Tattoo Removal. The Safe. The Sure Way

Why shouldn’t you be able to eliminate unwanted tattoos? Modern tattoo removal involves the use of Q-switched lasers to remove tattoo pigments. Or fade them to prepare the area for a different tattoo. Thanks to the only available tattoo removal specific laser machines at MSI “Q-switched Nd: YAG laser 1064nm infra-red laser” and frequency-doubled 532nm green KTP laser, you don’t have to live with an unwanted tattoo. This laser sends precise pulses of high-energy light into the skin, vaporizing some tattoo inks and fragmenting other tattoo inks into thousands of tiny particles, which are then safely eliminated from your skin. Test spots should also be considered for cosmetic, medical, traumatic, or decorative tattoos with light colors. Paradoxical darkening is likely to be encountered in these tattoos. After laser treatment of tattoos, skincare is like skincare after having a tattoo. Gentle cleansing of the skin and applying an antibiotic ointment will help tattoos heal quickly after treatment. Protect the treated area from sun exposure until the skin is completely healed and the skin color has returned to normal. Your tattoo usually fades over 4-6 weeks. Other non-laser methods of tattoo removal include surgical excision (cutting the tattoo out), dermabrasion (scrubbing away the skin), sal-abrasion (using salt to abrade the tattoo), and chemical peels (using acid to burn away layers of skin). These methods are painful, expensive, and may result in scarring.


Why shouldn’t you be able to eliminate unwanted tattoos? Modern tattoo removal involves the use of Q-switched lasers to remove tattoo pigments. Or fade them to prepare the area for a different tattoo. You don’t have to live thanks to the only available tattoo removal specific laser machines at MSI “Q-switched Nd: YAG laser 1064nm infra-red laser” and frequency-doubled 532nm green KTP laser with an unwanted tattoo.

This laser sends precise pulses of high-energy light into the skin, vaporizing some tattoo inks and fragmenting other inks into thousands of tiny particles, safely eliminating them from your skin. I should also consider testing spots for cosmetic, medical, traumatic, or decorative tattoos with light colors. Paradoxical darkening is likely to be encountered in these tattoos. After laser treatment of tattoos, skincare is like skincare after a tattoo.

Gentle cleansing of the skin and applying an antibiotic ointment will help tattoos heal quickly after treatment. Protect the treated area from sun exposure until the skin is completely healed and the skin color has returned to normal. Your tattoo usually fades over 4-6 weeks.

Other non-laser methods of tattoo removal include surgical excision (cutting the tattoo out), dermabrasion (scrubbing away the skin), salabrasion (using salt to rub the tattoo), and chemical peels (using acid to burn away layers of skin). These methods are painful, expensive, and may result in scarring.

History of Tattoos

The term tattooing is derived from “tattoo,” a Tahitian word that translates as “to mark,” and is a process of implanting permanent pigment granules in the skin. Tattoos have fascinated humankind from all cultures and strata of society for centuries.

From the ancient Egyptian, Greek, and Roman civilizations to modern society, skin markings have been used to enhance beauty, demonstrate uniqueness, signify belonging, and sometimes identify, shame, or punish.

  • Tattoos date back to 5200 years. The early tattoo was made by cutting the skin and rubbing powdered charcoal in the wound.
  • Scientists believe tattoos may have been the first form of medical treatment.
  • The tattoo has been found on female Egyptian mummies. Ancient Egyptians believed tattoos prevented complicated pregnancies and births.
  • In the 10th and 11th centuries, crusaders had cross-shaped tattoos. If killed, that person would receive a Christian Burial.
  • The tattoo was to mark enslaved people and criminals.
  • In many tribal communities, facial tattoos indicate a person’s status and accomplishment.
  • In the fifth century, the Japanese developed tattoos in fine art with intricate designs and colors.
  • In 19th and 20th century America, tattoos were primarily associated with sailors, fringe cultures, prisoners, and gangs.

How is a Tattoo Done?

Tattoos are created by introducing exogenous pigment in to the dermal skin layer and can be placed with intent or result of accidents and injury. Tattoo inks are composed of pigments or dyes combined with a tattoo pigment vehicle that entraps, encases, incorporates, complexes, encapsulates or is otherwise associated with the pigment to form pigment/vehicle complexes that retain the pigment in the tissue.

Professional tattoo

artists purchase pre-made inks (pre-dispersed inks), while some tattoo artists mix their own using a dry pigment and a carrier. Professional inks may be made from iron oxides (rust), metal salts, or plastics. Homemade or traditional tattoo inks may be made from pen ink, soot, dirt, blood, or other ingredients. M manufacturers are not required to reveal their ingredients or conduct trials, and recipes may be proprietary.

