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Undoing Tattoos

Raychelle BurksMar 20, 2017

Click to Enlarge Image Many writers have noted the certainty of death and taxes. Many people would add tattoos to this short list of certain things. Once you’re inked, that tattoo is staying put thanks to your very own immune system. ACS Reactions explains:

We’ve thought tattoos are permanent for so long, we might have forgotten that people have had schemes to side-step tattoos since ancient times. From antiquity to the modern day, tattoo removal has required tattoo holders to put some skin in the game. Literally. Getting rid of a tattoo requires the destruction or removal of skin. This has typically been achieved in three ways: thermally, chemically, or mechanically.

Click to Enlarge Image If you’re envisioning burning your skin with flame or a hot metal poker—STOP. The top thermal technique is laser tattoo removal, which has been in use since the 1970s. Today, Q-switched lasers (there are several types: Alexandrite, Ruby, and ND:YAG; Q-switching refers to their ability to produce very short light pulses with high power levels) are the “… gold standard of tattoo removal.” Whereas a flame or hot metal poker would indiscriminately damage all cells it came into contact with, a Q-switched laser provides selective destruction. We don’t want lots of other cells destroyed—just the ones packed full of ink. That ink needs to be broken up so that our macrophages can take it away, clearing the area of ink. Q-switched lasers provide nanosecond (1x10-9 seconds) to picosecond (1x10-12 ) blasts of light at specific wavelengths. Different wavelengths target different tattoo ink colors, neatly summarized by University of Miami’s Sonal Choudhray and his colleagues in the table above.

As an ink absorbs its preferred wavelength of light, it will begin to fragment. Thus, only limited, localized tissue is damaged. One’s immune system will kick into gear, and soon that tattoo will be a faded memory. SmarterEveryDay dug deep into the laser tattoo removal process in the video below.

The best result of laser therapy might just be less of a tattoo, not a totally clean slate. Clearance results vary based on the patient, the tattoo, the number of laser therapy sessions, and the Q-switched laser used. Survey data published in 2014 reported 38 percent of respondents that had undergone laser tattoo removal saw all the tattoo ink go away. In their paper Laser Tattoo Removal: A Clinical Update, Stephanie G. Y. Ho and Chee Leok Goh of the National Skin Centre in Singapore stated, “Patients should be counseled that tattoo clearance is often incomplete and a residual tattoo outline and textural changes may be seen.” Elaborate multicolored tattoos present the biggest challenge, with different wavelengths of light and many sessions being required to see the kind of ink clearance patients usually hope for.

Does Q-switched laser removal hurt? Yes. A topical anesthetic such as lidocaine is often used to ease the pain. The cliché of no pain, no gain is only for getting tattoos. Because you’re damaging the skin, you’ll likely also get an antibacterial ointment to spread over the treated area. Is the laser removal expensive? It can be, depending on how many sessions are needed to boot that tattoo off your body. Do you have an elaborate, multicolored tattoo? The cost can be staggering. Ho and Goh said it best: “The removal of tattoos is generally more costly and time consumingthan acquiring them.” For some tattooed, any drawbacks are worth a regretted tattoo’s removal. For others, the pain—given the tattoo’s location—is too much to bear. If the cost and access to removal is a major roadblock in one’s life, charities and outreach programs have been started to assist applications, including the Catholic Charities Diocese of Monterey’s Tattoo Removal Program, Fresh Start Tattoo Removal Program, Inc., and Tataway’s INK Program.

The history of tattoo removal began far before a laser was even a pipedream for its inventors. Earlier methods were often chemical and mechanical, although old-school thermal techniques were also used. As you can image, some removal methods were quite gruesome. Vitriol (sulfuric acid) on the arm, anyone? A chunk of your cheek removed, perhaps? Burn scars as cover? In an article for The Atlantic, Mairin Odle highlighted a particular method from a 6th-century encyclopedia of medicine titled Tetrabiblos by physician Aëtius of Amida:

They call stigmata things inscribed on the face or some other part of the body, for example on the hands of soldiers … In cases where we wish to remove such stigmata, we must use the following preparations … When applying, first clean the stigmata with niter, smear them with resin of terebinth, and bandage for five days … The stigmata are removed in twenty days, without great ulceration and without a scar.

What’s being described here is a combination of chemical and mechanical methods of tattoo removal. Niter, also known as saltpeter, is potassium nitrate (KNO3). This salt is famous for its use as an oxidizer in gunpowder. The niter was probably rubbed over the “stigmata”—think salt dermabrasion. This method would cause not only mechanical tissue damage, but also corrosive chemical skin damage because niter is a skin irritant. Next comes “smear them with resin of terebinth.” A host of Pistacia tree species are known collectively as terebinth trees and are dubbed “turpentine trees” because their resin was an important historical source of the chemical turpentine. Like niter, turpentine is a skin irritant, and both chemicals have long histories in tattoo removal. Dermabrasion by niter would allow the terebinth resin to penetrate the skin a bit deeper to cause damage. Would this method work as easily and as wonderfully as suggested? I doubt it, as do others. We’re talking about repeated, painful applications of chemical irritants, with the end result likely being obfuscation of a tattoo due to fading, scarring, and discoloring of the skin.

