by the body. The tattoos made by using such a solution can be removed using a single treatment. Tri-Luma Tri-Luma is a commercially available bleaching cream that combines tretinoin, hydroquinone, and fluocinolone acetonide (Tri-Luma cream, Galderma Laboratories, Fort Worth, Texas) has been effective for lightening the epidermal pigment overlying untreated tattoos or for treating postinflammatory hyperpigmentation in treated tattoos [46]. Imiquimod In 2007, Raminez et al. [47], evaluated the efficacy of topical imiquimod cream as an adjuvant to laser removal of mature tattoos in an animal model and found that the combination of the Q-switched alexandrite laser and the topical imiquimod-treated group was clinically and histologically rated as having less pigment than the tattoos that were treated with laser alone. Adjuvant imiquimod treatment had greater inflammation and fibrosis on posttreatment skin biopsies. In the same year, a randomized, prospective, doubleblind, case-controlled study was conducted by Ricotti et al. to study this combination (Q-switched Nd:YAG laser with a wavelength of 1,064 nm was used to treat blue and black pigments, a frequency-doubled Nd:YAG laser (532 nm) was used for red pigments, and a Q-switched alexandrite 755-nm laser was used for aqua and green pigments) for tattoo removal [48]. Nineteen out of the 20 patients that completed the study showed tattoo clearance. 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. Adverse effects were observed more often with the combination than the laser alone. Elsaie and colleagues [49] demonstrated that imiquimod plus laser therapy demonstrated a more favorable outcome when evaluated by the investigators or subjects in another recent study.

The flashpump-pumped pulsed dye laser emits a wavelength of 510 nm and a long pulse time of 300 ns with a 3-mm spot size. It is used only for treating red dyes or certain orange and yellow pigments. Successful clearing without scarring usually occurs in 37 treatments performed at 1-month intervals using 33.75 J/cm2. Purple, orange, and yellow pigments require an average of five treatments for complete ink removal [43].

Whats new in tattoo removal Picosecond lasers These lasers have been developed as the need for lasers with shorter pulse durations than the above Q-switched lasers, to decrease the number of treatments necessary to remove tattoos and optimize treatment. To do this, Ross et al. [44] performed a study comparing two Nd:YAG lasers; a 10-ns pulse duration and a 35-ps pulse duration laser, for effectiveness at removing black tattoo pigment. Out of the 16 tattoos that were treated at 4-week intervals, 12 tattoos had a better outcome with the picosecond lasers. Efforts are also being made to develop lasers that can improve optical properties of skin and to increase the depth

624 Table 1 Evidence-based table for lasers for tattoo removal Investigators Lee et al. [61] Beute et al. [65] Objective Red/brown tattoo removal (6-mm spot size) using the QS Nd: YAG laser (1,064 nm) at low fluences of 23 J cm2, 5 J cm2, 5.5 and 6.0 J cm2 To establish the absorption spectra of common tattoo pigments and India ink and to determine their response to laser irradiation at 532 and 752 nm and correlate this to their composition To evaluate the safety and efficacy of topical 5% Imiquimod cream used daily in conjunction with laser therapy to remove unwanted tattoos Results/conclusions

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Patient was treated 5 times at 6-week intervals. Complete clearance was seen after the fifth treatment 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 Nineteen subjects completed the study. 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. There was no difference in subjective pain during and between laser sessions and no undesirable pigment alterations were reported More than 95% lightening was achieved in five patients after three to six sessions at fluence range of 67.5 J/cm2 and >75% lightening in 10 subjects after three to six sessions of treatment at fluence range of 47.5 J/cm2 In all patients, a nearly complete clearance of the traumatic tattoo was achieved in one laser session. No scarring, skin atrophy, or hypo- or hyperpigmentation was observed. A high patient satisfaction rate of 8 on a scale of 10 was found, since a nearly complete clearance was achieved in one or two sessions Intradermal injection of clearing agents induced dermal clearing, but resulted in necrosis and scar. 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. Clearing should lead to increased penetration of laser light to tattoos and should, therefore, increase treatment efficiency At the last follow-up, the clearance score was 4 in 92% of the patients and 3 in the remainder. Transient (24 months) mild hyperpigmentation was noted in 177 (44%) patients, and mild textural changes in two, both treated with the Qswitched laser. There were no cases of scarring or permanent pigmentary changes In a 48-year-old patient, a frequency-doubled Nd:YAG laser (532 nm, 2.0 J/cm2, 2-mm spot size) was used for the lip area, while the same laser at 1,064 nm, 3.9 Jcm2, 2-mm spot size was utilized for the eyebrows. Significant but incomplete resolution of the tattoo ink was achieved. Multiple laser systems are needed to remove cosmetic tattoos. Test areas must be done before treatment

Ricotti et al. [48]

Bukhari [66]

Cambier et al. [67]

The removal of tattoos in Arabic women of skin types IIIIV using the Q-switched alexandrite laser. Study design/materials and methods: 20 female subjects aged 3550 years from similar racial and ethnic background with amateur tattoos were treated using the Q-switched alexandrite laser To evaluate the efficacy and safety of removing traumatic tattoos in the skin by a erbium:YAG laser

