N e w Ta t t o o A p p ro a c h e s i n

Dermatology
Stefanie Luebberding, PhDa,*,
Macrene Alexiades-Armenakas, MD, PhDa,b

KEYWORDS
 Tattoo  Tattoo removal  Laser-based tattoo removal  QS laser  Picosecond laser
 Multipass treatments  Dermal scatter reduction

KEY POINTS
 Nonablative and laser-assisted tattoo removal is a frequently performed treatment in today’s
dermatologic practices.
 Quality-switched ruby, alexandrite, and Nd:YAG laser technologies have been well investigated in
numerous randomized and controlled studies and are considered to be the gold-standard for rela-
tively safe and effective tattoo removal.
 Determining the optimal wavelength and treatment modality requires a careful patient evaluation,
which must include an assessment of skin type and the tattoo itself.
 Current research in the field of tattoo removal is focused on faster lasers and more effective target-
ing of tattoo pigment particles in the skin.
 Systematic, randomized, and controlled in vivo studies are required to assess if new innovations are
indeed effective and safe.

INTRODUCTION have at least one tattoo. Around 50% of these indi-

viduals have 2 to 5 tattoos, whereas 18% indicate
Body art, such as tattoos, have fascinated mankind that they have 6 or more tattoos.2 The reasons
for centuries and have already been found in cited for getting a tattoo include “impulsive deci-
ancient Egyptian, Greek, and Roman cultures. In sion making”, “to be part of a group”, “just wanted
the past, such body markings served to enhance one”, and “for the heck of it”, but people also strive
beauty, provide healing, declare belongings, and for individuality and uniqueness when making such
were even used to identify criminals and slaves.1 a decision.3
The symbolic importance of tattoos has endured Throughout the course of the past 20 years, the
through the present day. However, although tat- prevalence of tattoos has significantly increased.
tooing in ancient times was a slow and tedious Consequently, the demand for tattoo removal has
process reserved for a select few, the invention of increased as well. Although surveys suggest that
electric tattooing machines in the 20th century up to 20% of owners may be dissatisfied with their
made tattooing available and affordable for the tattoo, 11% consider removal and approximately
mainstream. Thus, tattoos have become an impor- 6% actually seek tattoo removal.4 Reasons cited
tant part of the modern lifestyle. According to for tattoo removal vary, but patients reported feel-
statistics published the Pew Research Center, an ings of embarrassment, low self-esteem, problems
American think tank organization, 38% of men with clothing, changing of life roles, medical prob-
and women between the ages of 18 and 29 years lems, and stigmatization.1,4,5
derm.theclinics.com

a
Dermatology and Laser Surgery Center, 955 Park Avenue, New York, NY 10028, USA; b Department
of Dermatology, Yale University School of Medicine, 333 Cedar Street, LCI 501, PO Box 208059 New Haven,
CT 06520, USA
* Corresponding author.
E-mail address: [email protected]

Dermatol Clin 32 (2014) 91–96

http://dx.doi.org/10.1016/j.det.2013.09.002
0733-8635/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
92 Luebberding & Alexiades-Armenakas