Heavy metals used for colors include mercury (red); lead (yellow, green, white); cadmium (red, orange, yellow); nickel (black); zinc (yellow, white); chromium (green); cobalt (blue); aluminum (green, violet); titanium (white); copper (blue, green); iron (brown, red, black); and barium (white). Metal oxides used include ferrocyanide and ferricyanide (yellow, red, green, blue).

Organic chemicals used include azo-chemicals (orange, brown, yellow, green, violet) and naptha-derived chemicals (red). C carbon (soot or ash) is also used for black. Other pigments include antimony, arsenic, beryllium, calcium, lithium, selenium, and Sulphur.

Both blacklight and glow-in-the-dark inks have been used for tattooing. Glow in the dark tattoo ink absorbs and retains a light and then glows in darkened conditions by phosphorescence. The ingredients in some “glow” inks are listed as: (PMMA) Polymethylmethacrylate 97.5% and microspheres of fluorescent dye 2.5% suspended in UV sterilized, distilled water.

Blacklight ink does not glow in the dark but reacts to non-visible UV light, producing a visible glow by fluorescence. The resulting brightness of both these inks is highly variable. The safety of such inks for use on humans is widely debated in the tattoo community. Unsubstantiated claims have been made that some inks fade over time, yielding a “semi-permanent tattoo.”

After Tattooing, What Happens?

The presence of foreign material activates the immune system’s phagocytes to engulf the pigment particles. After initial injection, the pigment is dispersed through a homogenized damaged layer through the epidermis and upper dermis. As healing proceeds, the damaged epidermis flakes away (eliminating surface pigment) while more rooted in the skin granulation tissue forms, which is later converted to connective tissue by collagen growth.

This repair the upper dermis, where pigment remains trapped within fibroblasts, concentrating in a layer below the dermis/epidermis boundary. The presence there is stable, but in the long term (decades), the pigment tends to migrate deeper into the dermis, accounting for the degraded detail of old tattoos. Tattoo pigment has been reported intracellularly and extracellularly, with mild fibrosis and occasional foreign-body giant cell reactions, allergic granulomas, and sarcoid reactions.

Tattoo ink is remarkably nonreactive histologically, despite tattoo artists’ frequent use of different pigments of unknown purity and identity. Though it rarely occurs, red (mercury), yellow (cadmium), green (chromium), and blue (cobalt) tattoo pigments have elicited persistent, localized allergic or photoallergic dermatitis and, more infrequently, systemic reactions. Interestingly, the colors most involved in allergic reactions (red and yellow) often spontaneously disappear from a tattoo without clinical signs of a response.

Complex and light-absorbing molecules are implanted in the skin. When tattooed skin receives UV radiation or natural sunlight, photochemical cleavage of the pigments may occur. The decomposition products are hazardously showing a potential risk of being toxic or even carcinogenic. A risk assessment is not feasible since the concentration of pigments and their decomposition products in the skin is unknown.

Sun protection is necessary for successful laser tattoo removal. First, it decreases the number of melanin pigments that compete with laser absorption with tattoo pigments. This means reduced intake of tattoo pigments (reduced efficacy and increased absorption by melanin pigments (epidermal injury and more side effects).

How to Do Safe Tattooing? What are the Complications?

The tattooing should be carried out by trained personnel to place the pigment appropriately. T thorough cleaning of the surface to be tattooed is mandatory to prevent resident organisms of the skin from being introduced into the dermis. The inks should be sterile and of superior quality without external contaminants to reduce the incidence of allergic and granulomatous reactions.

The instruments should be sterile, and preferably he should use all disposables to avoid transmissible diseases such as Hepatitis B, C, HIV infection, and leprosy. Strict aseptic precautions are essential to prevent bacterial, viral, and fungal infections. Some regulations restrict blood donation following a tattoo. T e period varies from 4 months to 1 year in different counties.

Who Gets Laser Tattoo Removal? Why?

In the United States, rates of tattooing have increased over the past several decades. It is currently estimated that twenty-one% to twenty-four% of the population in the United States has at least one tattoo. T tattoos also seem increasingly common in younger generations. It has been estimated that up to a quarter of young to middle-aged adults in the United States have at least one tattoo.

Tattoos become 28% of people who get tattoos regret the decision within the first month. The motivation for tattoo removal includes new jobs or careers, the need to portray an image at work or in new social circles, and other negative feelings towards old tattoos.

