The word tattoo is derived from the Tahitian word ‘tattau’, which translates as ‘to mark’ and refers to a type of body art involving skin puncture with needles to insert tattoo ink permanently into the dermal layer of the skin. Tattoos are done for cosmetic (decorative/permanent makeup) or therapeutic (medical tattoos) purposes or are unintentionally introduced (traumatic tattoos).
Although there has been a substantial increase in people getting cosmetic tattoos, tattoo removal is also on the rise due to the following reasons: changes in personal taste; poor tattoo quality; religious reasons or occupations that prohibit visible tattoos.
It is a process of removing the permanent ink from the body. It is a tedious and complicated procedure, requiring several sessions to remove the permanent ink below the skin surface. A qualified medical professional should perform tattoo removal. The cost of tattoo removal varies depending on the size and location of the tattoo, the type of ink and the number of treatment sessions.
Laser treatment has made tattoo removal easier, less complicated and less painful than other procedures. It uses bursts of high-intensity light to break down the pigments into tiny particles, eventually removed by the immune system. The colours in the tattoo determine the type of laser to be employed as different colours absorb different wavelengths of light. Multi-coloured tattoos require multiple lasers.
They are the most commonly used lasers for tattoo removal. Nanosecond pulses of high-energy light are directed towards the ink that absorbs this light energy, causing fragmentation of the tattoo pigments, without damaging the surrounding tissues. The QS lasers currently employed for tattoo removal are the QS ruby laser (694 nm), QS alexandrite laser (755 nm) and neodymium-doped yttrium aluminium garnet (QS Nd:YAG, 1064 nm) laser.
This is a new technology where the duration of the pulses is much shorter (in picoseconds) than the QS laser. Thus, these lasers direct short and powerful light energy pulses towards the ink, creating a photoacoustic effect (a mechanical pressure wave is produced), effectively breaking down the ink particles and providing precise and faster treatment. Picosecond lasers can aid tattoo removal in fewer sessions than QS lasers.
Ablative (top layer of skin is removed) or non-ablative (underlying skin tissue is heated and the skin surface is unharmed) fractional resurfacing (the laser energy is divided into many small beams targeting a specific area of the skin) has achieved good results when used alone or combined with a QS ruby laser. It has demonstrated enhanced pigment clearance, reduced hypo-pigmentation and no blistering. It has been effective in removing multi-coloured, allergic and traumatic tattoos.
In this method, multiple laser passes are used in one session. The R20 method uses four laser passes in one session with a 20 minute-interval between passes. The interval time aids in resolving the frosting after laser treatment. The R0 method uses perfluorodecalin for topical application before QS laser treatment, resolving the whitening in a few seconds. Both methods showed more effective tattoo removal than traditional single-pass laser treatment.
The tattoo ink colour and skin type determine the laser type employed.
Blue or black tattoos are effectively removed with QS ruby (694 nm), QS alexandrite (755 nm) and QS Nd:YAG lasers (1064 nm). Although QS ruby is superior to others in ink clearance, it is frequently associated with hypo-pigmentation. In contrast, QS Nd:YAG causes less pigmentary changes and allows greater light penetration, making it the treatment of choice for patients with a dark skin tone.
When the frequency of light emitted from QS Nd:YAG (1064 nm) is doubled, it produces a light of 532 nm wavelength. This is effective in removing orange, red and yellow inks. QS ruby is suited for purple ink removal, and QS alexandrite is suited for green ink removal.
Removal of tan, pink or white-coloured tattoos (used for permanent makeup) can cause paradoxical darkening where titanium dioxide or iron oxide is reduced upon laser exposure and turns the pigment black. Thus, a small area should be tested before exposing the entire tattoo to the laser. Q-switched lasers are not recommended for treating tattoos containing these inks. Fractional Er:YAG or fractional CO2 laser is advised to prevent paradoxical darkening.
The patient’s tattoo and skin type should be carefully determined. The extent of sun exposure, prior isotretinoin treatment (increases scarring risk), keloidal tendency (a hereditary condition with abnormal scar tissue growth following skin injury), herpes infection and systemic gold therapy should be evaluated to take necessary precautions during treatment. Digital photographs of pre-treatment appearance and subsequent post-treatment changes must be obtained.
Patients must be counselled on the treatment options, expected outcomes, post-treatment care and potential risks. They should be given ample time to clarify their concerns, and setting realistic expectations results in patient satisfaction. Informed consent stating the benefits and risks must be obtained before tattoo removal.
The risks may include incomplete ink removal, scarring, texture changes and hypo- or hyper-pigmentation. Patients with a dark skin tone must be cautioned of side effects, such as oedema, transient vesiculation (bubble formation beneath the skin) and crusting. Sun protection before and after treatment is essential to avoid complications.
On average, 7–10 sessions are needed for tattoo removal. The Kirby-Desai scale helps the dermatologist determine the number of sessions and is useful during patient counselling. The six parameters included in this scale are as follows: Fitzpatrick skin phototype, amount of tattoo ink used, tattoo colour, tattoo location, ink layering and scarring. Numbers are assigned to each factor and added up to obtain an estimated score of the number of sessions. A limitation of this scale is that it does not include laser type as one of the factors.
The skin should be thoroughly cleaned to remove residual makeup or skincare products applied. Flammable cleansing agents, such as isopropyl alcohol should not be used. As tattoo removal is painful, a topical anaesthetic, such as a combination of lidocaine and prilocaine is applied. The dermatologist should wear wavelength-protective goggles and protective goggles should be provided to the patient. Intraocular metal eyeshields should be placed if the treatment is near the orbit. For cosmetic tattoos, test spots should be considered as paradoxical darkening is frequently encountered.