TATTOO REMOVAL NONABLATIVE TATTOO REMOVAL

Tattoos are made by inserting indelible ink into the The groundbreaking theory of selective photother-
dermis layer of the skin to change the pigment. molysis, described by Anderson and Parrish12 in
Although these body marks were once considered the early 1980s, paved the way for a new genera-
to be permanent, the technical and scientific prog- tion of laser-based tattoo removal. This theory of
ress in recent years has made it possible to re- selective photothermolysis refers to the precise
move tattoos partly or fully by various treatment targeting of chromophores, such as melanin, wa-
modalities. Today, tattoo removal is a frequently ter, or oxyhemoglobin, using a specific wavelength
performed procedure in dermatologic practices. of light with the intention of absorbing light into the
The methods for tattoo removal can be distin- specific target area while leaving surrounding
guished into 2 groups, namely ablative and nona- areas relatively untouched.
blative tattoo removal procedures. The method of selective photothermolysis im-
plies that the laser causes targeted heating of
exogenous chromophores in the skin, the tattoo
ABLATIVE TATTOO REMOVAL pigments, by means of selectively absorbed wave-
Historically, several ablative techniques were used lengths.13 The high-temperature gradient pro-
to remove tattoos. One of the earliest methods, duced by the laser results in the formation and
salabrasion, was introduced by the Greek physi- propagation of acoustic waves that cause me-
cian Aetius in 543 AD. Salabrasion is a process chanical destruction of surrounding structures.1,14
incorporating the application of salt and abrasion Therefore, the target chromophore has to be heat-
to rub off the top layers of the skin. Tattoo removal ed very quickly and for no longer than its thermal
with an abrasive devise was also performed earlier relaxation time, which is defined as the time
by using dermabrasion, a process by which a wire required for the target chromophore to lose 50%
brush or diamond fraise was used to mechanically of its heat.1,15 Very small structures, such as the
abrade the tattooed skin. Another approach used tattoo pigment, require rapid heating. In practice
trichloroacetic acid to chemically remove the top this can be accomplished by Q-switching, a tech-
layers of the skin up to the dermal layers where nique that produces nanosecond (10 9 s) laser
the tattoo ink resides.1,6 pulses by suddenly releasing all of the excited-
A significant innovation in the area of tattoo state energy from the laser medium. Therefore,
removal was the use of lasers in dermatology. In contemporary technology involves the use of
1965, Leon Goldman first demonstrated the ability QS lasers13 that are considered to be the gold-
of the quality-switched (QS) ruby laser to selec- standard treatment option for the removal of
tively destroy pigments in the skin.7 However, unwanted tattoo ink in the skin.6
because the mechanisms and medical potential
for selectively absorbed, high-energy QS lasers QUALITY-SWITCHED LASERS
were not well understood, the dermatologic use
of ruby lasers was abandoned for some time.8 The QS ruby laser, introduced by William H. Reid in
In the early 1970s, a variety of continuous lasers 1983,16 was the first commercially available QS
were developed for scientific and industrial pur- laser for tattoo removal, followed by the QS
poses, including carbon dioxide (far infrared, Nd:YAG and QS alexandrite laser. All 3 lasers are
10.6-mm wavelength) and argon-ion (Ar-ion; visible still used today in dermatologic practice. However,
spectrum, 488 and 514-nm).8,9 These laser ap- because the tattooed pigment comes in a wide
proaches used water as the targeted chromo- range of colors, multiple wavelengths of laser light
phore and removed the tattooed skin by ablating are required to successfully remove tattoos.1,13
the epidermal layers up to the dermis. Ablative car- Studies have shown that dark pigmented tattoos
bon dioxide and argon-ion lasers became the can theoretically be treated by any laser, because
treatment of choice for tattoo removal for quite black absorbs virtually every wavelength of light.13
some time.9 However, Leuenberger and colleagues17 and
Although ablative laser treatment modalities for others18–20 found the QS 694-nm ruby and QS
tattoo removal were somewhat successful, they 755-nm alexandrite laser to be superior in light-
were often accompanied by a wide range of un- ening black-blue tattoos compared with the
wanted side effects, including scarring and dyspig- 1064-nm QS Nd:YAG, but these treatments are
mentation. Additionally, the clinical outcome was frequently associated with transient pigmentary
often unpredictable and results were not satis- changes, including rare depigmentation. Although
fying.10,11 For this reason, the demand for safer the 1064-nm QS Nd:YAG laser is slightly less effi-
and less ablative treatments became evident. cient in the removal of black ink, dyspigmentation
 New Tattoo Approaches 93