Various psychosocial reasons, especially when names are tattooed, and patients reconsider or change of faith in case of religious symbols. Ma y occupations, such as the armed forces, prohibit the presence of tattoos and seek tattoo removal. It has been rightly sung by Jimmy Buffett, an American singer, that a tattoo is a permanent reminder of a temporary feeling.

How Does Laser Remove My Tattoo?

The mechanism of action of the QSL is through photon absorption by tattoo pigment within fibroblasts. During the 40-nanosecond pulse, temperatures exceeding 1000°C can occur. Gaseous products of pyrolysis or pores created by superheated steam may account for the lamellated appearance of the granules after laser exposure.

The reduction in pigment particle size and fragmentation of pigment-containing cells results from rapid thermal expansion, shock waves, and potentially localized cavitation. Fluence-dependent thermal damage to collagen immediately surrounding the irradiated tattoo pigment also occurs. Q- switched Nd: YAG lasers can emit two wavelengths of light, 1064- and 532-nm wavelengths.

Th s enables effective treatment of dark tattoo pigments such as black and dark blue using the 1064-nm wavelength and removing orange pigments using the 532-nm wavelength. The laser sends precise pulses of high-energy light into the skin, vaporizing some tattoo inks and fragmenting other tattoo inks into thousands of tiny particles, which are then safely eliminated from your skin by macrophages immune cells.

What are the Types of Tattoos?

Tattoos can be divided into Decorative tattoos (amateur& professional), cosmetic, medical, and traumatic categories.

Decorative tattoos are tattoos placed on the skin as a decoration. The classic types of tattoos, such as amateur tattoos, have paved the way for highly intricate multi-colored professional tattoos. The current trend is 3D tattoos, optical illusion tattoos, head mandala tattoos, foot tattoos, miniature portraits, etc.

Amateur tattoo inks consist of simple carbon particles originating from burnt wood, cotton, plastic, or paper, or a variety of inks, including Indian ink, pen ink, and vegetable matter. A needle is used to deposit ink at various depths of the skin. The amateur tattoo is easy to remove as it contains a low volume of pigments and is superficially placed.

Professional tattoos contain more ink, deeper ink, and multiple colors with the help of a hollow needle or a tattoo gun to inject pigments into the dermal layer of skin. The granule depth remains uniform and is located at the bottom of about four hundred ums in the upper to mid-dermis. This explains the difficulty in treating these tattoos compared to amateur tattoos, which are superficially placed.

Cosmetic tattoos are also known as micro-pigmentation or permanent cosmetics. This type of tattoo is used for permanent eyeliner, lip liner, lipstick, and other permanent cosmetic purposes. This tattoo also covers skin pigment disorders, scars, and other blemishes. In the hands of professionals, permanent cosmetics can form a practical last step in treating many patients—cosmetic tattoos using skin-colored tones like medical tattoos used as radiation markers.

A medical Tattoo is used to treat a condition, communicate information, or mark a body location. Tattoos have also been used to notify emergency personnel that a person has diabetes mellitus. Due to ng breast reconstruction after mastectomy or breast reduction surgery, tattooing is sometimes used to replace the areola or to fill in areas of pigment loss, which may occur during breast reduction performed with a free nipple graft technique.

Medical therapeutic tattooing has been used as a camouflage technique in vitiligo, camouflage for permanent hair loss after craniofacial surgery, and scars following plastic and reconstructive surgery. The inks used often contain pigments that are red, brown, white, or flesh-colored; inks containing titanium dioxide and iron oxide are difficult to remove

I must treat traumatic tattoos acquired by fireworks or explosives with great caution. Traumatic tattoos are deposited in the skin following abrasion, laceration, or explosive injuries. Pressurized penetration of dark particles into the deep dermis gives rise to black or blue tattoos, depending on the depth of the pigment. Some of the particles embedded in the skin may be flammable and may reignite after laser treatment. This may result in significant scarring. These tattoos must be approached with care and a small test spot performed before embarking on the removal of large areas.

Your Consultation for Tattoo Laser Removal


A thorough medical history and examination are essential in establishing the type of tattoo and the patient’s skin type before treatment. It is important to note if the patient was ever treated with systemic gold therapy (e.g., rheumatoid arthritis therapy). This is an absolute contraindication to QS laser treatment since the darkening of gold-containing skin is immediate and irreversible.

Previous isotretinoin treatment, herpes infection, keloidal tendencies, a tendency toward post-inflammatory hypo- or hyperpigmentation, and sun exposure habits should be considered, as additional preventive measures may be needed. I usually recommend that patients stop tanning, cover their tattoos, and apply bleaching cream 2-4 weeks before the first session, Egyptian patients with the III-IV skin type.

Just as critical as the patient selection is the evaluation of the lesion itself.