The initial treatment should be performed at the lowest fluence (energy received/unit area on the skin) possible to achieve immediate skin frosting and limited thermal injury, such as blisters and scarring. In subsequent sessions, the fluence is increased as the tattoo ink fades; however, caution should be exercised to limit pinpoint bleeding (breaking of capillaries in the skin). The gap between laser treatment sessions is usually 4 weeks or more to promote ink clearing and skin healing.
Immediately after treatment, patients can expect the area to be swollen and red, which can be resolved using a cold compress. Protective bandages and antibiotic ointment/an emollient healing ointment are recommended for 7–10 days post-treatment. Patients should be advised on possible side effects such as blisters and crust formation, and long-term effects, including hypo- or hyper-pigmentation, scar formation and tattoo pigment colour alteration.
Tattoo type: It is important to determine if the tattoos are professional or amateur as the ink composition and depth of ink placement affect the number of sessions required for removal. Professional tattoos require more sessions as they are placed deep in the dermis, whereas amateur tattoos require fewer sessions as they are placed in the upper epidermis.
Tattoo age: Older tattoos are easier to remove because the ink has broken down with time.
Tattoo colour: Dark colours, such as black, blue and dark green are easier to remove than bright colours, such as yellow, red or green. Flesh-coloured tattoo removal is complicated as the pigments turn black (oxidised) upon laser treatment.
Tattoo size and location: Large tattoos require more sessions than small tattoos. Tattoos on the chest and back are easier to remove than those on the hands and feet due to increased blood flow and lymph node proximity, permitting quick pigment removal by the immune system.
Skin type and health: Tattoo removal is easier for people with light skin tones than those with dark skin tones because light-coloured skin does not absorb laser light and most of the laser is focused on the pigment. People with dark skin tones are more susceptible to scarring.
Smoking: Smokers have lower rates of tattoo removal than non-smokers because smoking directly affects wound healing.
General health: Laser tattoo removal involves heat to break down the ink particles that must be removed from the body. A robust immune system can help clear these particles from the body. Local or systemic allergies experienced while getting a tattoo can relapse with laser treatment for tattoo removal.
The complications of laser tattoo removal have been classified as immediate and delayed as discussed below.
The immediate complications include pain, crusting, blisters and pinpoint haemorrhage. An urticarial lesion, an acute allergic reaction, has also been reported. Pain can be reduced with a topical anaesthetic cream during the procedure.
One study has suggested passing laser light through a microscopic glass slide to decrease pain and blister formation. Crusting can be resolved using a topical antibiotic or emollient. Picking at the crusts can cause pigmentary changes, and patients should be advised against it. Pinpoint haemorrhage naturally subsides.
Hypo- or hyper-pigmentation occur 4–6 weeks after laser treatment. However, these pigmentary changes are transient. Prolonged pigmentary changes can be seen in people with a dark skin tone. Thus, low fluence and long wavelength lasers are used for patients with dark skin.
Local allergic reactions (pruritic papules, scaly plaques and nodules) and photoallergic reactions occur in tattoos with yellow or red pigments. These allergic reactions are treated with intra-lesional or topical corticosteroids.
A ghost image or residual pigment is observed while removing multi-coloured professional tattoos, which can result in transient or permanent textural changes. High fluence can cause scarring in patients with dark skin tones as melanin absorbs most of the laser energy.
If you’re considering tattoo removal, it’s vital to choose a competent medical professional. At Kauvery Hospital, with branches located in Chennai, Hosur, Salem, Tirunelveli, and Trichy, experienced dermatologists uphold the highest standard of care, ensuring your tattoo removal process is performed safely and effectively. Let us help you start your journey towards a tattoo-free future.
Laser treatment is the best option for safe and effective tattoo removal. Patients must be counselled on the benefits, risks, side effects and possible complications before the treatment. Laser selection is based on the skin type and ink colour, with different lasers showing effective removal of specific ink colours. Picosecond lasers have demonstrated better outcomes with fewer treatment sessions. Tattoo removal is a tedious process with complications, including scarring, texture changes and residual pigmentation. Therefore, it is advised to get the procedure done from a board certified dermatologist.
Laser tattoo removal uses bursts of high-intensity light to break down tattoo pigments into tiny particles. These particles are then eliminated by the body’s immune system over time.
Some discomfort is associated with the process, similar to getting a tattoo. Topical anesthetics are often applied to minimize pain.
On average, 7–10 sessions are required, depending on factors like tattoo size, colour, age, and depth of ink placement.
Dark colours like black and blue are easier to remove. Bright colours like yellow, green, and red may require additional treatments or specialized lasers.
Common side effects include redness, swelling, blistering, and temporary pigmentary changes like hypo- or hyper-pigmentation. These usually resolve with proper aftercare.
Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai (Alwarpet & Vadapalani), Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.
Chennai Alwarpet – 044 4000 6000 • Chennai Vadapalani – 044 4000 6000 • Trichy – Cantonment – 0431 4077777 • Trichy – Heartcity – 0431 4003500 • Trichy – Tennur – 0431 4022555 • Hosur – 04344 272727 • Salem – 0427 2677777 • Tirunelveli – 0462 4006000 • Bengaluru – 080 6801 6801
