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Tattoo Removal with an Electro-Optic Q-Switched Nd:YAG Laser with Unique Pulse Dispersion Michael Gold, MD

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Tattoo Removal with an Electro-Optic Q-Switched Nd:YAG Laser with Unique Pulse Dispersion Michael Gold, MD STUDY Tattoo Removal With an Electro-optic Q-Switched Nd:YAG Laser With Unique Pulse Dispersion Michael Gold, MD The objective of this study was to evaluate the clinical effectiveness of an electro-optic Q-switched Nd:YAG laser with standard pulse and pulse dispersion options for the treatment of unwanted tattoos. tatistics released in 2002 from the American the treatment of tattoos, the following principles apply2-4: Society of DermatologicalCOS Surgery suggested DERM (1) amateur tattoos are easier to remove than professional that 50% of individuals receiving tattoos ones; (2) distally located tattoos are harder to remove, at that time would want them removed in theoretically due to lymphatic drainage; (3) older tattoos 5 years.1 The growing demand for effective are easier to remove; (4) darker Fitzpatrick skin types Stattoo removal without scars, pigmentation issues, or have a greater risk for scarring and pigmentary changes textural changes has fueledDo the search forNot alternatives during Copy laser tattoo removal procedures. to dermabrasion, cryotherapy, surgical excision, CO2 or Three types of Q-switched lasers (694-nm Q-switched argon laser treatment, and other superficial and nonspe- ruby, 755-nm Q-switched alexandrite, and the 1064-nm cific destructive methods of the past.2 Studies with ruby Q-switched Nd:YAG) have been studied in the treatment of lasers in the 1960s were early milestones in the use of tattoos. Each wavelength has an affinity for selective absorp- light-based therapy for the clearance of tattoo ink. In tion by certain ink colors, the most common colors being the succeeding 30 years, the Q-switched ruby, Nd:YAG, black (Q-switched ruby, Q-switched Nd:YAG, Q-switched and alexandrite lasers would all prove the usefulness alexandrite), blue-black (Q-switched ruby, Q-switched of the theory of selective photothermolysis in this area. Nd:YAG), green (Q-switched ruby, Q-switched alexandrite), Advances in Q-switched laser technology continue to and blue (Q-switched alexandrite). Newer Q-switched provide increasingly effective methods for tattoo removal, ruby lasers with a shorter pulse duration (approximately addressing the need for low-risk, practical solutions to 25 ns) and higher fluences (8–10 J/cm2) have shown the problems presented by unwanted professional, ama- greater effectiveness in tattoo ink clearance, but with a teur, traumatic, and cosmetic tattoos. drawback of more nonspecific tissue damage.4 Long- Although the biological pathways are not always fully lasting hypopigmentation and transient hyperpigmentation understood, practitioners generally acknowledge that in are common side effects of Q-switched ruby laser treat- ment. Hypopigmentation is also a common occurrence Dr. Gold is Medical Director, Gold Skin Care Center, Nashville, Ten- with the Q-switched alexandrite laser, affecting approxi- nessee, and Clinical Assistant Professor, Tennessee Clinical Research mately 50% of patients.4 The 1064-nm/frequency-doubled Center, Nashville. 532-nm Nd:YAG laser provides a deeper penetration Dr. Gold is an advisor for HOYA ConBio. into the skin and less interaction with melanin,5 and the Correspondence: Michael H. Gold, MD, Tennessee Clinical 532-nm wavelength has the added benefit of red ink clear- Research Center, 2000 Richard Jones Rd, Suite 220, Nashville, TN, ance.4 A 1996 study of the Q-switched Nd:YAG in tattoo 37215. removal from darker Fitzpatrick skin type VI provided 186 Cosmetic Dermatology® • april 2009 • VOL. 22 NO. 4 Copyright Cosmetic Dermatology 2010. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. evidence of the suitability of Nd:YAG therapy for patients provided with verbal and written posttreatment skin care at significant risk for keloid scarring or the unwanted instructions to gently clean the skin with warm water and destruction of natural pigment during tattoo removal.6 a mild cleanser a maximum of 2 to 3 times daily. Subjects With its lower risk for hypopigmentation and proven clear- were advised to apply a thin layer of antibacterial oint- ance record for the most common dark blue and black ment to the treated area after each cleansing. Although inks, the Q-switched Nd:YAG offers a clear advantage in showers were allowed on the day after the treatment, the growing field of tattoo removal. The present study was subjects were advised not to scrub the area, and if a performed with an electro-optic (EO) Q-switched Nd:YAG scab should form, it should not be picked, scratched, or laser with a unique pulse dispersion (pTp) option. removed prematurely. Standardized photographs were taken at baseline and METHODS at 30 days following the final laser session. Subjects and Subjects