and textual changes are much less frequent due to topical perfluorodecalin (PFD), a highly gas solu-
its lower absorption by melanin and keratinocytes ble28 liquid fluorocarbon that resolves the whit-
in the epidermis; this makes the 1064-nm Nd:YAG ening reaction within seconds (R0 method).
laser an excellent choice of therapy for tattoo In a comparative study, Kossida and col-
removal in darker pigmented skin.21 leagues24 paralleled the efficacy of the conven-
The light emitted from the 1064-nm QS Nd:YAG tional single-pass laser tattoo removal, using the
laser may also be frequency-doubled to produce 755-nm QS alexandrite laser, to treatment in 4
light with a wavelength of 532-nm.1 Orange, red, consecutive passes separated by a 20-minute in-
and red-brown pigments, in particular, respond terval (R20 method). Results demonstrated that
well to this wavelength.18,20,22 The 532-nm option the multi-pass R20 method is a safe and far
of the QS YAG laser was also found to be superior more effective method in lightening tattoos in a
to the QS 694-nm ruby and the 1064-nm option of single treatment session when compared with
the YAG laser in the removal of red colors in profes- conventional single-pass laser treatment. Reddy
sional tattoos.19,23 The QS 755-nm alexandrite20 and colleagues27 used the QS 694-nm ruby or
and the QS 694-nm ruby laser19 were considered 1064-nm Nd:YAG laser to compare the conven-
the treatment modalities of choice for the removal tional single-pass treatment with the R20 and R0
of green-colored tattoos, whereas purple and vio- method. Results indicated that the multiple-pass
let ink respond best to the QS 694-nm ruby laser.20 tattoo removal method, using PFD to deliver rapid
sequential passes, is as effective as the R20
NEW ADVANCEMENTS IN LASER-ASSISTED method, but in a significantly reduced treatment
TATTOO REMOVAL time. Moreover, tattoo clearance of both the R0
and R20 methods are superior to the traditional
Laser-assisted tattoo removal with various QS single-pass laser method with comparable safety
laser devises still remains the gold-standard ther- potential.
apy in tattoo clearance. However, multiple treat-
ment sessions are required until reaching full or DERMAL SCATTER REDUCTION
acceptable lightening of the pigmented skin. The
number of treatment sessions depends on Studies have shown that absorption and the natu-
pigment color, composition, density, depth, age ral strong scattering of epidermal and dermal tis-
of the tattoo, body location, and the amount of sue significantly reduce the depth of light
tattoo ink present.24 On average, 4 to 6 treatment penetration and laser energy that may reach the
sessions, which are typically spaced 1 to 2 months dermal tattoo pigment.29 This becomes even
apart, are required for the complete removal of more evident when treating red, orange, or yellow
amateur tattoos, whereas up to 20 sessions are pigmented tattoos. These inks tend to consist of
required for professional tattoos.25,26 Mediocre pigments that need shorter wavelength lasers,
clinical results as well as prolonged and costly such as the 532-nm QS Nd:YAG, whose effective-
treatment sessions leave more to be desired ness is limited by skin scattering and hemoglobin
from both patient and clinician. Therefore, newer absorption.20 However, by temporary reduction
unconventional laser-assisted techniques and of the scattering coefficient of intervening skin
treatment approaches have been developed to layers, increased laser energy and shorter wave-
achieve faster and more effective removal of un- length light may be transmitted more efficiently
wanted tattoos. to the tattoo ink particles in the skin.30,31
Therefore, optical-clearing techniques, first
MULTIPASS TREATMENT introduced by Tuchin and colleagues,29 may be
used to effectively reduce the scattering of dermal
Recently published studies have focused on the tissues by transdermal or intradermal injection of
possibility to effectively remove tattoos in fewer optical-clearing agents (OCAs) with high refractive
treatment sessions using a multipass method. In indices and hyperosmolarity.32 OCAs such as glyc-
order for this method to be effective, immediate erol, dimethylsulfoxide, and glucose have been
laser-induced cutaneous whitening reactions, shown to significantly reduce dermal scatter in an-
likely resulting from thermally induced cavitation imal models.32–34 McNichols and colleagues30
bubble formation in the dermis, must subside studied the effectiveness of intradermal and trans-
before delivery of each pass,24,27 which can be dermal application of glycerol in clearing the skin
achieved in 1 of 2 ways: either by waiting for spon- and compared the outcomes of single-laser treat-
taneous resolution of whitening reactions, which ment sessions for both cleared and uncleared
requires an average of 20 minutes time after tattoo sites using the QS 755-nm alexandrite
each pass (R20 method) or by application of and the 532-nm Nd:YAG lasers. Both intradermal
94 Luebberding & Alexiades-Armenakas

