Serup J, Bäumler W (eds): Diagnosis and Therapy of Tattoo Complications. With Atlas of Illustrative Cases.

Curr Probl Dermatol. Basel, Karger, 2017, vol 52, pp 132–138 (DOI: 10.1159/000452966)

Guide to Treatment of Tattoo Complications and

Tattoo Removal
Jørgen Serup a  Wolfgang Bäumler b
a The ‘Tattoo Clinic’, Department of Dermatology, Bispebjerg University Hospital, Copenhagen, Denmark;
b Department of Dermatology, University of Regensburg, Regensburg, Germany

Abstract Removal of tattoos in individuals regretting their tattoo

Clinicians in the fields of general medicine, dermatology, is performed using Q-switched nanosecond lasers and
and plastic surgery are in their work now and then con- the recently introduced picosecond lasers. In view of the
fronted with tattoo complications. Recognizing the rath- various tattoo pigments with different absorption spec-
er few important diagnostic groups and urgencies, the tra and the limited number of laser wavelengths, it is dif-
medical ‘decision tree’ of treatment becomes quite sim- ficult to predict treatment outcome, and it is recom-
ple. Acute conditions are dominated by bacterial infec- mended to pretreat small test spots. Black and red colors
tions needing antibiotic treatment. Systemic infection is are removed best, while other colors are difficult. Remov-
a matter of urgency and requires intravenous treatment al of large tattoos, especially when multicolored, is hard-
in a hospital without delay to prevent septic shock. In- ly achievable and not recommended. Clients often have
flammatory reactions are a real challenge. Chronic aller- unrealistic expectations, and informed consent and dia-
gic reactions in red tattoos are mostly nonresponsive to logue between the client and the laser surgeon before
topical corticoid and best treated with dermatome shav- and during a treatment course is important since the cli-
ing with complete removal of the hapten concentrated ent shall know the risk that removal can be unsuccessful,
in the outer dermis. Laser treatment of allergic reactions with complications and even disfiguring leading to regret
can boost the allergy with worsening and a potential risk at the end. © 2017 S. Karger AG, Basel
of anaphylaxis and is thus not recommended in tattoo al-
lergy. Chronic papulonodular reactions in black tattoos
with pigment agglomeration can respond to local corti-
coid or be treated with dermatome shaving or lasers de- The treatment of tattoos in clinics and hospitals is
pending on availability. It is important to recognize sar- grouped into 2 major categories, namely treat-
coidosis, which is strongly associated with reactions in ment of medical complications and treatment of
black tattoos. Tattoo complications also include many patients who regret their tattoo due to change of
rare but specific entities, which require individual treat- mind and fashion. The following guide to treat-
ment depending on the case and the disease mechanism. ment follows this main distinction.
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Treatment of Medical Complications actions of dark-colored tattoos are rather com-
mon as a mild and sometimes acute complaint
Proper diagnosis is a paramount need behind [see chapter by Serup, this vol., pp. 18–29], but
choice of rational treatment, which in this field is reactions can be chronically intermittent and
widely empiric due to the paucity of systematic reach the burden of disease. Treatment is stan-
studies. An armamentarium of diagnostic ap- dard physical and chemical photo protection as
proaches and methods is described in the chapter recommended for photosensitive skin. Burning
by Serup [this vol., pp. 42–57]. In the chapter by sensation during magnetic resonance scanning is
Serup [this vol., pp. 58–73] a modern concept of acute and may interrupt scanning. Often it is fol-
diagnostic classification of the broad spectrum of lowed by inflammation for a few hours, but it is
tattoo complications is presented with definitions not a thermal burn, thus ulceration has not been
and clues to diagnosis. There are many entities of reported. Burning sensation is predominantly
very different causes and mechanisms. seen in cosmetic tattoos in the sensitive perior-
In the clinic a major distinction is made be- bital skin.
tween complications, which are acute, chronic,
local in the tattoo, regional, generalized in the Chronic Complications
skin, or systemic, the latter possibly with impair- Chronic complications are mostly local in the tat-
ment of the general condition and, ultimately, life too but sometimes there are manifestations of
threatening. systemic disease.
Inflammatory tattoo reaction is by far the larg-
Acute Complications est group. The separation of inflammatory reac-
Acute complications happen during and immedi- tions into allergic and nonallergic cases is essen-
ately after tattooing or during the phase of heal- tial and critical in the choice of proper treatment
ing. There are a number of conditions, which can and, thus, must be sharp. The distinction is guid-
make the person faint during tattooing, with pain, ed by the color of the tattoo and by the specific
exhaustion, dehydration, and hypoglycemia as clinical pattern [see chapter by Serup, this vol.,
the commonest reasons. Syncope due to cordial pp. 58–73]. Allergic reactions are very often seen
disease or epilepsy can happen as casualties need- in red tattoos or in nuances of red affecting every
ing hospital treatment. Bacterial infections, local, part of the tattoo of that particular color at the
regional, and systemic, are by far the largest group same time, with ‘plaque elevation’ (in the past giv-
and require treatment with oral or intravenous en the imprecise label ‘lichenoid reaction’), with
antibiotics [see chapter by Serup, this vol., pp. 30– ‘excessive hyperkeratosis’, and with ulcerating af-
