Tattoo removal

Following are three types of tattoo removal methods:

• Dermabrasion: After numbing the skin area to be treated by chilling it, a rotators dermabrasion device is applied to it. The outer layers of the skin are stripped away and the tattoo dye pigments are allowed to leach out of the deeper dermis layer. However, the skin becomes raw and redness can last for up to months. Due to unpredictable results and undesirable complications, dermabrasion is not the recommended treatment for tattoo removal.
• Surgical excision: This method is best suited for smaller tattoos. The skin containing the tattoo to be removed is numbed with a local anaesthetic injection. After its effect kicks in, the skin is emitted with a scalpel, the edges are sewn together and antimicrobial ointments are applied. This produces a scar and is thus not recommended for larger tattoos. Although effective, it holds the risks associated with any surgical procedure.
• Laser tattoo removal with Q-switched lasers: Laser tattoo removal remains the treatment of choice. After numbing the skin with a local anaesthetic injection, the tattoo pigments are broken up with a high-intensity beam of laser energy. Q-switched Nd:YAG lasers are the preferred means today; they also offer the added benefit of not causing a change of colour of skin in people with darker skin types. The laser energy absorbed by the tattoo dye pigments causes them to break up and be slowly excreted through the body. Black and other dark dyes absorb all laser light energy and are thus treated most effectively. However, pigments of different colours (like yellows and greens) require the use of different wavelength laser light energy for optimal dissipation. Multiple sessions are generally needed with laser tattoo removal therapy for complete or near-total removal of tattoos. The number of sessions, durations and other particulars depend on the type, size, location and colour of the tattoo as well as the individual’s own skin colour and other characteristics that can impact healing. Skin blistering after laser tattoo removal sessions is possible and antimicrobial ointments should be applied.

Not all tattoos can be safely removed through these methods. The following characteristics make a tattoo an ideal candidate for removal:

• Smaller tattoos
• Less colourful tattoos
• Dark pigment tattoos like ones that are black, brown and dark blue
• Lighter skin colour (while dark skin types are at added risk of permanent change of skin colour after tattoo removal sessions, appropriate methods can be selected for tattoo removal for them)

After thoughtfully making the decision to get a tattoo removal procedure, the patient must meet and consult with a trained professional (this could be a dermatologist specialising in tattoo removals). The professional will take a medical history, conduct a physical examination and make note of any preexisting conditions or medications in addition to assessing the tattoos in question. Tattoo removal can be impacted by the number, colour, size, type and location of the tattoo. The individual’s overall health, age and skin colour may also be a factor. Following this initial assessment, a tattoo removal plan will be made and discussed with the patient, explaining the procedure, precautions to be taken, potential risks and aftercare. An individualised regimen will be instituted and the number and duration of laser sessions will differ accordingly.

(Read more: Laser Therapy)

Laser tattoo removal is carried out at an aesthetic clinic by a trained technician. The patient is given a pair of protective eye goggles and the area to be treated can be numbed with local anaesthesia. A Q-switched laser is tested on the patient’s skin to regulate the energy needed for treatment. After this, the Q-switched laser is applied to the tattoo and the high energy laser beam is absorbed by the tattoo pigments breaking them up. After the session, the tattoo will appear visibly lightened but may not have disappeared entirely. Skin can turn red, become blistered and even bleed after laser treatment. Ice packs can be applied to soothe the skin. Although the number of sessions varies with the type of tattoo and the individual’s characteristics, typically 6 to 8 sessions are needed for the best results. The practitioner will prescribe aftercare measures to be followed by the patient for optimal results and prevention of side effects.

Aftercare of laser tattoo removal: The tattoo removal technician will give specific instructions altered to the patient's circumstances. However, some general guidelines to follow are:

• Application of antibacterial ointment on the skin area being treated after every session for several days.
• Changing the bandage over the antibacterial ointment upon every application.
• Keeping the treated skin area dry and clean for at least two weeks after each session.
• Avoiding tight or restrictive clothing over the skin area being treated for at least two weeks or more after each session.
• Avoiding direct sunlight exposure to the skin area being treated for at least two weeks following each session.
• Ensuring to not pick at any scabs or blisters that may form in the skin area being treated. Doing so can result in permanent scarring.