investigators who were blinded to the randomization Fourteen subjects (8 male, 6 female), with tattoos of assignment and were not involved in the performance 636 cm or smaller who were not contraindicated or pre- of the laser treatments were asked to assess the percent- viously proven to be resistant to Nd:YAG laser treatment age of improvement according to the following scale: were enrolled in this institutional review board–approved 0%5no improvement; 1% to 25%5poor improvement; study at 3 sites. Subjects’ ages ranged from 18 to 46. Tat- 26% to 50%5fair improvement; 51% to 75%5good toos were located mostly on the arm (54.5%), with the improvement; 76% to 99%5excellent improvement; remainder located on the neck, ear, buttocks, toe, and and 100%5clear (no visible ink). Subjects reported on back (9.1% for each location). Subjects who had received the tolerability of the Sp and pTp modes of treatment. treatment for tattoo removal within 3 months or had used Stinging/burning sensations were recorded on a 4-point photosensitizing drugs within a time frame where those scale: 05none; 15mild; 25moderate; and 35severe. After drugs might still be present in the system were excluded. each half of the treatment was performed, blinded inves- All subjects gave informedCOS consent for treatment DERM tigators were asked to record the effects of the treatment and photographs. with regard to any erythema, scaling, dryness, edema, or blistering. These effects of treatment were judged on a Treatment Protocol 5-point scale: 05none; 15minor; 25mild; 35moderate; All treatments were performed with an EO Q-Switched and 45severe. These assessments were recorded indepen- Nd:YAG laser. Subjects Doin this prospective, Not randomized, dently Copy of adverse/unanticipated device events. split-treatment study received a total of 4 monthly laser treatments. The study was designed to evaluate the effi- RESULTS cacy of the laser in removing tattoos and to compare clini- Fourteen subjects received an initial treatment. Eleven cal ink clearance and tolerability between the standard subjects completed the study with 4 monthly treat- pulse (Sp) and pTp modes of the laser. The entire tattoo ments and were evaluated at 30 days following the final was treated at each session; half of the tattoo received laser session. Tattoos were composed of greater than treatment with the Sp mode and half of the tattoo 50% black and dark blue ink. Seven of the tattoos were received treatment with the pTp option. Subjects were professional, and one tattoo was amateur. One site with randomized as to which half of the tattoo area would be 3 subjects did not classify the tattoos. Blinded investiga- treated with the pTp option, as well as to the order of tors and subjects completed percentage of improvement treatment (left to right vs right to left). questionnaires. in the Sp mode, treatment parameters were set at 1064 nm, with a pulse frequency of 10 Hz, fluences of Investigator-Rated Percentage of Improvement 3.2 to 3.6 J/cm2, with a 6-mm spot size, and 2 to 3 passes Table 1 shows the percentage of improvement scores for dark ink colors (blue, black). For light ink colors (red, recorded by the blinded investigators for 11 subjects. green, sky blue), investigators had the option of using On the Sp-treated side of the tattoo, 4 subjects (36.4%) either 1064-nm or 532-nm wavelengths, with or without received excellent ink clearance of greater than 76%; 650-nm and 585-nm wavelengths. in the pTp mode, the 4 subjects (36.4%) received good results of at least 51% spot size was increased to 8 mm, with all other treatment improvement; 2 subjects (18%) showed fair improvement parameters identical to the Sp mode. investigators were of at least a 26% reduction in the appearance of tattoo allowed to use injectable or topical anesthesia for the ink; and one subject (9.1%) showed a poor improvement entire treatment area. After laser treatment, a dressing of less than 25%. On the pTp-treated side, investiga- and antibacterial ointment was applied. Subjects were tors rated 3 subjects (27.3%) as having achieved good VOL. 22 NO. 4 • april 2009 • Cosmetic Dermatology® 187 Copyright Cosmetic Dermatology 2010. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. LASER REMOVAL OF TATTOOS TABLE 1 Investigator Improvement Scores at 1 Month No Poor Fair Good Excellent Improvement Improvement Improvement Improvement Improvement Clear PTP 1 1 6 3 0 0 SP 0 1 2 4 4 0 Abbreviations: PTP, pulse dispersion; SP, standard pulse. TABLE 2 Subject Improvement Scores at 1 Month No Poor Fair Good Excellent Improvement Improvement Improvement Improvement Improvement Clear PTP 0 3 5 2 1 0 SP 0 COS0 3 DERM6 2 0 Abbreviations: PTP, pulse dispersion; SP, standard pulse. TABLE 3 Do Not Copy Tolerability During Treatment Posttreatment None Mild Moderate Severe None Mild Moderate Severe PTP 1 5 4 4 11 2 1 0 SP 1 4 7 2 11 2 1 0 Abbreviations: PTP, pulse dispersion; SP, standard pulse.
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