Moving from the 6th to the 19th century takes us to the “French method.” First described by Variot Nouveau, the French method is another chemical and mechanical combination. Again, the surface is abraded, but this time tannic acid is applied and injected at the site of the tattoo such that the area is “retattooed.” After a rinse, silver nitrate is rubbed into the skin. Ouch. A chemical reaction between tannic acid and silver nitrate–producing silver tannate turns the area black. That chemical reaction, the puncture damage, and an inflammatory response yield a crust that falls off in about two weeks. What’s left behind is just a scarred area that early practitioners said was “hardly noticeable” after a few months or “… after some time.” The French method was considered a big advance in its day and was considered more effective and less destructive than earlier methods. It’s important to keep in mind that the aforementioned chemical and mechanical removal methods typically were put to use on tattoos of a single ink color (often black or blue) and long before elaborate, multicolored tattoos were popular. And let’s not forget the risks these types of removal methods posed. Before the antibiotics era, an infection meant tattoo removal could be lethal.

Since the French method’s use began, other chemicals such as phenol and trichloroacetic acid (TCA)—known more for their use in chemical peels—have been used in tattoo removal. They could be injected like the French method or applied topically, typically requiring a number of treatments, just as the niter–terebinth resin, French, and modern laser methods do. Compared to the gold standard Q-switched lasers, phenol and TCA applications are considered less effective and cause greater scarring and skin discoloration.

High levels of scarring are also a drawback of purely mechanical methods of tattoo removal. Such methods include excision, which is really only advisable for small, superficial tattoos on lax areas of skin. Beyond excision, other mechanical techniques include modes to abrade the skin, such as the niter step in the niter–terebinth resin method of the 6th century. This niter step could be classified in modern times as “salabrasion” as the salt potassium nitrate (niter) was used to abrade the skin. Today, salabrasion uses plain old table salt (sodium chloride) applied to a wounded tattoo area with rubbing. Ouch. Although often classified as a mechanical technique, salabrasion is sometimes thought of as a dual (chemical and mechanical) technique, given that the chemical actions of salts are used. Like excision, salabrasion is best suited for superficial tattoos. Like chemical methods, scarring and skin discoloration often result to some extent, depending on the exact treatment protocol. Classic dermabrasion using abrading devices (for example, a wire brush or spinning diamond fraise wheel) suffers from the same challenges. Mechanical methods are some of the oldest and, like previously described methods, could have been lethal in the preantibiotics era.

In our antibiotics era, tattoo removal has gotten much safer, but the rare lethal case still occurs. In 2016, a tattoo removal death was reported in the Journal of Forensic Science by Zhen Li of Kunming Medical University in China and colleagues. The death wasn’t due to an infection. The cause of death was phenol toxicity. The decedent had a large tattoo and underwent a nonstandard practice described as a “prolonged removal session utilizing an idiosyncratic method of injecting phenol solution into the areas of pigmented skin with a tattoo machine.” This led to what the doctors called “a very unusual case of lethal phenol cardiotoxicity.”

Tattoo removal, like tattooing, requires expertise and top tools. As tattoos and tattooing continue to evolve, so will the ways we remove our ink. Our ability to remove tattoos is not on par with our tattooing, but future methods may bring us much less ink, at much less cost, with less risk, and hopefully less pain.

Further Reading

  • Bernstein, E. F. 2007. Laser tattoo removal. Seminars in Plastic Surgery 21 (3):175–192. doi:10.1055/s-2007-991186.
  • Burris, K., and K. Kim. 2007. Tattoo removal. Clinics in Dermatology 25 :388–392. doi: 10.1016/j.clindermatol.2007.05.011.
  • Goh, C., and S. Ho. 2015. Laser tattoo removal: A clinical update. Journal of Cutaneous and Aesthetic Surgery 8 :9–15. doi:10.4103/0974-2077.155066.
  • Ibrahimi, O. J., Z. Syed, F. Sakamoto, M. Avram, and R. Anderson. 2011. Treatment of tattoo allergy with ablative fractional resurfacing: A novelparadigm for tattoo removal. Journal of the American Academy of Dermatology 64:1111–1114.
  • Li, Z., H. Zhang, L. Shu-Hua, and R. Byard. 2016. Fatal phenol toxicity following attempted tattoo removal. Journal of Forensic Sciences 61:1143–1145. doi:10.1111/1556-4029.13106.
  • van der Velden, E., H. van der Walle, and A. Groote. 1993. Tattoo removal: Tannic acid method of Variot. International Journal of Dermatology 32:376–380. doi:10.1111/j.1365-4362.1993.tb01479.x.

This post is published in Macroscope

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