Therapeutic Outcome of Tattoo Removal with a Q-Switched Nd:YAG Laser in Thai Students – Comparison of Two Rural Regions Within a Tattoo Removal Program

DOI 10.1515/plm-2012-0016 Photon Lasers Med 2012; 1(3): 207–213

Akkrapol Mungnirandr*, Sumanas Bunyaratavej, Rattapon Thuangtong, Anchana Thoamphoemphol, Piyaporn Supasynth, Pakawadee Hatthanirun, Wanwilai Outtarawichian, Chaiwat Buathong and Yongyuth Vajaradul Therapeutic outcome of tattoo removal with a Q-switched Nd:YAG laser in Thai students – Comparison of two rural regions within a tattoo removal program

Laser-Tattooentfernung bei thailändischen Studenten mittels gütegeschaltetem Nd:YAG- Laser – Vergleich des Behandlungserfolges in zwei ländlichen Regionen innerhalb eines staatlichen Tattooentfernungsprogramms

Abstract and 5.9% of the cases, respectively. There was no statistically significant correlation between the person who did the tattoo, or the age of tattoo to the complications or side Objective: To review the results of laser tattoo removal in effects after laser tattoo removal. Thai students of Saraburi province. Conclusion: In a rural area of Thailand, more male Thai Material and methods: This is a retrospective review study students chose to have a tattoo than female students. of the students participating in our tattoo removal program Nearly all of the students did the tattoo themselves or had at Saraburi province, Thailand. The laser used was a 1064 it done by friends. The students did not initially know or nm Q-switched Nd:YAG laser (spot size, 3 mm; pulse dura- had not realized the possible medical complications or tion, 6 ns, fluencies, 1.25–12 J/cm2). A maximum of 5 laser social consequences of having a tattoo. From our study treatments per student was performed at 2-month inter- (students in the rural area and dark skin prototype), the vals. The data collected included age and sex of the stu- lower applied laser fluencies caused a lower rate of scar- dents and information regarding the tattoos (how long the ring. More laser sessions may be required to achieve tattoo had existed, person who performed the tattoo pro- standard clinical clearance. cedure, method and price of tattooing, number of tattoo figures, complications during and after tattoo procedure Keywords: laser tattoo removal; Thai students; including cleaning methods of tattoo needle) and the Q-switched Nd:YAG laser. laser procedure (laser parameters, pain level during laser removal assessed by pain score sheet, treatment results, complications, side effects). Correlations were analyzed between the person who did the tattoo and complications Zusammenfassung after laser tattoo removal procedure, the age of tattoo and results of laser treatment and complications. Zielsetzung: Bewertung der Effektivität der Laser-Tat- Results: The 78 students involved were aged between tooentfernung bei thailändischen Studenten der Provinz 10 years 4 months and 21 years. The mean time of tattoo Saraburi. existence was 2.3 ± 1.4 years. The majority of the students Material und Methoden: Die vorliegende retrospektive were tattooed by amateur practitioners and by hand. The Studie wertet die Ergebnisse der Laser-Tattooentfernung costs of tattoo procedure ranged between 0 and 1800 Thai bei Studenten in der thailändischen Provinz Saraburi Bahts. A clinical clearance of 76–100% was achieved in aus. Verwendet wurde ein 1064 nm gütegeschalte- 41.6% of the treated tattoos. Observed side effects were ter Nd:YAG-Laser (Spotgröße: 3 mm, Pulsdauer: 6 ns, textural changes, hyperpigmentation, hypopigmenta- Bestrahlungsstärke: 1,25–12 J/cm2). In Abhängigkeit vom tion, and scarring which occurred in 11.4%, 8.8%, 5.1%, Behandlungsergebnis wurden pro Student maximal 5 208 A. Mungnirandr et al.: Comparison of two rural regions within a tattoo removal program

