Updates on tattoo removal

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Dr. Biesman

Dr. Pozner

Dr. Geronemus

Tattoo regret is real, but removal innovations are helping to address unwanted treatment-related issues.

The Harris Poll published findings from an online survey of 2,225 U.S. adults from October 14-19, 2015, suggesting 29% of Americans had at least one tattoo but 23% of those with tattoos had, at some point, regretted the ink. 

And with regret often comes removal. And while tattoo removal has evolved in recent years, outcomes - even in the hands of experienced providers - aren’t 100%. More than 90% of RealSelf reviewers give tattoo removal a Worth It rating, but many comment that some of their tattoos remain or, in darker skinned patients, pigmentation issues emerge from laser treatment.

But we’ve got good news on the technology front: Innovations are helping to address some of these (and other) treatment-related issues.

The PFD Patch

Among the advances in tattoo removal is a silicone patch infused with perfluorodecalin (PFD), called the Describe PFD patch (Merz).

Brian S. Biesman, M.D., an oculoplastic surgeon in Nashville, Tenn., who helped to develop the PFD patch and conducted pilot and pivotal studies on the device, says he uses the PFD patch for every tattoo that he removes.

“It minimizes the epidermal whitening effect, which allows you to do multiple treatments during the same session as opposed to only being able to make one pass and you’re done. Within a period of 5 minutes, you can make between 3 and 4 passes with the laser as opposed to only one,” Dr. Biesman tells Dermatology Times. “It also allows for deeper transmission of light into the tissue, and it acts as a heat sink to help protect the epidermis.”

Plastic surgeon Jason N. Pozner, M.D., who offers tattoo removal at his Boca Raton, Fla., practice, says the Merz patch is particularly useful for q-switched devices.

Read more: When patients have tattoo removal regret

Dr. Biesman and colleagues conducted a pilot study published in 2015 in Lasers in Surgery and Medicine on using the PDF patch to treat patients’ black or dark blue tattoos with the Q-switched Alexandrite laser (755 nm). They found that the PFD patch delivers faster results, namely: “Rapid multi‐pass treatment of tattoos with highest tolerated fluence facilitated by a transparent PFD‐infused patch clears tattoos more rapidly than conventional methods.”

Dark-Skinned Strategy

To minimize dyspigmentation from laser tattoo removal, dermatologist, Roy G. Geronemus, M.D., director of the Laser & Skin Surgery Center of New York and clinical professor of dermatology at New York University Medical Center, says he uses a hydrogel dressing on patients with types IV through VI skin.

He performs laser treatment through the precooled, nonstick clear dressing, which he applies over the tattoo right before treatment.

“One can easily treat through the gel and achieve absorption within the tattoo. I generally observe the clinical reaction in an effort to avoid an overly brisk reaction which could lead to dyspigmentation,” says Dr. Geronemus, who was senior author on a clinical pearl on the use of hydrogel dressings to minimize dyspigmentation from laser tattoo removal, published September 2019 in the Journal of the American Academy of Dermatology.

“Hydrogel dressings are commercially available off the shelf and economical (averaging approximately $1 or less per dressing), thus allowing for easy, widespread adoption. Additional benefits of the technique include reduced laser-induced tissue splatter and increased patient comfort from the cooling effect,” Dr. Geronemus and coauthors write.

Nd:YAG vs. Picosecond

The Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser remains the gold standard in in laser tattoo removal, despite the advent of newer picosecond lasers, researchers report in a study published in the April-June 2019 Journal of Cutaneous and Aesthetic Surgery.

But Dr. Biesman says he thinks there is a role for both traditional short-pulse duration q-switched devices and picosecond devices.

“If you have access to both nanosecond and picosecond pulse duration devices that’s optimal,” Dr. Biesman says.

Treating darker skin types is more dependent on the wavelength, he says.

“To treat darker skin types the bottom line is you need to use longer wavelength, like the 1064,” Dr. Biesman says.

Dr. Geronemus says he mixes and matches the laser to the colors of the tattoo and the phototype of the patient.

“I generally use picosecond lasers at 755, 532 and 1064 mm wavelengths,” Dr. Geronemus says.

Early studies suggest picosecond pulses effectively remove tattoo and are especially effective at clearing black tattoos. Picosecond laser treatment also appears to be less painful, according to a study published Feb. 13, 2019, in Photochemical and Photobiological Sciences.

“Consequently, picosecond technology may be a new strategy for more effective removal of tattoo pigments at a lower rate of side effects. But there is an urgent need for more well-designed and randomized controlled trials to compare this treatment modality to the traditional nanosecond technology regarding efficacy and adverse reactions,” the authors of that study write.

A Range of Outcomes

Physicians and patients can expect a range of outcomes from tattoo removal, according to Dr. Biesman.

“There are patients - I had one back just yesterday who I treated three times and you can’t even see that his tattoo was ever there. But that’s not what happens every time. It depends on the color of the tattoo, what type of ink was used, the intensity of the pigment,” Dr. Biesman says.

In most cases, providers using laser technology can get substantial lightening - enough clinical improvement to where most tattoo removal patients are satisfied, Dr. Biesman says.

Tattoo removal isn’t easy and takes time. Dermatologists and others should encourage patients to go to experienced physician providers to have tattoos removed, according to Joel Cohen, M.D., director of AboutSkin Dermatology and DermSurgery, in Greenwood Village, Colo., and associate clinical professor of dermatology University of California at Irvine.

“Tattoo removal is something where people really need to seek out the right treatment and usually that’s with a slow, methodical treatment approach in a dermatology office using either a q-switched laser or pico-type wavelengths. Oftentimes, we can integrate the PFD patch. There is an art to tattoo removal, and we see, unfortunately, a lot of patients with bad outcomes who go to non-medical facilities or even hair salons. People really want to look for the right equipment or right office,” Dr. Cohen says.

Disclosures:

Dr. Geronemus reports serving on medical advisory boards for Allergan, Candela, Cearna, Cynosure, Cytrellis, Lutronics and Soliton; serving as an investigator for Allergan, ArchiMedus, Candela, Cynosure, Cytrellis, Endo Pharmaceuticals, Kerastem, Lutronic, Merz, Miramar, New York Stem Cell Foundation, Revance, Sciton, Sienna Labs; and being a stockholder of Cytrellis.

Dr. Biesman is a consultant for Merz, Allergan, Galderma, Evolus and Revance and serves on medical advisory boards for Allergan, Cytrellis, and Solta. He receives research support from Allergan, Merz, Sienna, Cytrellis, and is a stockholder of Cytrellis.