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THE MANAGEMENT OF TATTOOS WITH LASERSThe treatment of tattoos on the National Health Service is rather a grey area. Many purchasers refuse payment. However, as a dermatologist, I see patients with tattoos who are severely stigmatised in many ways and the resulting disfigurement and disability is just as great as, for instance, patients with extensive port wine stains. I look sympathetically on trying to arrange treatment as a National Health Service patient for individuals who have a tattoo which is producing emotional and psychological distress. Each year I see two or three patients who, for instance, try to commit suicide because of their tattoos. Another group who merit treatment, in my view, are those who are unable to get a job because of their tattoos. An increasing number of large organisations preclude anyone with tattoos from employment. Moreover, if a tattoo is causing marital disharmony I think a case can be made for removal as a National Health Service patient. I would certainly not support the removal of tattoos in a youngster with a personality disorder, with a tattoo put on one day, wanting it removed the next, and then another put on the next day. I don't think anyone can expect the National Health Service to fund this type of removal. It is important, also, to make a distinction between amateur and professional tattoos. As a generalisation, an indian ink amateur tattoo is much easier to remove than a tattoo acquired professionally. A simple, straightforward amateur tattoo will respond very satisfactorily to treatment with a Q-switched frequency-doubled Nd:YAG laser, which in my view is the treatment of choice for such tattoos when emitting at 1064 nm. Alternative lasers include the Q-switched Ruby laser and the Alexandrite laser. However, the Q-switched Nd:YAG laser at 1064 nm has a lesser effect on pigmented skin than either the Alexandrite or the Ruby laser and is much faster to operate, having a much higher pulse repetition rate than either the Alexandrite or the Q-switched Ruby laser. In addition, light at 1064 nm is more penetrating than Ruby laser light and so more deeply placed tattoo pigment is dealt with effectively. Five to eight treatments are usually necessary, but in unusual instances the tattoo may disappear after two or three treatments. With regard to professional tattoos, these are much more difficult to treat because of the wide variety of colours often present. It is important to note that no one individual laser can effectively remove al1 tattoo pigments at this time and so any centre undertaking to do removal should have access to a minimum of two different laser systems. For instance, a Q-switched Ruby laser is not effective against red pigment whilst a laser emitting green/blue light is unlikely to be helpful in abolishing green pigment. Green pigment in particular is very difficult to eradicate, even with a red laser such as the Q-switched Ruby laser, or better, with the Alexandrite laser and up to 20 treatments may be necessary. The frequency-doubled Nd:YAG laser, operating at 532 nm is effective in removing red pigment, and in difficult instances the pulsed dye laser at 585 nm can be utilised also. One factor of importance in determining how many treatments will be necessary is the age of the tattoo. A recently acquired tattoo contains a lot of pigment and may require, therefore, more treatment sessions to remove this pigment than a tattoo that has been present for 20 to 30 years. The results of treatment are generally good, but many patients do not persist with treatment until the tattoo has completely disappeared, so that a small amount of ghosting of pigment often remains. However, most patients seem happy with this result. The treatment itself causes some discomfort. There is usually immediate whitening of the skin, which persists for a few minutes. This is due to the release of steam bubbles within the skin. If a higher energy fluence is used punctuate bleeding is also quite usual. Despite quite extensive punctuate bleeding, however, the skin usually heals well and it is unusual to develop any scarring after the use of Q-switched lasers. Pigmentary change in the skin is more likely if the Ruby laser is being used. Immediate pigment darkening following laser treatment may occur, especially when iron containing flesh coloured pigments are treated. If this happens, laser treatment should be stopped. In some patients appropriate further laser treatment may be helpful, but it is not successful in all patients. In the USA some patients have been described who have developed severe anaphylactic shock following laser treatment of the red areas in their tattoos. So far, to my knowledge, this has not occurred in the UK, but it does underline the necessity of having resuscitation equipment available in all establishments undertaking tattoo removal. Moreover, staff in these clinics should be fully conversant with resuscitation techniques. Accidental post traumatic tattoos, for instance, following road traffic accidents, respond well to treatment with the Q-switched frequency doubled Nd:YAG laser. It is important, however, not to treat post traumatic accidental tattoos in the skin following firework explosions. These tattoos may contain minute amounts of explosive material and may themselves explode if treated with the laser. This type of accidental tattoo is best treated by surgical removal. Finally, it is important to be very careful treating a tattoo in a patient receiving gold therapy for rheumatoid arthritis. Laser treatment in such patients can induce severe pigmentary changes in the skin due to gold.
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The Disfigurement Guidance Centre |