41]. In systemic infection institution of treatment fections with dermal necrosis if allergy is strong.
is urgent and critically needed. Allergic reactions Therapeutic response to local corticoids very of-
with severe generalized rash within a day after tat- ten is poor, and reactions remain cumbersome.
tooing in persons with a known strong allergy to Some dermatologists may favor intralesional cor-
nickel, and after a few weeks in primary sensitiza- ticoid; however, such treatment is symptomatic,
tion against preservatives and other new contact needs repeated injections, and may easily cause
allergens, may require oral prednisone followed skin atrophy. As in other cutaneous allergies, the
by other immunosuppressant. Allergy to latex fundamental treatment is elimination of the aller-
provoked by tattooists’ gloves is exceptional but gen, in this case a hapten formed in the dermis
dangerous with risk of anaphylactic collapse. Ur- over time. Pigment and hapten are located in the
ticarial reactions to tattoos are discussed un- outer part of the dermis, and therefore surgery
der Chronic Complications. Photosensitivity re- with dermatome shaving is rational and posi-
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Serup J, Bäumler W (eds): Diagnosis and Therapy of Tattoo Complications. With Atlas of Illustrative Cases.
Curr Probl Dermatol. Basel, Karger, 2017, vol 52, pp 132–138 (DOI: 10.1159/000452966)
tioned as the first-line treatment [see chapter by to local corticoids, which should be tried as first-
Sepehri and Jørgensen, this vol., pp. 82–93]. Der- line treatment.
matome shaving is documented in recent re- Cumbersome reactions of high pigment den-
search. Surgical excision is only feasible in some sity are best treated with dermatome shaving or
cases and may require coverage with a transplant. with Q-switched nanosecond lasers and picosec-
Surgical excision often leaves ugly scars that can- ond lasers depending on what methods are avail-
not be fixed contrasting acceptable scarring after able and feasible also considering the anatomical
dermatome shaving with the option to have a site and tattooed area [see chapters in this vol. by
cover-up tattoo. In allergic cross-reaction with ac- Sepehri and Jørgensen, pp. 82–93; Karsai, pp.
companying reactions of old tattoos triggered by 105–112; Adatto et al., pp. 113–123]. With black
a fresh allergic reaction in a red tattoo, the react- tattoos there is no concern regarding use of lasers
ing tattoo(s) normally need no treatment. Spon- and potential risk of provoking allergy. Black pig-
taneous regression occurs once the trigger tattoo ment is a strong absorber of light and the favorite
has undergone full removal of the pigment hap- color of laser surgeons.
ten from the skin by surgery. Laser removal of al- Tattooing is directly accompanied by obliga-
lergic tattoo reactions should be seen as contrain- tory traumatic urticarial reactions due to the
dicated due to the risk of laser light-induced pho- multiple needle pricks of tattooing, a condition
tochemical breakdown of pigment boosting the not needing any treatment or any special precau-
allergy, with worsening and the reported poten- tion [see chapter by Serup, this vol., pp. 18–29].
tial risk of anaphylaxis. Pretreatments such as an- Chronic urticaria after tattooing can be active for
tihistamine and oral corticoid cannot eliminate several months, very cumbersome, and require
this risk. Laser clinics are not equipped for, not treatment with antihistamines in normal, dou-
staffed for, and not experienced in treating severe ble, or triple dose, which nevertheless often are of
allergy with acute cardiovascular collapse. Fur- limited benefit. Oral prednisone dosed individu-
thermore, lasers are an incoherent multiple-spot ally is often efficient and can be supplemented
treatment of uncertain depth control, thus as a with cyclosporine or another immunosuppres-
method not able to produce the consequent, su- sant for long-term control. There is no experi-
pervised, and clean-cut removal of pigment ob- ence with the biologic omalizumab on this indi-
tained with a dermatome, which slice by slice re- cation.
moves the outer skin to a desired level under the A simplified ‘decision tree’ with suggested
pigment. Red pigment can absorb laser light of therapies of inflammatory tattoo reactions is pre-
YAG laser systems, but blue, green, and yellow sented in table  1. The table summarizes experi-
are mostly poor absorbers. Allergic reactions sel- ences from the ‘Tattoo Clinic’ obtained in more
dom may occur in blue, green, violet, purple, and than 500 patients.
yellow tattoos. Nonallergic reactions are predomi- Tattoo reactions representing uncommon and
nant in black tattoos with only some parts of the specific entities [see chapter by Serup, this vol., pp.
tattoo being affected with variably sized papules 58–73] are treated depending on the suggested
and nodules, i.e. with the ‘papulonodular’ pattern cause of the problem and the mechanism behind
[see chapter by Serup, this vol., pp. 58–73]. The the manifestation. For example, an abnormal scar
severity of the reaction depends on the dose of after traumatic tattooing with hazardous needle
black pigment in the dermis and the pigment’s damage to the skin and sensory hypersensitivity
tendency to spontaneous aggregation and forma- with chronic hyperalgesia and invalidating pain
tion of pigment foreign bodies in the skin causing in a tattoo require very different approaches, de-
the inflammation. Sometimes reactions respond pending on the specific case. Keratoacanthoma is
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Serup J, Bäumler W (eds): Diagnosis and Therapy of Tattoo Complications. With Atlas of Illustrative Cases.
Curr Probl Dermatol. Basel, Karger, 2017, vol 52, pp 132–138 (DOI: 10.1159/000452966)
Table 1. Therapy of inflammatory tattoo reactions: simplified ‘decision tree’ and hypothetical pathology