  • Is it an amateur, professional, traumatic, aesthetic, or medical tattoo?
  • How long has it been present?
  • What colors of inks/dyes were used?
  • Were inks mixed to make the colors?
  • Is there any white or skin-colored ink in the tattoo to the patient’s knowledge?
  • Has the patient attempted to remove or alter the tattoo previously? If so, what technique was used?

Establishing realistic patient expectations through good rapport help achieve a satisfactory outcome and obtaining informed consent with a clear outline of the risks and the benefits before tattoo removal is essential and protects both the clinician and patient. It’s imperative to deliver the message that Multiple laser treatments are usually required to remove a tattoo.

Your Tattoo Laser treatment


The tattoo area is photographed before each session. I could cleanse the area to be treated thoroughly and free from residual cosmetics or skincare products. Sometimes I use microdermabrasion or micro-needling before the application of topical anesthetic cream. This helps to increase the efficacy of anesthetic cream and laser treatment.

Topical anesthetics such as 5% lidocaine cream (LMX-5) and 2.5% lidocaine/2.5% prilocaine (EMLA) are often applied for 45-60 minutes under occlusion.

I should remove the anesthetic cream before the treatment, and the treatment area is cleansed again. I should exercise caution if the region is significant, as topical anesthetics can produce toxicity. Other methods of reducing discomfort for the patient include chilly air during treatment, local infiltration of lidocaine, regional nerve block, IV sedation, or a combination of these modalities.

In the case of cosmetic tattoo laser removal of eyebrows, I advised patients to shave their hair immediately before laser sessions. These hairs turn ash grey or whiten when a QS laser is applied. Its melanin content will absorb a significant part of laser energy. This will decrease the efficacy of the Qs laser to remove tattoo pigments. All medical personnel must wear wavelength-specific protective goggles during the laser procedure.

I must also provide the patient with protective goggles or external metal eye shields. If the area treated is on the eyelid or near the orbit, intraocular metal eye shields should be placed for the patient. High-energy short pulses cause a pressure shock wave that ruptures blood vessels and aerosolizes tissue (with potentially infectious particles), requiring a barrier or a cone device to protect the operator from tissue and blood contact. Lower fluency eliminates this problem but results in more treatment sessions. Scarr ng or tissue textural changes are also attributable to hot spots within the beam and pulse-to-pulse variability.

Maintaining a high-energy output with a more prominent spot size (which decreases fluency) is equally effective, with less hazard to the operator and fewer adverse effects (less epidermal disruption) for the patient. It is essential to wear a mask to prevent inhalation of debris and blood splatter—the presence of forceful smoke evacuation. We cover tattoos with thin plastic sheets for the exact reason in such patients.

Test spots can be carried out and evaluated at 4-6 weeks for efficacy and side effects in darkly pigmented patients. I should also consider testing spots for cosmetic, medical, traumatic, or decorative tattoos with light colors. Paradoxical darkening is likely to be encountered in these tattoos. The m in parameters include pulse duration, wavelength, fluence, and spot size. All t e Q-switched lasers are in the nanosecond range, and the laser predetermined pulse width. Wavelength is chosen based on the best available wavelength for the tattoo ink color.

For example, red ink is best treated by a green wavelength (510 or 532 nm), and green ink is best handled by a red wavelength (694 or 755 nm). When melanin is present, the 1064-nm wavelength is the best choice to avoid disruption of the epidermis.

Fluence should be enough to produce immediate whitening without immediate bleeding or blistering. Large spot sizes provide deeper penetration and should be used if I can obtain enough fluency. This maximizes the distribution of laser light to the dermal pigment and minimizes cutaneous injury.

The optimal fluence is the lowest possible setting that elicits this endpoint to reduce the risk of thermal injuries, such as blister formation and scarring. The d sired endpoint of QS laser treatment (Nd: YAG, alexandrite, and ruby) is immediate tissue whitening, although this may not occur if the tattoo has faded significantly. Such whitening can last 20 minutes and results from the chromophore’s rapid heating, leading to gas formation.

A low starting fluence should be used to attain this desired endpoint during initial tattoo treatment, especially when the tattoo pigment density is very dark. The fluence can be increased as the tattoo becomes lighter. Frequently, the initial treatment session produces a more dramatic response than in subsequent sessions. Specific sites of clearing corresponding to laser impacts are often seen. Other tattoos are highly unresponsive during the initial treatment phases, although biopsy samples reveal fragmentation of tattoo granules.