and transdermal application of glycerol showed PICOSECOND LASERS

greater tattoo clearance post-laser treatment
when compared with the control, particularly for Most tattoo pigments have a particle size of 30 to
black and light red tattoo pigment. However, intra- 300 nm, corresponding to a thermal relaxation
dermal injection was accompanied by a higher risk time of less than 10 nanoseconds.4,41 As it has
of necrosis and scarring. been previously mentioned, the shorter the pulse
length, the more rapid the heating process of
the targeted chromophores, and consequently
IMIQUIMOD the more effective the removal of the tattooed
Histopathologic findings have shown that in acute- pigment in the skin. Besides the QS lasers, which
phase tattoos, pigments persist partly as free offer a pulse duration already in the nanosecond
granules in the epidermis and dermis for up to 1 range (10 9 s) and newer laser technologies
week after ink placement before tattoo maturation shorten that pulse time to picoseconds (10 12
has been completed.35 In this acute phase, seconds), promising more effective results in
pigment response to tattoo removal techniques tattoo removal.
may be increased. Fifteen years ago, Ross and colleagues42 re-
A recently published study in guinea pigs con- ported that for the same laser energy, tattoo
firms this assumption and indicates the successful removal becomes more efficient as the laser pulse
and nonsurgical removal of acute-phase tattoos by length is shortened to the picosecond range. In a
topical application of 5% imiquimod cream for side-by-side comparison of responses of tattooed
7 days post-treatment.36 Imiquimod is a topically pigment to picosecond and nanosecond QS
applied immunomodulator drug that indirectly stim- 1064-nm Nd:YAG lasers, Ross and colleagues42
ulates both innate immune response as well as found that 12 out of 16 black tattoos showed
cell-mediated acquired immunity.37 Therefore, imi- greater lightening with a pulse duration of 35 pico-
quimod is believed to interfere with tattoo pigment sesonds than with a pulse duration of 10 nano-
phagocytosis and prevent tattoo maturation.36 seconds. Similar results were found by Herd and
A study completed by Taylor and colleagues38 colleagues25 and Izikson and colleagues41 who
demonstrated that laser-based tattoo removal compared the efficacy of the picosecond tita-
was able to recreate the biologic elements of nium:sapphire (795-nm, 500 picoseconds) laser
an acute-phase tattoo by inducing phagocytic and the QS alexandrite (758-nm, 50 nanoseconds)
response and lymphatic transport of ink particles, laser in the treatment of tattooed porcine models.
which were shattered by the laser beam. The Both studies found greater clearance of tattoos
efficacy of this method as an adjunct approach treated by picosecond lasers.
for laser-based removal of mature tattoos was The first commercially available picosecond
confirmed by Ramirez and colleagues39 in an ani- laser, the 755-nm alexandrite laser, was launched
mal study. The combination of the 755-nm QS in the first quarter of 2013. Recently published
alexandrite laser in conjunction with triweekly appli- studies already confirm the effectiveness of
cations of 5% imiquimod cream showed greater shorter pulse lengths in the treatment of tattoos
tattoo lightening than laser treatment alone, but with safety equivalent to that of QS lasers.43 Bra-
involved greater risk for inflammation and fibrosis uer and colleagues44 described the successful
post-treatment. and rapid treatment of 12 tattoos containing blue
Two randomized, double-blind, controlled and/or green pigment with the novel, picosecond,
studies conducted by Ricotti and colleagues37 755-nm alexandrite laser in men. The research
and Elsaie and colleagues40 evaluated the safety group demonstrated at least 75% clearance of
and efficacy of topical 5% imiquimod cream used blue and green pigment after 1 or 2 treatments,
daily in conjunction with laser therapy to remove with more than two-thirds of these tattoos more
unwanted tattoos in men. Based on evaluations closely approaching 100% clearance.
by both investigators and subjects, Elsaie and col-
leagues40 demonstrated more favorable lightening MICROENCAPSULATED TATTOO INK
results with the combination therapy. Although
Ricotti and colleagues37 found the results of the Currently, neither the Food and Drug Administra-
QS laser treatment in combination with imiquimod tion nor any other regulatory authority in the United
to be slightly superior when compared with control, States regulates the ink and pigment used for
the research group concluded that topical imiqui- tattooing. This implies that there are no legal obli-
mod was not effective for laser-assisted tattoo gations for manufacturers to disclose pigment
removal due to the significantly higher risk of ingredients or maintain pharmaceutically pure
adverse events. compositions.1
 New Tattoo Approaches 95

