How technology revolutionized the business of tattoo removal

This is the second in a two-part series about tattoos and tattoo removal.

Tattoo removal has become big business with entire clinics devoted to helping people rid themselves of unwanted body art. But not too long ago, dermatologists weren’t rushing to reap rewards from regret.

“It was nothing to hear things like ‘I don’t want those people in my waiting room’ or ‘I choose to have tattoo removal clinic on a day when I don’t bring in any other patients,’ ” says Myrna Armstrong, Ed.D., RN, an emeritus professor at Texas Tech University Health Sciences Center in Lubbock, TX and one of the nation’s leading tattoo researchers.

It didn’t help that physicians, especially dermatologists, tended to be “pretty WASPy” -- white, Anglo-Saxon Protestant, she says. This shared background, she says, molded their prejudices about tattoos and those who had them. And, of course, anti-tattoo bias in society as a whole contributed to the phenomenon of tattoo regret.

READ: From rebellious to routine: A Path to tattoo regret

But things changed over the past decade or so, Armstrong says. Now, dermatologists are much more willing to work with patients who want their tattoos to go away. At the same time, laser technology is giving dermatologists more power than ever to make tattoos dim or disappear.

But tattoo removal isn’t a simple, painless, or inexpensive process. “Patients are quickly discouraged by the cost and the number of treatments,” cautions Suzan Obagi, M.D., an associate professor of dermatology and plastic surgery and director of the cosmetic surgery and Skin Health Center at the University of Pittsburgh Medical Center.

Indeed, only the simplest and least colorful tattoos tend to vanish entirely after treatment. “Many patients come in with unrealistic expectations, and only about 50% of them follow through on the treatments to the bitter end,” says George J. Hruza, M.D., MBA, a dermatologist in private practice and adjunct professor of Dermatology at St. Louis University. “The ones that stick with it are very motivated.”

Next: Ink-busting lasers offer tattoo relief

Ink-busting lasers offer tattoo relief

Up until about the mid-1980s, dermatologists didn’t have good options on the tattoo-removal front. “A tattoo could be excised or cut out, or sanded off with dermabrasion and sometimes with salt,” says Melbourne, Fla., dermatologist Terrence A. Cronin Jr., M.D. “All these methods led to scarring, and it wasn't until lasers came along that the hope of scarless removal of tattoos began to be considered.”

Q-switched lasers changed the tattoo-removal business for good in the mid-1980s. “With the laser, you actually fragment the tattoo ink particles and kill the cells that contain them,” Dr. Hruza says. “Over several treatments, you can fade a tattoo, and the damage is confined to the area of the ink and the cells that contain it.”

This approach wasn’t ideal, however. According to Dr. Hruza, a number of treatments were needed, and they had to be separated by 2 months, he says. But advances in technology over the past several years have revolutionized the business of tattoo removal.

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For one thing, Dr. Hruza says, physicians can perform multiple treatments on individual patients in one day instead of spreading them out over many months. Also, he says, lasers can now deliver pulses in less than a nanosecond, packing a punch of power in a short pulse that pulverizes the ink particles more efficiently.

The key, he says, is to use lower energy at first when densely packed ink can overcome the body’s ability to recover easily. “Then you increase the energy as the tattoo fades, and you have less ink,” he says.

Obagi cautions that dermatologists must be careful to not burn the skin. “Otherwise, the patient will be left with a hypopigmented shadow in the shape of the tattoo,” she says. “Or worse yet, the patient can be left with hypertrophic scarring in the shape of the tattoo.”

Next: Mastering expectations is key

Mastering expectations is key

“A good rule of thumb for tattoo removal is to always lower patient expectations,” says Cronin. “Never promise perfection, as complete removal may not be possible, and many sessions may be required for satisfactory results.”

A variety of factors affect whether a tattoo can be fully or partially removed via laser:

• “The best candidates still tend to be patients with light skin and dark tattoos -- black and dark blue,” says Obagi. “The patient will still require multiple treatments, but fewer with picosecond laser than nanosecond lasers.”

• Red inks may also be removed with a smaller number of treatments, while green inks respond well to alexandrite lasers, Dr. Hruza says.

• Flesh-colored tattoos are the hardest to remove, Obagi says. “The flesh-tone ink contains various iron oxides that can turn from flesh color to black when hit with a laser. So a barely noticeable flesh-colored tattoo can become a black tattoo if treated. Red ink, as in lip tattoos, has the same potential risk.”

According to Dr. Hruza, skin-colored and pastel-colored tattoos can also turn permanently black with laser treatment.

 • Black eyeliner and eyebrow tattoos can often fade easily with treatment,

Dr. Hruza says, but “the process is slower when you move farther from the head and neck.” Ankle tattoos, for example, tend to not respond as well to treatment, he says. For her part, Obagi says black tattoos on the thin skin of the wrist are the easiest to remove.

Next: Tattoo removal isn't cheap

Tattoo removal isn’t cheap

The cost for removal of a small tattoo can be $200-$300 per treatment for 5-10 treatments, Hruza says. For larger tattoos, he says, the treatments may cost $500-$600 for a total of as much as $5,000.

Insurance won’t cover tattoo removal except in isolated cases. “If someone is in the military, we’ve actually had their insurance cover tattoo removal,” Hruza says. And he says insurance may cover the removal of an involuntary tattoo due to dirt ground into skin in a vehicle accident.

Check out: Tattoo removal is a booming business

Considering the hassle and expense, are removable tattoo inks on the horizon? Matt Lodder, Ph.D., a tattoo researcher and lecturer in contemporary art and visual culture at the University of Essex in the U.K., says researchers have been trying to design inks that are vulnerable to lasers. However, he says they have limitations and aren’t popular.

“For most tattoo collectors, the permanence is actually an important part of tattooing,” he says. “Most artists I speak to would certainly not embrace a technology which made tattooing easily removable.”

That means the big business of tattoo removal will be hard to dislodge -- just like tattoos themselves.