The response differs from one patient to another and involves the efficiency of mobile macrophages in removing fragmented tattoo pigment debris and the density and amount of tattoo pigment present. The speed of the macrophage response and the maximum amount of pigment removed per session varies from patient to patient and from treatment to treatment.

The more superficial the tattoo pigment and the less the total pigment volume, the fewer the number of procedures necessary to remove the dye.

You are lucky if you have light skin, as the practitioner has several options. The QS alexandrite (755 nm), the QS ruby (694 nm), and the QS Nd: YAG (1064 nm) lasers are all helpful for dark-blue and black tattoos. On the other hand, the QS Nd: YAG is the laser of choice for patients with dark skin.

The optimal laser wavelength for removing red tattoo ink is 532 nm (QS frequency-doubled Nd: YAG). Furthermore, red tattoo ink is often the culprit for immediate and delayed allergic reactions in the tattoo itself. Laser removal of the red ink can cause more dispersion of the antigen resulting in urticaria or systemic allergic response. In these cases, an ablative CO2 or Er: YAG laser can be employed to vaporize the tattoo.

What Should I Do “Skincare” after Laser Tattoos Removal?

In short, it is pretty like skincare after having a tattoo. Gentle cleansing of the skin and applying an antibiotic ointment will help tattoos heal quickly after treatment. You should continue this until the area has completely re-epithelialized. A dry crust should never be allowed to form and, if developed, never removed. The treatment area should improve within 5–14 days. Protect the treated area from sun exposure until the skin is completely healed and the skin color has returned to normal.

Your tattoo usually fades over 4-6 weeks. The degree of fading will be more comfortable to see when you compare your tattoo with pre-treatment photographs or video-dermatoscopy photos. There may be some lightening or darkening of the skin for several months after laser treatment. For these patients afraid that laser will affect hair regrowth (eyebrows or eyelashes), I prescribed Lumigan (bimatoprost) eyedrops cautiously. They are applied in localized areas of pigment loss.

What are the Risks of Tattoo Laser Removal?

In most cases, laser treatment leads to good fading or complete removal of the tattoo without significant side effects. Serious side effects are very unusual but sometimes occur, and one must be adept at dealing with these side effects.

Incomplete Tattoo Removal

The most widespread problem with tattoo treatment is incomplete fading or removal of the tattoo. This I an issue with intricate multi-colored tattoos. Not all tattoo inks respond, and rarely specific colors can get worse. Massive professional tattoos may not completely fade. In some cases, changing to a different laser may be worthwhile due to the intrinsic differences in wavelengths, pulse durations, and spot sizes.

Dyspigmentation and Textural Changes

The increased melanin absorption seen with shorter wavelengths increases the risk of hypopigmentation. With 5-nm and 532-nm wavelengths, the hypopigmentation typically resolves; however, with the QSRL, long-term hypopigmentation is possible. However, hyperpigmentation is more related to the patient’s skin type, with darker skin more prone regardless of the wavelength.

Treatment with hydroquinone and broad-spectrum sunscreens usually resolves hyperpigmentation within a few months, although, in some patients, it can prolong resolution. Transient textural changes are often noted but resolve within 1-2 months; however, permanent textural changes and scarring. Longer treatment intervals are recommended if a patient is prone to pigmentary or textural changes.


Vesicle and bullae formation are more common occurrences following picosecond laser tattoo treatment than Q-switched. These typically resolve without sequelae within one week but can sometimes be significant and unsettling to laser treatment patients.

Allergic reactions

Local allergic responses to many tattoo pigments have been reported, and reactions to tattoo pigment after Q-switched laser treatment are also possible. Unlike the destructive modalities previously described, Q-switched lasers mobilize the ink and may generate a systemic allergic response. Q-switched laser treatment is not advised if an allergic reaction to ink is noted.

Erbium high-energy, pulsed carbon dioxide lasers can de-epithelialize the tattoo, promoting trans-epidermal ink elimination. Oral antihistamines and anti-inflammatory steroids, such as prednisone, have also been used. Multiple treatments are required, and the risk for dyspigmentation and scarring increases.

Ink darkening

Paradoxical darkening of flesh-tone, red, and white tattoo inks with QSRL. The darkening usually becomes apparent once the immediate whitening has faded. In clinical practice, multiple colors, including flesh tones, red, white, and brown containing pigments (iron oxide, titanium dioxide) and several green and blue tattoo pigments, changed to black when irradiated with Q-switched laser pulses.

This change results from an oxidation-reduction reaction or the ignition of ferric oxide above 1400°C. These reactions require the extreme temperatures generated during the short pulse of Q-switched lasers; several hundred to thousands of degrees Celsius are estimated.