Detailed knowledge with respect to the identity REFERENCES

and dye composition of tattoo pigments would
be beneficial not only with regard to photo- 1. Kent KM, Graber EM. Laser tattoo removal: a review.
allergenic, granulomatous, and anaphylactic Dermatol Surg 2012;38:1–13.
reactions but will also be useful in improving 2. Pew Research Center. MILLENNIALS A Portrait of
treatment planning and response prediction to generation next. 2010; 57–58. Available at: http://
laser therapy.45 Klitzman46 designed a perma- www.pewsocialtrends.org/files/2010/10/millennials-
nent but more removable tattoo ink using insol- confident-connected-open-to-change.pdf.
uble and bioresorbable pigments (such as 3. Armstrong ML, Roberts AE, Koch JR, et al. Motiva-
beta-carotene and iron oxide), which are stabi- tion for contemporary tattoo removal: a shift in iden-
lized through microencapsulation in transparent tity. Arch Dermatol 2008;144:879–84.
polymethylmethacrylate beads. The micro- 4. Bergstrom KG. Tattoo removal: new laser options.
spheres contain discrete pigment that can be J Drugs Dermatol 2013;12:492–3.
targeted by specific laser wavelengths. Laser- 5. Klein A, Rittmann I, Hiller KA, et al. An Internet-
based tattoo removal will cause the capsule to based survey on characteristics of laser tattoo
break, exposing the pigment, which is then removal and associated side effects. Lasers Med
resorbed by the body.13 Recently presented, Sci 2013. [Epub ahead of print].
unpublished data of Klitzman and colleagues46 6. Kirby W, Chen CL, Desai A, et al. Causes and rec-
showed significantly increased tattoo remov- ommendations for unanticipated ink retention
ability in hairless rats and guinea pigs. One laser following tattoo removal treatment. J Clin Aesthet
treatment effectively removed 80% of tattoo in- Dermatol 2013;6:27–31.
tensity, whereas only 20% of conventional ink 7. Goldman L, Wilson RG, Hornby P, et al. Radiation
was removed in a single identical laser treat- from a Q-switched ruby laser. Effect of reapeted im-
ment. Although these results appear promising, pacts of power output of 10 megawatts on a tattoo of
the safety and efficacy of microencapsulated man. J Invest Dermatol 1965;44:69–71.
tattoo ink in human skin needs to be investigated 8. Anderson RR. Dermatologic history of the ruby laser:
in further studies as no clinical data have yet the long story of short pulses. Arch Dermatol 2003;
been published. 139:70–4.
9. Reid R, Muller S. Tattoo removal with laser. Med J
Aust 1978;1:389.
SUMMARY
10. Reid R, Muller S. Tattoo removal by CO laser derm-
Nonablative and laser-assisted tattoo removal is abrasion. Plast Reconstr Surg 1980;65:717–28.
a frequently performed treatment in today’s 11. Brady SC, Blokmanis A, Jewett L. Tattoo removal
dermatologic practices. Thus far, QS ruby, alex- with the carbon dioxide laser. Ann Plast Surg 1979;
andrite, and Nd:YAG laser technologies have 2:482–90.
been well investigated in numerous randomized 12. Anderson RR, Parrish JA. Microvasculature can be
and controlled studies and are considered to be selectively damaged using dye lasers: a basic the-
the gold-standard for relatively safe and effective ory and experimental evidence in human skin.
tattoo removal. However, each laser has its Lasers Surg Med 1981;1:263–76.
benefits and to date no generally applicable 13. Choudhary S, Elsaie ML, Leiva A, et al. Lasers for tattoo
procedures are yet available; determining the removal: a review. Lasers Med Sci 2010;25:619–27.
optimal wavelength and treatment modality re- 14. Ho DD, London R, Zimmerman GB, et al. Laser-
quires a careful patient evaluation, which must tattoo removal: a study of the mechanism and the
include an assessment of skin type and the optimal treatment strategy via computer simulations.
tattoo itself. Lasers Surg Med 2002;30:389–97.
Current research in the field of tattoo removal 15. Anderson RR, Parrish JA. Selective photothermoly-
is focused on faster lasers and more effective sis: precise microsurgery by selective absorption
targeting of tattoo pigment particles in the skin. of pulsed radiation. Science 1983;220:524–7.
These newer, unconventional modalities include 16. Reid WH, McLeod PJ, Ritchie A, et al. Q-switched
picosecond laser devises, multipass treatments, Ruby laser treatment of black tattoos. Br J Plast
and microencapsulated tattoo ink. Initial published Surg 1983;36:455–9.
studies show promising results, which may pave 17. Leuenberger ML, Mulas MW, Hata TR, et al. Com-
way for safer and more effective laser-based parison of the Q-switched alexandrite, Nd:YAG,
tattoo removal. However, systematic, randomized, and ruby lasers in treating blue-black tattoos. Der-
and controlled in vivo studies are required to matol Surg 1999;25:10–4.
assess if these new innovations are indeed effec- 18. Kilmer SL, Anderson RR. Clinical use of the Q-
tive and safe. switched ruby and the Q-switched Nd:YAG (1064
96 Luebberding & Alexiades-Armenakas