Local in the tattoo

Allergic reactiona (mainly red color*), chronic
Local corticoid (occlusive, intralesional) 1
Dermatome shaving 1
Surgical excision 2
Prednisone/immunosuppressant 3
No laser
Cross-reactionsa in other red tattoos, allergic1
Eliminate trigger tattoo, no treatment observation of reacting tattoos 1
Local corticoid* 2
Nonallergic inflammationb (mainly black color), chronic
Local corticoid 1
Dermatome shaving 2
Laser removal 2
Photosensitivity (dark colors), intermittent
Sun screen (chemical and physical) 1
Local corticoid 2
Generalized in the skin or systemic
Allergic rash (any color**), acute
Prednisone 1
Immunosuppressant 2
Urticaria (any color***), chronic
Antihistamine 1
Prednisone 2
Immunosuppressant 3
Sarcoidosisc (black color****), chronic
Prednisone 1
Local corticoid 1
Immunosuppressant 2
Dermatome shaving 3
Laser removal 3
‘Rush phenomenon’ in other black tattoos, autoimmune2
Prednisone 1
Local corticoid 2

The numbers in the second column indicate treatment priority 1, 2, and 3. Priority may depend on local availability of
treatment.
a
Manifested as plaque elevation (lichenoid) pattern or excessive hyperkeratosis. Ulceronecrotic allergy shall be ob-
served, surgery contraindicated. b Manifested as papulonodular reaction pattern. c Manifested as a papulonodular
reaction (a special subgroup with granulomatous reaction or sarcoid granuloma in the tattoo by histology).
* Caused by pigment-related hapten made in the skin over time; allergic reactions are widely resistant to local corti-
coid given as open application. ** Suggested to be caused by nonpigment ingredients of ink (preservatives, etc.),
contaminants (nickel, etc.), or soluble pigment breakdown products. *** Cause of allergy unknown; self-limiting and
thus unlikely to be due to insoluble pigment. **** Caused by large pigment aggregates with suggested adjuvant ef-
fect resulting in autoimmunity, systemic activation, and sometimes manifest sarcoidosis.
1
Local tattoo reaction (trigger) in a recent tattoo followed by widespread allergic reactions in older tattooos of red
color (reacting tattoos) hitherto tolerated. 2 Local tattoo reaction (trigger) in a recent tattoo followed by abrupt and
widespread autoimmune reactions in older tattooos of black color (reacting tattoos) hitherto tolerated; may be paral-
lelled by other signs of active sarcoidosis in skin and internal organs.
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Serup J, Bäumler W (eds): Diagnosis and Therapy of Tattoo Complications. With Atlas of Illustrative Cases.
Curr Probl Dermatol. Basel, Karger, 2017, vol 52, pp 132–138 (DOI: 10.1159/000452966)
clinically benign and is best observed until spon- ing to local microbiologists’ recommendation is
taneous regression occurs, which typically hap- required.
pens after a few months. Skin cancers in tattoos Tattoo reaction and systemic disease are dom-
are considered coincidental and not related to the inated by the association between papulonodular
tattoo pigment and thus treated following com- reactions of black tattoos and sarcoidosis affecting
mon standards in skin oncology. There is no in- the tattoo, internal organs, and other parts of the
dication that radiotherapy and tattoo pigment in- skin with scar sarcoidosis and erythema nodosum
teract. Photodynamic therapy can be influenced sometimes occurring at the same time [see chap-
by the light-absorbing tattoo pigment and con- ter by Serup, this vol., pp. 58–73]. The association
tribute to the already quite strong tissue response is strong and with autoimmunity as the suggested
and the pain associated with this treatment. Fur- linkage. The treatment of the local tattoo reac-
thermore, tattoo pigment may screen the light tions showing granulomatous reaction or sarcoid
and in cancers invading the dermis reduce the ef- granuloma by histology is primarily local corti-
fect of the treatment. Such screen may be signifi- coid, which may ameliorate symptoms without
cant in the perilesional skin of the cancer when clearing reactions. In associated systemic disease
the cancer is progressing subclinically and hori- the preferred treatment is oral prednisone, meth-
zontally in the outer dermis. The tattoo shall not otrexate, and another immunosuppressant. In-
be considered a premalignant lesion, and the local ternists should be involved. In the ‘rush phenom-
site of the treated tumor shall be followed accord- enon’, with abrupt reaction in any black tattoo all
ing to normal skin cancer checkup standard. In- over the skin following the onset in a recent black
cidentally tattooed benign nevi in a larger tattoo tattoo, oral prednisone is the drug of choice and
later in life transformed into malignant melano- efficient. The Koebner phenomenon in patients
ma shall be treated following general standards. with psoriasis with a psoriasis replica overlapping
Over-tattooed and thus camouflaged nevi carry a fresh tattoo is treated with local corticoid or left
the risk that malignant transformation and devel- for spontaneous healing over a few months. The
opment of malignant melanoma later in life be- association of psoriasis and tattoo is limited to
come diagnosed too late. Sentinel lymph nodes newly acquired tattoos, and there is no real evi-
can be dark-colored due to tattoo pigment, there- dence that a tattoo can provoke psoriasis in other
by simulating regional metastasis of melanoma parts of the skin. In general worsening of psoria-
and complicating radical surgery. sis, a tattoo of course can be affected by coinci-
Chronic complications also may include hepa- dence, and treatment is then directed toward re-