It may be permanent Approach the laser treatment of cosmetic tattoos with caution, especially those of red or flesh tone. For this reason, a single small inconspicuous test spot is recommended to ensure that this complication does not occur. Even after testing, it is appropriate to obtain the patient’s written consent that they understand tattoo ink darkening may still arise during future treatments.

The resulting gray-black tattoo may prove challenging to remove and is more visible than the flesh tone; therefore, test sites are recommended with patient consent. If darken ng occurs, immediately re-treat the area, then wait several weeks to assess the darkened tattoo’s response. If it has lightened significantly, treatment can proceed. Q-switched lasers seem ideal for removing large black facial tattoos (tarsal fanning of pigment, eyebrow tattoo).

However, the beam size (2-6.5 mm) may make removing small dots of precisely confined tattoo pigment (e.g., eyeliner tattoo) technically challenging without risk of temporary or permanent hair loss from heat damage to the terminal hair. I use a spot size of less than 1mm for those patients. Alternatively, eyeliner patients may be treated with high-powered carbon dioxide and erbium lasers because of the precision and need to bypass the ink-darkening phenomenon. The picosecond laser may also be an option to treat paradoxical tattoo darkening.

In non-cosmetic tattoos, pastel colors such as light blue, turquoise, yellow, light green, lavender, and pink should also raise suspicion of white ink additives. Treatment may result in immediate and permanent tattoo darkening in white and red tattoos.

If pigment darkening does occur in a decorative tattoo, it may be improved with subsequent treatment with the QS Nd: YAG laser operated at 1064 nm. The laser pulse can reduce ink from rust-colored ferric oxide (Fe2O3) to jet-black ferrous oxide (FeO). Similarly, white ink made up of titanium dioxide (TiO2, T4+) can be reduced to blue Ti3+ upon laser treatment.

Textural Changes and Mild Scarring

Although true scarring is very unlikely, there can be some slight change in the skin’s texture (1-2% of cases). Sometimes, a pre-existing texture change in the skin is caused by the tattooing process or previous unsuccessful attempts. There can be some loss of natural tanning ability in the treated area, which usually improves with time.

You can reduce the chance of irregular tanning by protecting the tattooed area from sun exposure. Hypopigmentation (lightening of the skin) or hyperpigmentation (darkening of the skin) are infrequent and temporary.

African, Asian, and Mediterranean people can safely treat their tattoos without changing the surrounding skin color. Prof. Moawad uses Q-switched Nd: YAG laser, the safest for dark skin colors. He recommends using bleaching agents before initiating laser treatment and between laser sessions to prevent darkening of the skin in dark-skinned and tanned patients.

Tattoo Removal by Non-Medical Laypeople

The introduction of quality-switched lasers has provided an effective removal method that tattoo studios themselves are increasingly being exploited. It became apparent that tattoo removal by medical laypeople is unacceptable from the point of view of patient safety, and laws need to ban this practice swiftly. Dermatologists are frequently confronted with complications and side effects of tattoo removals performed by non-professionals.


I identified your major problem areas: rare but potentially severe allergic or toxic effects of decomposition products of the tattoo pigments; bodily harm caused by out-of-specification usage of the laser devices; a malignant disease that is obscured within the area of a tattoo and requires accurate dermatological diagnosis; and preliminary pre-operative consultation of patients about the risks, side effects and realistic expectations on the therapeutic outcome.

Tattoo or Laser Tattoo Removal Skin Reaction

The introduction of foreign substances into the skin can result in several adverse effects, including toxic or immunologic reactions to the tattoo pigments, the transmission of infectious diseases, and the localization of skin disease within the tattoo. Complications resulting from decorative tattoos are surprisingly rare, but the incidence increases.

Acute inflammatory reactions

Acute inflammatory reactions are associated with physical tissue injury and pigment, dyes, or metals in the skin. This reaction usually recedes without consequence within 2-3 weeks and is an expected adverse effect of the tattooing process. Many reports describe allergic contact dermatitis from a temporary henna tattoo (technically not a tattoo but a painted-on skin decoration).

The reaction is due to the brightener in the henna, which is often para-phenylenediamine, a known allergen. There have been several cases of generalized allergic reactions after laser treatment, presumably because of the release of antigenic tattoo ink particles into systemic/lymphatic circulation.

Eczematous hypersensitivity reactions

Once any acute inflammatory changes have resolved, the most frequent response observed with tattoos is an allergic sensitivity to one of its pigments. Allergic reactions to red tattoo pigments are the most common and may be caused by various pigments. Hypersensitivity reactions to a tattoo pigment result in contact dermatitis or photoallergic dermatitis. This condition may manifest clinically as localized eczematous eruptions or, rarely, as exfoliative dermatitis.