McNichols et al. [68]

To improve reduction in the attenuation coefficient of the dermis and epidermis using short wavelengths of Q-switched 755-nm and 532-nm lasers on three different inks

Lapidoth et al. [42]

To describe the use of laser technology for tattoo removal in a high-risk dark-skinned (Fitzpatrick skin type V or VI) population of 404 subjects

Jimenez et al. [62]

To emphasize the wisdom of small test areas when treating cosmetic tattoos and the need for multiple laser systems

Contratubex gel In some clinical studies Contractubex gel (Merz Pharma, Frankfurt, Germany) (components: 10% aqueous onion extract, 50 U heparin per gram of gel, 1% allantoin) has been shown to be effective in the treatment and prevention of hypertrophic scars and keloids and was tried by Ho and colleagues on 61 tattoos (52 patients), to evaluate the efficacy of Contractubex gel in the prevention of scarring after laser removal of tattoos in Chinese patients [50]. They
Table 2 Lasers and their use in tattoo removal for different color pigments Laser Alexandrite 755 nm Ruby 694 nm Nd:YAG 1,064 nm Nd:YAG 532 nm Black X X X Blue X X X Green XX X X Red

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found that the Contractubex group had a statistically significantly lower rate of scarring than the control group. Fractional resurfacing Fractional photothermolysis, which is a relatively new skin resurfacing laser technology for treating wrinkles, melanocytic pigmentation, scars, and photodamaged skin, can possibly help improve the texture of the skin in the region that underwent laser removal of tattoo [51, 52]. Fractional resurfacing utilizes an improvised version of original ablative lasers as it creates microzones of injury in the skin that are surrounded by normal intervening skin that rapidly heals the injured tissue, at the same time yields great cosmetic outcomes.

red pigment tattoos, developing an allergic reaction, with Q-switched lasers. Intralesional steroids have been used to control the allergic reaction followed by removal of red pigments in tattoos with allergic reaction [58, 59]. Cadmium is used to impart yellow color in tattoos and can be the cause of photoallergy. Ink darkening Paradoxical ink darkening has been noticed in cosmetic tattoos during tattoo removal using lasers. Red, pink, skintone, and white are the most common ones undergoing such a reaction, but yellow, blue, and green could also get altered in a similar way [45, 60]. These pigments used in cosmetic tattooing contain iron oxide and titanium dioxide. Iron oxide changes color from brown to black when heated above 1,400C due to oxidation-reduction reaction or the ignition of ferric oxide above 1,400C. These reactions require the extreme temperatures generated during the short pulse of Q-switched lasers. Ferric oxide (rust colored) changes to ferrous oxide (black) or Ti4+ (white) to Ti3+ (blue-black) [61]. This pigment change is often resistant to additional Q-switched laser therapy. Multiple other color changes, including orange, yellow, and green, after treatment of cosmetic tattoos with a frequency-doubled Nd: YAG laser have been described [62]. Epidermal debris The high-energy short pulses delivered by the laser during tattoo removal cause a pressure shock wave. This can cause blood vessels to rupture and an aerosolization of tissue. There may be infectious particles present in this material and thus a barrier is required to protect the operator from tissue and blood contact. Also, high-energy output and larger spot size are effective in reducing hazards to the operator [63]. Potential carcinogenicity Some clinical studies have shown by chemical analysis that laser therapy may cleave certain azo dyes to potentially carcinogenic or toxic decomposition products such as nitroaniline [64]. It was observed that the tattoo colorants already contain such compounds before laser irradiation.

Complications Dyspigmentation and textural changes As melanin is the main competing pigment when treating tattoos with Q-switched lasers, increased melanin absorption with shorter wavelengths has resulted in hypopigmentation [50, 53]. This may be transient (seen with 510- and 532-nm lasers) or long-term (seen with QSRL). Gundogan et al. [54] treated hypopigmented areas that had remained unchanged for over 4 years after tattoo removal with the Q-switched Nd: YAG laser, using the 308-nm xenon-chloride excimer laser. It 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 was demonstrated with electron microscopy. Hyperpigmentation is another concern more in the darker-skinned individuals, so they can be better treated with the Nd:YAG laser, the longer wavelength of which better spares the epidermis. If QSRL or Q-switched alexandrite lasers must be used, then it should be compensated by lower fluences. Also, dark-skinned and tanned individuals should be treated with bleaching agents before initiating laser treatment. Additionally, in patients prone to pigmentary and textural changes, longer treatment intervals may be helpful. Patients should avoid sunexposure. Treatment may consist of hydroquinone and regular use of sun protection. Fractional photothermolysis may be considered [55, 56]. Allergic reactions Local allergic reactions may occur to various tattoo pigments but the most common one known is red pigment [57]. The allergy may manifest as nodular, scaly, and pruritic change in the tattoo at the red pigment area. As the Q-switched laser acts by dispersing pigment, it can trigger a systemic allergic reaction, so it is advisable to not treat such