titis B and C, which may need up-to-date medical lieving psoriasis by appropriate routine treat-
treatment used in infectious medicine [see chap- ment.
ter by Serup, this vol., pp. 30–41]. HIV infection
introduced by a tattoo is rare. In some countries
inoculation of endemic infections by tattooing is Laser Removal in Tattoo Regret
an issue requiring treatment according to local
expertise. Chronic infection of the tattoo with en- The use of lasers to treat abnormal tattoo reac-
vironmental mycobacteria, especially Mycobacte- tions is discussed in the previous section. The fol-
rium chelonae, is a very uncommon infection lowing guide is directed towards treatment of
highlighted in the literature but nevertheless rare. normal tattoos that the person wishes to be re-
Infection may occur as local outbreaks. Relevant moved due to plain regret or due to social incom-
antimycobacterial treatment for a period of sev- petence experienced by the person in his/her
eral months with a combination of drugs accord- private life or professional career necessitating
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Serup J, Bäumler W (eds): Diagnosis and Therapy of Tattoo Complications. With Atlas of Illustrative Cases.
Curr Probl Dermatol. Basel, Karger, 2017, vol 52, pp 132–138 (DOI: 10.1159/000452966)
the removal if technically achievable. Historical Today, the Q-switched nanosecond YAG laser
methods, such as chemical caustics and derm- is the gold standard method for tattoo removal
abrasion, have been replaced by modern lasers of [see chapter by Karsai, this vol., pp. 105–112]. It
the nonablative type, which may selectively erad- operates with very short pulses and thus can
icate the pigment in the skin without causing sig- spare the normal tissue with less risk of scarring
nificant harm to the normal tissue. The basic and dyspigmentation. This laser is primarily ap-
principles of laser therapy are explained in the plicable to black and red tattoos. Blue, green, and
chapter by Bäumler [this vol., pp. 94–104]. Laser yellow tattoos are more difficult to remove, or
surgeons shall master their device and based on they cannot be removed. Laser irradiation of
their skills and experience from the start make the some tattoo pigments can cause photochemical
best possible prediction of benefit and risk by changes of these pigments, white tattoos can
treating the particular case [see chapter by Hut- turn into black color and so can tattoos made
ton Carlsen et al., this vol., pp. 124–131]. Clients with iron pigments. Since iron pigments are
request laser removal with intuitively high expec- commonly used in cosmetic tattoo inks, laser re-
tations, but about 1/3 of clients will not reach ac- moval of tattoos in the orbital region can be es-
ceptable removal of the tattoo, despite the pecially unpredictable with the laser worsening
surgeons having done their very best. The sur- the problem. The new picosecond lasers working
geon shall continuously educate and challenge with even shorter pulse durations have the po-
the client during the progress of the treatment tential to be more efficient with less harm to nor-
course in the direction of realistic expectations mal tissue and thus may have a better risk-to-
adjusted relative to treatment experience ob- benefit ratio [see chapter by Adatto et al., this
tained in the client, aiming at satisfaction or ac- vol., pp. 113–123]. This also implicates that this
ceptance by the client at the end of a completed type of laser can do the job with fewer treatment
or interrupted treatment course [see chapter by sessions. The 2 types of lasers are comparable re-
Hutton Carlsen et al., this vol., pp. 124–131]. garding wavelength versus absorbance of tattoo
Some people with tattoo regret will regret laser pigments, and benefits are mainly related to the
removal and end up with a disfigured tattoo with delivery and dosing of the laser light into the
some colors removed and others disturbed, skin. The preference of equipment is presently
blurred, or unaffected. While most of the black much dependent on local availability and the
tattoos fade upon laser treatment, the reaction of economy involved.
colored tattoos is frequently unpredictable. It is There are other types of lasers applied to tattoo
always good advice to pretreat small test spots and removal, and such lasers may expand the range of
read lightening effect of the laser before the entire tattoo colors, which can be treated. However, this
tattoo is approached. Some individuals having is not a promising field and a field for laser spe-
smaller black tattoos can obtain a visibly com- cialists. The CO2 laser, which is ablative and un-
plete removal with perfectly intact skin texture. In limited burns all tissues and pigments irrespec-
some tattoos, changes of skin texture and pig- tive of color, can be used to ultimately remove any
mentation may appear when the tattoo ink disap- tattoo but it always leaves scars, which easily can
pears. These changes are usually caused by the be advanced and hypertrophic. This laser is only
tattooing needles and not by laser treatment. The used for critical tattoo removal on very special in-
informed consent of the client is very important. dications with the client fully accepting scarring
Clients shall from the start understand and en- as the foreseeable outcome. Fractional CO2 lasers,
gage in shared risk taking, together with the laser which treat the skin with narrow vertical tunnels
surgeon. Some clients shall be denied treatment. and practically leave no scar, are sometimes used
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Guide to Treatment 137