Photo-aggravated Reactions

Photo-aggravated reactions are caused by yellow (cadmium sulfide) tattoo pigment. Edema and erythema ma may develop upon exposure to sunlight. Although the mechanism is not precise, cadmium sulfide is the light-sensitive material used in photoelectric cells; therefore, the reaction is believed to be phototoxic. Red tattoos have been associated with photo-aggravated tattoo reactions less frequently than yellow tattoos. These reactions may relate to the trace amounts of cadmium added to brighten the red pigment.

In contrast to hypersensitivity reactions to red tattoos, responses to pigments created by green, blue, and black tattoos are much less common. Chromium green tattoo pigment has been associated with localized eczematous reactions at the dye site, eczema of the hands, and generalized eczematous results. Previously quiescent, green-colored tattoos may become inflamed during patch testing in potassium dichromate–sensitive individuals.

Blue tattoos that contain cobalt aluminate have been linked to localized hypersensitivity reactions and (rarely) the spontaneous development of uveitis. Allergic reactions to black tattoo pigment are infrequent—these individuals are sensitive to carbon.

Granulomatous Reactions

Most red pigment is associated with a granulomatous tattoo reaction; however, several reactions involving chromium (green pigment) and cobalt (blue dye) have also been reported. In contrast to an eczematous hypersensitivity tattoo reaction in which patch test results may be positive, granulomatous tattoo reactions are associated with negative patch test results.

Manganese causes a granulomatous reaction in purple tattoos, but enough evidence is not available to establish manganese as the definitive etiologic agent. Granulomatous reactions have been reported in permanent eyeliner tattoos. Treatment is painful because of the proximity to the lid margin.

Pseudo-lymphomatous Reactions

Pseudo-lymphomatous reactions can develop after a variety of foreign substance exposures, including insect bites, acupuncture, antigen injections, earrings, and tattoos. Tattoo-induced pseudo-lymphoma occurs primarily within red portions of the tattoo. Green or blue tattoos rarely induce this reaction.

Lichenoid Reactions

Lichenoid hypersensitivity tattoo reactions are less common than eczematous reactions. Evidence exists that the lichenoid response is an expression of delayed hypersensitivity to a lymphocytic T-cell infiltrate, which may simulate the graft-versus-host response. Mercury (red pigment) is responsible for most lichenoid tattoo reactions.

Clinically, wart papules or plaques typical of hyperkeratotic lichen planus are usually confined to the red portion of the tattoo. Like granulomatous s tattoo reactions, lichenoid reactions are associated with negative patch test results.

Localization of Disease in Tattoos

Several cutaneous disorders show a preference for tattooed skin. Lichen planus, p psoriasis, sarcoidosis, and lupus erythematosus have been associated with localization to a tattoo site. Keratoacanthoma, keratinizing squamous cell neoplasm of unknown origin characterized by rapid growth, has been observed with several types of skin injury.

Although rare, eruptive keratoacanthomas have been reported in red and multi-colored tattoos. The eruption may represent the initial manifestation of the disease or the accentuation of an existing disorder in the tattoo. Several cases of skin cancer occurring at the site of tattoos have been reported, including squamous cell carcinoma, basal cell carcinoma, and melanoma.

While tattooing r results in the deposition of metallic salts and organic dyes in the skin, potentially for the remainder of the recipient’s lifetime, the carcinogenic effects remain unclear. Further research s needed to explore this relationship.

How to treat Allergic Reactions?

Unfortunately, there are currently few requirements or regulations and no legislation for the safety of tattoos. The sterility of the pigments and equipment is uncertain as many are being performed on the roadside and in makeshift salons. In contrast to drugs and cosmetics, tattoo pigments have never been controlled or regulated. The manufacturer often keeps the exact composition of a given tattoo pigment as a “trade secret.”

An allergic reaction can occur after treatment, especially if you already have an allergic reaction (redness and itching) to your tattoo. Allergic granuloma to tattoo ink is almost seen in the cinnabar in red-colored inks. Allergic reactions are usually caused by metallic dyes, which contain mercury, manganese, chromium, cobalt, or cadmium. Treatment of allergic tattoo reactions is challenging, mainly when surgical excision is not practical or desired. Prof. Moawad treats such reactions with topical or intralesional corticosteroids and avoids laser treatment altogether.

It may worsen the allergic reaction and produce systemic symptoms or even an anaphylactic response. QS frequency-double Nd: YAG lasers have been used to remove red allergic tattoos. I can employ an ablative laser, such as carbon dioxide, to simultaneously remove the offending ink and destroy the granulomas. Before laser treatment, biopsies should be considered to rule out sarcoidosis, infectious granulomas such as atypical mycobacterial infections, and other entities.