Laserapplikationen im Abstand von jeweils 2 Monaten Anchana Thoamphoemphol: Division of Surgical and Orthopedics durchgeführt. Es wurden sowohl allgemeine Daten (Alter, Nursing, Department of Nursing, Mahidol University, Siriraj Geschlecht) als auch Informationen zu den Tattoos (Anzahl Hospital, Bangkok, Thailand Piyaporn Supasynth: Division of Surgical and Orthopedics Nursing, und Alter der Tattoos, Angaben zum Tätowierer, Täto- Department of Nursing, Mahidol University, Siriraj Hospital, wiermethode, Kosten der Tätowierung, Komplikationen Bangkok, Thailand während und nach der Tattoo-Prozedur einschließlich der Pakawadee Hatthanirun: Faculty of Medicine, Perioperative Nursing angewendeten Nadeldesinfektion) und zur Laserprozedur Division, Mahidol University, Siriraj Hospital, Bangkok, Thailand (verwendete Laserparameter, Schmerzlevel, Behandlungs- Wanwilai Outtarawichian: Faculty of Medicine, Perioperative Nursing Division, Mahidol University, Siriraj Hospital, Bangkok, ergebnis, auftretende Komplikationen und Nebeneffekte) Thailand erfasst. Korrelationen zwischen Art und Alter der Täto- Chaiwat Buathong: Faculty of Medicine, Medical Education wierung und dem Behandlungsergebnis wurden statistisch Technology Center, Mahidol University, Siriraj Hospital, Bangkok, ausgewertet. Thailand Ergebnisse: An der Studie nahmen insgesamt 78 Studen- Yongyuth Vajaradul: Faculty of Medicine, The Bangkok Biomaterial Center, Mahidol University, Siriraj Hospital, Bangkok, Thailand ten im Alter zwischen 10 und 21 Jahren teil, deren Tattoos durchschnittlich 2,3 ± 1,4 Jahre alt waren. Die meisten Tattoos wurden von Hand gestochen und von Laien ausge- führt. Die Tätowierungskosten lagen zwischen 0 und 1800 Thai Bahts. Bei 41,6% der behandelten Tattoos konnte 1 Introduction eine Clearingrate von 76–100% erreicht werden. Als uner- wünschte Nebeneffekte traten auf: Texturänderungen der About 1–2% of Thai students in a rural area undergo a Haut (11,4%), Hyperpigmentierung (8,8%), Hypopigmen- tattoo procedure [1]. The majority of these students does tierung (5,1%), und Narbenbildung (5,9%). Art und Alter not initially know or realize the possible medical com- der Tätowierung hatten auf etwaige Komplikationen und plications or social consequences of having a tattoo. Nebeneffekte der Laserbehandlung keinen statistisch sig- Consequently, tattoo removal is usually performed by the students themselves, by their parents or by the nifikanten Einfluss. person who had carried out the tattoo. Mechanical or Schlussfolgerung: Im untersuchten Studienkollektiv chemical means are very often used for the removal of hatten sich mehr männliche als weibliche Studenten tattoos which results in scarring on top of the tattoo tätowieren lassen. Fast alle Studenten hatten sich die figures, as well as possible infection. As a result of this Tätowierungen selbst gestochen oder sich von Freun- problem, a multidisciplinary team in Saraburi prov- den tätowieren lassen. Dabei spielten Überlegungen ince was formed with the aim of offering a safe tattoo zu möglichen medizinischen Komplikationen oder removal procedure as well as instructing the students späteren sozialen Konsequenzen keine Rolle. Wie sich in health education. zeigte, konnte durch die Applikation niedriger Ener- Many methods have been used to remove tattoos giedichten die Narbenbildung bei den behandelten such as mechanical, chemical, and thermal methods [2]. Studenten mit zumeist dunklem Hauttyp sehr gering The Q-switched Nd:YAG laser has been reported as being gehalten werden. Allerdings sind für die üblicherweise an effective type of laser especially for removing tattoos erreichten höheren Clearingraten mehr Lasersitzungen from dark-skinned individuals [3, 4]. Therefore a 1064 nm erforderlich. Q-switched Nd:YAG laser was used in our tattoo removal program at Saraburi Hospital, Saraburi province, Thai- Schlüsselwörter: Laser-Tattooentfernung; thailändische land. The study presented here is a retrospective review Studenten; Q-switched Nd:YAG-Laser. of 78 students who participated in this program.

*Corresponding author: Akkrapol Mungnirandr, Faculty of Medi- cine, Division of Pediatric Surgery, Department of Surgery, Mahidol University, Siriraj Hospital, Bangkok, Thailand, 2 Material and methods e-mail: [email protected] Sumanas Bunyaratavej: Faculty of Medicine, Department of Dermatology, Mahidol University, Siriraj Hospital, Bangkok, 2.1 Study group Thailand Rattapon Thuangtong: Faculty of Medicine, Department of Derma- On October 2008, a multidisciplinary team (pediat- tology, Mahidol University, Siriraj Hospital, Bangkok, Thailand ric surgeon, alternative medical doctor, nurses, and A. Mungnirandr et al.: Comparison of two rural regions within a tattoo removal program 209 medical photographers) was formed supported by 2.4 Statistical analysis the Interdisciplinary Network of the Royal Institute of Thailand under the patronage of HRH Princess Maha Correlations between the person who tattooed and com- Chakri Sirindborn. The team went to Amphor Muang, plications after laser tattoo removal procedure (wound Saraburi province to take a holistic approach to the infection, delay of wound healing, wound redness), age tattooing problems in a program in which 78 students of tattoo and results of laser treatment (degree of clearing) participated. and side effects (hyperpigmentation, hypopigmentation, Before starting the project, the students’ parents had scarring) were analyzed by Pearson’s χ2-test and indepen- to sign informed consent for tattoo removal. The students dent t-test. The significance level was uniformly set at 5% were informed about the risk of the tattoo procedure and (p = 0.05). other social consequences.