Conclusions The physical mechanisms for laser-tattoo interactions and the tattoo breakup process are not well understood and remain to be under constant evaluation and appraisal. Each laser has its benefits, and determining the right laser for a

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Lasers Med Sci (2010) 25:619627 16. Bailin PL, Ratz JR, Levine HL (1980) Removal of tattoos by CO2 laser. J Dermatol Surg Oncol 6:9971001 17. Reid R, Muller S (1980) Tattoo removal by CO2 laser dermabrasion. Plast Reconstr Surg 65:717721 18. Anderson RR, Margolis RJ, Watenabe S, Flotte T, Hruza GJ, Dover JS (1989) Selective photothermolysis of cutaneous pigmentation by Q-switched Nd:YAG laser pulses at 1064, 532 and 355 nm. J Invest Dermatol 93(1):2832 19. Kilmer SL, Lee MS, Grevelink JM, Flotte TJ, Anderson RR (1993) The Q-switched Nd:YAG laser effectively treats tattoos. A controlled, dose-response study. Arch Dermatol 129(8):971978 20. Kilmer SL (1997) Laser treatment of tattoos. Dermatol Clin 15 (3):409417 21. Leuenberger ML, Mulas MW, Hata TR, Goldman MP, Fitzpatrick RE, Grevelink JM (1999) Comparison of the Q-switched alexandrite, Nd:YAG, and ruby lasers in treating blue-black tattoos. Dermatol Surg 25(1):1014 22. Bernstein EF, Kornbleuth S, Brown DB, Black J (1999) Treatment of spider veins using a 10 millisecond pulse-duration frequencydoubled neodymium YAG laser. J Dermatol Surg 25:316320 23. Ho DD, London R, Zimmerman GB, Young DA (2002) Lasertattoo removala study of the mechanism and the optimal treatment strategy via computer simulations. Lasers Surg Med 30(5):389397 24. Herd RM, Alora MB, Smoller B, Arndt KA, Dover JS (1999) A clinical and histologic prospective controlled comparative study of the picosecond titanium:sapphire (795 nm) laser versus the Qswitched alexandrite (752 nm) laser for removing tattoo pigment. J Am Acad Dermatol 40(4):603606 25. Bernstein EF (2006) Laser treatment of tattoos. Clin Dermatol 24 (1):4355 26. Antony FC, Harland CC (2003) Red ink tattoo reactions: successful treatment with the Q-switched 532 nm Nd:YAG laser. Br J Dermatol 149(1):9498 27. Goldman L, Blaney DJ, Kindel DJ Jr, Richfield D, Franke EK (1965) Pathology of the effect of the laser beam on the skin. Nature 197:912 28. Goldman L, Wilson RG, Hornby P, Meyer RG (1965) Radiation from a Q-switched ruby laser. Effect of repeated impacts of power output of 10 megawatts on a tattoo of man. J Invest Dermatol 44:6971 29. Levine VJ, Geronemus RG (1995) Tattoo removal with the Q-switched ruby laser and the Q-switched Nd:YAG laser: a comparative study. Cutis 55(5):291296 30. Anderson RR, Parrish JA (1983) Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 220:524527 31. Taylor CR, Gange RW, Dover JS et al (1990) Treatment of tattoos by Q-switched ruby laser. A dose-response study. Arch Dermatol 126:893899 32. Scheibner A, Kenny G, White W, Wheeland RG (1990) A superior method of tattoo removal using the Q-switched ruby laser. J Dermatol Surg Oncol 16:10911098 33. Kilmer SL, Anderson RR (1993) Clinical use of the Q-switched ruby and the Q-switched Nd:YAG (1064 nm and 532 nm) lasers for treatment of tattoos. J Dermatol Surg Oncol 19:330338 34. El Sayed F, Ammoury A, Dhaybi R (2005) Treatment of fireworks tattoos with the Q-switched ruby laser. Dermatol Surg 31(6):706 708 35. Fusade T, Toubel G, Grognard C et al (2000) Treatment of gunpowder traumatic tattoo by Q-switched Nd:YAG laser: an unusual adverse effect. Dermatol Surg 26:10571059 36. Taylor CR (1998) Laser ignition of traumatically embedded firework debris. Lasers Surg Med 22:157857 37. Fitzpatrick RE, Goldman MP (1994) Tattoo removal using the alexandrite laser. Arch Dermatol 130:15081514

given practice depends upon the type of tattoos seen, as well as the skin types of patients presenting for tattoo removal. The Q-switched ruby and alexandrite lasers are useful for removing black, blue, and green pigments. The Q-switched 532-nm Nd:YAG laser can be used to remove red pigments, and the 1,064-nm Nd:YAG laser is used for removal of black and blue pigments. The most common adverse effects following laser tattoo treatment with the Q-switched ruby laser include textural change, scarring, and pigmentary alteration. Newer unconventional modalities are under appraisal with much focus of the research on the picoseconds lasers.

Conflict of interest None of the authors has a conflict of interest.

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