How Should I Wait for Long Between Sessions?


The appropriate treatment interval is critical and yet poorly understood. Early on, patients were treated every four weeks. The current recommendation is to treat at 6- to 8-week intervals unless a more extended period of 2-3 months is needed for tissue recovery. I schedule them every two weeks for highly motivated patients if only QS lasers are used.

Fractional CO2 or Ultra-pulse CO2 is used every 4-6 weeks to help skin recover. It would be best if higher fluences and shorter pulse widths remove tattoo pigment more rapidly but may induce excessive shock wave tissue reaction; therefore, I must balance them with the desire to remove dye without scarring or hypopigmentation. We thought of the adding and eventual elimination of your tattoo as a project you might work on from time to time over the next year or two.

Will the Tattoo Completely Disappear?


In many possibilities, the tattoo can disappear or fade to the point where you are the only person who can find a trace of it because you know where to look. At this point, I used the fractional CO2 laser alone to change the geometry of the tattoo shadow.

Also, I may use E-light or long-pulsed Nd: YAG (1320nm or 1064nm) to treat residual pigmentation, hypopigmentation, and textural changes. Dark (blue/black) inks and red inks usually fade the best. Dark inks respond quicker than bright-colored inks because dark colors absorb laser energy better. Oranges and purples often respond well.

Light colors such as light green, yellow, and turquoise can be challenging to remove. Multi-colored professional tattoos respond slowly to laser treatments, especially on the lower legs. Many colorful tattoos will need ten or more treatment sessions for good fading or complete removal. Sometimes chemicals like iron oxide or titanium dioxide are added to tattoo ink to brighten the tattoo – but these chemicals make it much more difficult to remove the tattoo.

Fluorescent “Day Glo” pigments are almost impossible to extract. Some tattoos are now made with dark tar-based ink or “laser resistant ink,” I can only remove these tattoos (fortunately, they are rare) by cutting them out. Tattoos on the face and trunk often respond faster to laser treatment than tattoos on the ankles.

Some people choose to over-tattoo (use “cover-art”) to hide an undesirable tattoo. This is especially common. The original tattoo contains a former lover’s name. If you have one tattoo on top of an older tattoo, other laser treatments will be needed because there will be tons of ink (ink from the new cover-up tattoo plus ink from the old tattoo).

Many tattoo artists e courage customers to have several laser treatments to lighten an existing tattoo before covering it with a new one. This will reduce any chance that the old tattoo will be visible through the new tattoo. It would be best to wait a month or two after your final laser treatment before placing a new tattoo in the treated area.

How Many Laser Treatments are Required?


Until recently, a significant issue with laser tattoo removal was the inability to predict or estimate the number of sessions needed to eliminate tattoos. Patients often wish t obtain a rough estimate of the number of sessions required to give a significant clearing of tattoos.

This indirectly impacts the financial implications so the patients can plan their budget for the laser sessions. It is well-accepted that the number of sessions depends more on the kind of tattoo than on the laser used; thus, 5-10 sessions are standard for amateur tattoos and 15-20 for professional tattoos, even up to twenty-five courses in rare cases.

The number of treatments t sessions also depends on pigment color, composition, density, depth, age, body location, and the amount of tattoo ink present. The Kirby-Desai Scale is a valuable index to correlate with the number of treatment sessions required for satisfactory tattoo removal. This is based on the following six factors:

  • Fitzpatrick skin type
  • Location
  • Color
  • Amount of ink used
  • Scaring and tissue damage
  • Ink layering

By allotting a numeric value to each of these and totaling it, a rough estimate can be made as to the number of sessions for a given tattoo. This is a significant step forward as patient counseling becomes easier. Because there is a great deal of variability in the kinds, mixtures, and quantities of ink used in tattoos, and because there is some variability in people’s natural ability to clear away tattoo pigment after laser treatment, it is not possible to “promise” you that a particular result will happen after a fixed number of procedures.

Prof. Moawad will exp in what is likely to happen, but he cannot precisely predict or guarantee what will happen in any case. Prof. Moawad will show you photos illustrating the range of results, from fading through to the complete disappearance of the tattoo. I can remove some light pigmented, black, or dark blue homemade tattoos in one treatment.

Amateur tattoos (usually have a small amount of superficial ink) are often bright after two to six treatments. New tattoos need more t treatment sessions because they have more ink than old tattoos. Older tattoos have less ink because, like tattoo ages, the body absorbs some of the ink.

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