2.2 Laser procedure 3 Results

Local anesthesia (EMLA® cream; M/s AstraZeneca, USA) The study included 78 students, aged between 10 years 4 was applied at least 45 min before starting the laser months and 21 years (mean ± SD = 14 ± 2 years, median age: tattoo removal procedure. All patients were treated 13 years and 9 months). Of this group 66 (85%) were male with a Q-switched 1064 nm Nd:YAG laser (Won-CosJet and 12 (15%) were female. The mean time of tattoo exis- TR; M/s Won Technology Co., Ltd., South Korea) using a tence was 2.3 ± 1.4 years. All students lived in the Saraburi 3 mm spot size and a pulse duration of 6 ns. The fluen- province. In all but two patients the tattoos were carried cies used were in the range of 1.25–12 J/cm2. After the out by amateur practitioners. The majority of the students laser treatment, the tattoo figures were cooled using ice were tattooed by hand with needles (74/78; 95%), and the in a sterile plastic bag. Patients with large tattoos were remaining 5% were tattooed using a tattoo machine. The given an oral antibiotic to prevent wound infection. cost of the tattoo procedure ranged between 0 and 1800 Only one surgeon performed the laser tattoo removal Thai Bahts (mean cost: 27 Thai Bahts). procedure. A maximum of five laser tattoo removal pro- Only 34 out of 74 students answered the question cedures was performed per student at 2-month intervals, regarding who had performed the tattoo. Thus, the tattoo respectively. practitioners were their friends (21/34; 61.8%), themselves (11/34; 32.4%), and their cousins (2/34; 5.8%). Tattoo procedures were painful in 28 out of 78 stu- 2.3 Documentation dents (35.9%) and caused bleeding in 39 out of 78 students (50%). Of the 78 tattooists, 3 (3.9%) did not change Before starting the laser procedure, data were collected the tattoo needle between tattoo subjects, and of a total of which included the age and sex of the students, time of 31 tattoo needles used, 4 (12.9%) were not cleaned by any tattoo existence, detail about the person who performed method. Complications resulting from tattoo procedures tattoo procedure, method and the price of tattooing, included redness and swelling of wound in 25/78 (32.1%), number of tattoo figures, complications experienced wound infection in 1/78 (1.3%), poor wound healing in during and after tattoo procedure including tattoo needle 4/78 (5.1%) and itching in 18/78 (23.1%) of the students. cleaning methods. Details of the locations used for performing tattoo The patients’ tattoos were photographed by a medical procedure are presented in Table 1. photography specialist before and after each laser tattoo Each of the students had 1–5 tattoos (mean ± SD = removal procedure. The pictures were sent to two derma- 1.5 ± 0.9), in total 119 figures. All were black in color. The tologists to evaluate the results of laser tattoo removal majority of the students did not know which kind of ink procedure and their complications and side effects. The was used for tattooing, but in most cases Chinese ink evaluation of the degree of clearing was based on the com- (black color) and Indian ink (black color) was likely to parison between pretreatment and the last follow-up visit have been used. and was subjectively graded using the quartile scale. The The most common site for tattooing was the ankle two dermatologists also evaluated whether or not there (43%), followed by the shoulder (16%), the finger (11%), were side effects, i.e., textural changes, hyper- or hypopig- the hand (9%), and the wrist (8%). The body locations of mentations, and scarring. the tattoos are presented in Table 2. 210 A. Mungnirandr et al.: Comparison of two rural regions within a tattoo removal program