Some preexisting conditions or factors can make removal difficult if not impossible. It is important to address these with caution to achieve the best possible outcome of treatment.

• Contraindications to dermabrasion: 
  • Eczema
  • Skin sensitivity or active skin disease in the area of dermabrasion 
  • Blood thinner medications: Patients on blood thinners (like aspirin or warfarin) can be put at an added risk of bleeding and haemorrhage with dermabrasion procedures. 
  • Darker skin colour: People with darker skin tones are at risk of permanent skin colour change at the site of dermabrasion.
• Absolute contraindications to laser tattoo removal: The presence of any of the following factors makes laser removal of tattoos impossible and necessary to avoid. These include:
  • Active local infection
  • Photo-aggravated skin diseases
  • Tattoo granuloma
  • Allergic reactions to tattoo pigment
  • Unstable vitiligo
  • Psoriasis
• Relative contraindications to laser tattoo removal: The presence of any of the following factors requires careful deliberation and certain precautionary measures before laser tattoo removal therapy. These include:
  • Keloids or keloidal tendencies
  • Patient on isotretinoin for acne treatment 
  • History of herpes simplex
  • A patient who is not co-operative or has unrealistic expectations

As with all medical procedures, tattoo removal is also linked with a series of potential risks and possible complications. Certain measures can be taken, in some cases, to reduce the incidence of such issues.

• Complications of surgical tattoo removal:
  • Scarring at site of tattoo skin excision
  • Bleeding or haemorrhage from the site of tattoo skin excision
  • Infection at the site of tattoo skin excision
• Complications of laser tattoo removal: Most complications following laser tattoo removal are seen in patients with darker skin colour as the melanin in their skin may compete with the tattoo pigment for the laser beam energy. However, with the use of Q-switched lasers for tattoo removal, these complications can be minimised in patients of all skin types.
  • Tattoo clearance is often incomplete and a residual tattoo outline and textural changes may be seen
  • Blistering
  • Edema
  • Crusting
  • Erythema
  • Bleeding
  • Pain
  • Infections
  • Scarring
  • Hyperpigmentation
  • Hypopigmentation
  • Colour change of tattoo pigment
  • Skin textural changes can occur after multiple laser treatment sessions
  • Dyspigmentation

(Read more: Pigmentation)

Following are a few precautions to keep in mind when considering tattoo removal: 

• Avoid direct sun exposure to the tattoo area for a minimum of 8 weeks leading up to laser removal procedures and up to 2 weeks after. Apply sunscreen (UV protection) for the 8 weeks before and 2 to 3 weeks after a laser tattoo removal session. 
• Certain drugs that can cause sun sensitivity may need to be stopped leading up to the laser tattoo removal procedure. 
• Self-tanning creams that increase the melanin content of the skin are forbidden before and after the laser tattoo removal sessions to reduce the risk of skin burns. 
• Perfumes, eau de toilettes, creams and/or deodorants are to be avoided on the treatment areas the day of the appointment.
• Many dangerous “home remedies” for tattoo removal have been prevalent in the past. It is important to note that not only are they ineffective but they can also cause extreme pain, scarring, hyperpigmentation, infections and worse. Some unhelpful, perilous, and ineffective home-based tattoo removal methods to beware of include: 
• Salabrasion: The harmful and ill-informed practice of rubbing salt on tattoos to abrade them can cause severe pain and scarring.
• Aloe vera and yoghurt: While this method may not be harmful to one’s skin, it is also not proven to have any effect on tattoos.
• Sand: Another “hack” that aims to remove tattoo pigment from the skin is the practice of rubbing sand grains on it. This, too, is ineffective and leads to skin abrasions, rashes, redness and scarring. 
• Tattoo removal creams: Many tattoo removal creams have become available online - it is important to note that they have not been approved by the FDA (Food and Drug Administration, USA) or any other drug regulatory body as they have not shown any promising results and also carry with them a host of side effects and risks for skin rashes and scarring.
• Lemon juice: While lemon juice is a common skin lightening component in many skincare home remedies, it has no effect on tattoo pigments.  
• Hydroxy acids: Alpha-hydroxy acids like glycolic acid and beta hydroxy acids like salicylic acid are useful agents in skincare products that strip away dead skin cells and reveal the undamaged skin beneath. These products have no role to play in tattoo removal.

(Read more: First aid for burns)