nm and 532 nm) lasers for treatment of tattoos. 33. Yoon J, Son T, Jung B. Quantitative analysis method
J Dermatol Surg Oncol 1993;19:330–8. to evaluate optical clearing effect of skin using a hy-
19. Levine VJ, Geronemus RG. Tattoo removal with the perosmotic chemical agent. Conf Proc IEEE Eng
Q-switched ruby laser and the Q-switched Med Biol Soc 2007;2007:3347–9.
Nd:YAGlaser: a comparative study. Cutis 1995;55: 34. Vargas G, Chan KF, Thomsen SL, et al. Use of
291–6. osmotically active agents to alter optical properties
20. Zelickson BD, Mehregan DA, Zarrin AA, et al. Clin- of tissue: effects on the detected fluorescence
ical, histologic, and ultrastructural evaluation of tat- signal measured through skin. Lasers Surg Med
toos treated with three laser systems. Lasers Surg 2001;29:213–20.
Med 1994;15:364–72. 35. Hurwitz JJ, Brownstein S, Mishkin SK. Histopatho-
21. Jones A, Roddey P, Orengo I, et al. The Q-switched logical findings in blepharopigmentation (eyelid
ND: YAG laser effectively treats tattoos in darkly pig- tattoo). Can J Ophthalmol 1988;23:267–9.
mented skin. Dermatol Surg 1996;22:999–1001. 36. Solis RR, Diven DG, Colome-Grimmer MI, et al.
22. Guedes R, Leite L. Removal of orange eyebrow tattoo Experimental nonsurgical tattoo removal in a guinea
in a single session with the Q-switched Nd:YAG pig model with topical imiquimod and tretinoin. Der-
532-nm laser. Lasers Med Sci 2010;25:465–6. matol Surg 2002;28:83–6.
23. Ferguson JE, August PJ. Evaluation of the Nd/YAG 37. Ricotti CA, Colaco SM, Shamma HN, et al. Laser-as-
laser for treatment of amateur and professional tat- sisted tattoo removal with topical 5% imiquimod
toos. Br J Dermatol 1996;135:586–91. cream. Dermatol Surg 2007;33:1082–91.
24. Kossida T, Rigopoulos D, Katsambas A, et al. 38. Taylor CR, Anderson RR, Gange RW, et al. Light and
Optimal tattoo removal in a single laser session electron microscopic analysis of tattoos treated by
based on the method of repeated exposures. J Am Q-switched ruby laser. J Invest Dermatol 1991;97:
Acad Dermatol 2012;66:271–7. 131–6.
25. Herd RM, Alora MB, Smoller B, et al. A clinical and 39. Ramirez M, Magee N, Diven D, et al. Topical imiqui-
histologic prospective controlled comparative study mod as an adjuvant to laser removal of mature tat-
of the picosecond titanium:sapphire (795 nm) laser toos in an animal model. Dermatol Surg 2007;33:
versus the Q-switched alexandrite (752 nm) laser 319–25.
for removing tattoo pigment. J Am Acad Dermatol 40. Elsaie ML, Nouri K, Vejjabhinanta V, et al. Topical imi-
1999;40:603–6. quimod in conjunction with Nd:YAG laser for tattoo
26. Alster TS. Q-switched alexandrite laser treatment removal. Lasers Med Sci 2009;24:871–5.
(755 nm) of professional and amateur tattoos. 41. Izikson L, Farinelli W, Sakamoto F, et al. Safety and
J Am Acad Dermatol 1995;33:69–73. effectiveness of black tattoo clearance in a pig
27. Reddy KK, Brauer JA, Anolik R, et al. Topical perfluor- model after a single treatment with a novel 758 nm
odecalin resolves immediate whitening reactions and 500 picosecond laser: a pilot study. Lasers Surg
allows rapid effective multiple pass treatment of tat- Med 2010;42:640–6.
toos. Lasers Surg Med 2013;45:76–80. 42. Ross V, Naseef G, Lin G, et al. Comparison of re-
28. Mackanos MA, Jansen ED, Shaw BL, et al. Delivery sponses of tattoos to picosecond and nanosecond
of midinfrared (6 to 7-microm) laser radiation in a Q-switched neodymium: YAG lasers. Arch Dermatol
liquid environment using infrared-transmitting opti- 1998;134:167–71.
cal fibers. J Biomed Opt 2003;8:583–93. 43. Saedi N, Metelitsa A, Petrell K, et al. Treatment of tat-
29. Tuchin VV, Maksimova IL, Zimnyakov DA, et al. Light toos with a picosecond alexandrite laser: a prospec-
propagation in tissues with controlled optical proper- tive trial. Arch Dermatol 2012;148:1360–3.
ties. J Biomed Opt 1997;2:401–17. 44. Brauer JA, Reddy KK, Anolik R, et al. Successful
30. McNichols RJ, Fox MA, Gowda A, et al. Temporary and rapid treatment of blue and green tattoo
dermal scatter reduction: quantitative assessment pigment with a novel picosecond laser. Arch Derma-
and implications for improved laser tattoo removal. tol 2012;148:820–3.
Lasers Surg Med 2005;36:289–96. 45. Timko AL, Miller CH, Johnson FB, et al. In vitro quan-
31. Fox MA, Diven DG, Sra K, et al. Dermal scatter reduc- titative chemical analysis of tattoo pigments. Arch
tion in human skin: a method using controlled appli- Dermatol 2001;137:143–7.
cation of glycerol. Lasers Surg Med 2009;41:251–5. 46. Klitzman B. Development of permanent but
32. Wen X, Mao Z, Han Z, et al. In vivo skin optical removable tattoos. First international conference
clearing by glycerol solutions: mechanism. on tattoo safety. BfR-Symposium. Berlin, June 7,
J Biophotonics 2010;3:44–52. 2013.