Location Number % Side effects of laser tattoo removal procedure evalu-

Home (not specified) 41 52.6 ated by the two dermatologists are presented in Table 4. School 22 28.2 Some of the results of laser tattoo removal are presented Friend’s home 9 11.5 in Figure 1. Tattoo shop 1 1.3 A clinical clearance of ≤ 25% was achieved in 7.6% of Temple 1 1.3 the treated tattoos, a clearing rate of 26–50% in 19.8%, Grave 1 1.3 a clearing rate of 51–75% in 31.1%, and a clearing rate of No data 3 3.8 Total 78 100.0 76–100% in 41.6% of the treated tattoos. Table 5 shows the evaluation details for the clearing rate of the individual Table 1 Place of tattoo procedure. dermatologists. No statistically significant correlations (p > 0.05) were found between the persons who tattooed and the age of Location Number % the tattoo and the occurring complications after laser

Ankle 51 43.0 tattoo removal procedures (wound infection, delayed Shoulder 19 16.0 wound healing, wound redness) and results of treatment Finger 13 10.9 and side effects (degree of clearing, textural changes, Hand 11 9.2 hyperpigmentation, scarring). Wrist 9 7.6 Leg 5 4.2 Arm 4 3.4 Thigh 3 2.5 4 Discussion Back 1 0.8 Scapula 1 0.8 Chest 1 0.8 From our study, nearly all of the students applied the Foot 1 0.8 tattoo themselves (self-administered tattoos) or had them Total 119 100.0 applied by their friends. These results correspond with other studies which showed that the majority of adoles- Table 2 Body locations of tattoo figures. cents had self-administered tattoos or had tattoos done by friends or family members [1, 5]. More male students underwent the tattoo procedure than female students. Not all patients received five laser treatments. About The most common location to carry out the tattoo pro- 3.9% (3/78) had only one laser session, 43.6% (34/78) two cedure was in their own, or in the homes of friends (64.1%). sessions, 19.2% (15/78) three sessions, 12.8% (10/78) four Twenty-two of 78 students (28.2%) had their tattoos done sessions and 20.5% (16/78) five sessions depending on the whilst at school. This result corresponds with our previous students’ satisfaction with the result of the therapy and study of students in Srakaew province [1], where 63.4% the social environment factors (Table 3). The applied flu- and 25.2% of the students had had tattoos at home or at encies, immediate reactions and complications of laser friends’ homes or at school, respectively. This should be treatments are presented in Table 3. emphasized when informing the parents and the school

Treatment session

12345

Number of patients 78 75 41 26 16 Fluence (mean ± SD) (J/cm2) 2.3 ± 0.4 2.9 ± 0.8 4.1 ± 1.7 4.9 ± 1.5 5.5 ± 1.6 Immediate whitening 76/78 (97.4%) 58/68a (85.3%) 29/37a (78.4%) 20/25a (80.0%) 11/16 (68.8%) Bleeding 1/78 (1.3%) 2/73a (2.7%) 0/41 (0%) 1/25a (4%) 0/16 (0%) Infection 6/68b (8.8%) 0/43b (0%) 0/23b (0%) 0/16b (0%) – Slow wound healing 11/62b (17.7%) 4/43b (9.3%) 1/22b (4.6%) 2/16b (12.5%) – Wound redness and swelling 27/63b (42.9%) 8/43b (18.6%) 5/23b (21.7%) 10/16b (62.5%) – Itching 13/61b (21.3%) 13/43b (30.2%) 4/23b (17.4%) 3/14b (21.4%) –

Table 3 The applied fluencies, immediate reactions and complications of laser treatments. aLack of data because of incomplete documentation by the operator. bLost data during follow-up. A. Mungnirandr et al.: Comparison of two rural regions within a tattoo removal program 211

Side effect First Second Mean (%) dermatologist dermatologist

Textural change 6/119 (5.0%) 21/119 (17.7%) 11.4 Hyperpigmentation 11/119 (9.2%) 10/119 (8.4%) 8.8 Hypopigmentation 5/119 (4.2%) 7/119 (5.9%) 5.1 Scarring 8/119 (6.7%) 6/119 (5.0%) 5.9

Table 4 Side effects of laser tattoo removal procedure.

authorities in order to prevent the children using either home or school as places to have tattoos applied. About 75% (89/119) and 28% (32/119) of tattoo figures were considered as exposed without cover by the common Thai student uniform and by normal Thai dress which is usually a short shirt and long trousers. Four percent of the tattooists did not change the tattoo needle between tattoo subjects and 13% of the tattoo needles were not cleaned by any method, which implies that the students either did not know or had not realized the possible medical complications. A Q-switched Nd:YAG laser at a wavelength of 1064 nm was used for tattoo removal in this study. The laser radiation at this wavelength is weakly absorbed by natural chromophores (melanin, hemoglobin, and water) and penetrates more than 2 mm into the skin making it ideal for absorption by deep dermal exogenous chromophores such as tattoo pigments [6]. A less adverse reaction to laser treatment, although performed on skin type II to IV, might be due to the 1064 nm wavelength, which barely interacts with melanin. The applied laser fluencies were reported between 5–12 J/cm2 [7–9]. Clinical clearance was reported between 75–79% with hyperpigmentation, hypopigmentation, and scarring in 1.1–77%, 4.3–12.5%, and 0.94–23.5% of the cases, respectively [2, 3, 7, 10–13]. With the focus on the group of patients who had Fitzpatrick skin type III–IV, the Q-switched ruby laser could achieve an excellent lightening effect through to complete clearance of tattoo motives in 84% of the cases, with 22% of the patients developing pigmentary changes [14]. Also the Q-switched alexandrite laser was found to be an effective instrument for tattoo removal with excellent lightening through to complete clearance in 75% of the patients without inducing scarring or permanent alterations [15]. In our study, the clinical clearing rate ( > 75%) was achieved in 41.6% of the treated figures. Hyperpigmenta- tion, hypopigmentation, and scarring were found in 8.8%, 5.1%, and 5.9%, respectively, figures which are compara- Figure 1 Tattoo pictures of Thai students before (left) and after ble with other studies [2, 3, 7, 10–13]. Compared with other (right) laser treatment. Results after (A) one laser session, studies, our study had lower applied laser fluencies [7–9] (B) three laser sessions, (C) three laser sessions, and (D) four laser and received the lower clinical clearance rate. Compared sessions. 212 A. Mungnirandr et al.: Comparison of two rural regions within a tattoo removal program

Clearing rate optimal. In addition, most Thais have darker skin prototypes than those of White and Northern Asia. Patients ≤ 25% 26–50% 51–75% 76–100% with dark skin prototypes are associated with a higher First dermatologist 10/119 16/119 38/119 55/119 risk of laser-induced pigmentary alterations and scar for- (8.4%) (13.5%) (31.9%) (46.2%) mation [16, 17]. From our study, we found that the lower Second dermatologist 8/119 31/119 36/119 44/119 (6.7%) (26.1%) (30.3%) (37.0%) applied laser fluencies caused a lower rate of scarring. Mean (%) 7.6 19.8 31.1 41.6 However, more laser sessions may be required to achieve standard clinical clearance. Table 5 Results of the laser tattoo removal. We could not find statistically significant correlations (p > 0.05) between the person who performed the tattoo, the age of the tattoo and complications after laser tattoo with the study of decorative tattoo removal from east Asia removal procedure (wound infection, delayed wound which reported 82% clearing rate with 9% hyperpigmen- healing, wound redness) and results of treatment and side tation, 7.2% permanent hypopigmentation, and 23.5% effects (degree of clearance, hyperpigmentation, hypopig- scarring, after 5.3 treatment sessions [13], our study had mentation, scarring). a lower clearance rate but accompanied by a lower rate of hypopigmentation and scarring. The response of tattoo clearance was related to fluen- 5 Conclusion cies [7]. Compared with our previous study that focused on the same group of population (children in the rural In a rural area of Thailand, more male Thai students area, same skin type and climate, same surgeon, laser chose to have a tattoo than female students. Nearly all of machine and techniques), we had lower applied laser the students applied the tattoo themselves or they were fluencies in the first four laser sessions with an average applied by their friends. The students did not know or had overall mean fluency of 3.3 J/cm2 (5.5 J/cm2 in the previ- not realized the possible medical complications or social ous study) and lower rate of clinical clearance (41.6% vs. consequences of tattooing. From our study (students in 75%) [1]. However, we also had a lower rate of scarring the rural area and dark skin prototype), the lower applied (5.9% vs. 17%). The scarring rate of our previous study laser fluencies caused a lower rate of scarring but more was relatively high. Our study focused on children and laser sessions may be required to achieve standard clini- adolescents (under 21 years) in the rural area of Thailand. cal clearance. We found that the most common complications after laser procedure were wound redness and swelling. The Acknowledgements: Thanks are given to Ms. Supaporn possible causes of wound redness and swelling (celluli- Tunpornpituk and Ms. Chonthicha Jivarattanapong for tis) include mechanical wound trauma or minor wound statistical analysis of this work, and Mr. Werapong Fak- infection. Proper wound care could be less than optimal charoen for picture management of this work. for students of school age. The majority of tattoos were located on the distal part of extremities that are not Received April 23, 2012; revised May 30, 2012; accepted May 30, well supplied with blood, so that wound healing is not 2012

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