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Serup J, Bäumler W (eds): Diagnosis and Therapy of Tattoo Complications. With Atlas of Illustrative Cases.
Curr Probl Dermatol. Basel, Karger, 2017, vol 52, pp 132–138 (DOI: 10.1159/000452966)
on special indications supplementary to the Q- Commentary
switched nanosecond laser. This recent type of la-
ser system has not found a defined indication in The tattoo removal market which, besides lasers,
relation to laser removal. Argon lasers used in the offers a broad spectrum of claimed treatments, in-
past are today considered obsolete for tattoo re- cluding various topical remedies and injectables,
moval. such as lactic acid and other caustics, is generally
Intense pulsed light (IPL) is a high-power poorly regulated or not regulated at all. There is
broad-band nonlaser light that with limited con- no formal quality of care standard a customer can
trol burns any tissue and thus very easily causes refer to or rely on. The removal marked is price
scarring. The treatment of small tattoo pigment sensitive, and lasers are positioned expensive. The
particles in the skin requires pulse durations of business is a mix of many amateurs and fewer pro-
nanoseconds or picoseconds. Being no laser, the fessionals. The legal position of a client making a
IPL technology provides a pulse duration in the wrong choice of provider and method of removal,
range of a few milliseconds only. Thus, the pig- laser, or other method, with a bad result and
ment particle would be heated way too long and sometimes severe and disfiguring sequel is very
the excessive heat would cause collateral damage poor. The generalist doctor on request and in the
in the adjacent tissue yielding a high rate of severe guiding of his/her patient should be aware of this
side effects. The IPL method, which may be of- situation and encourage the patient, or client, to
fered by nonprofessional clinics in the tattoo re- be critical and go for professionalism, recognized
moval business, should not be practiced on this method, technical skill, and ethical standard of the
indication. provider rather than a low price of the delivery.

Prof. Jørgen Serup, DMSc

Department of Dermatology D41, Bispebjerg University Hospital
Bispebjerg Bakke 23
DK–2400 Copenhagen NV (Denmark)
E-Mail joergen.vedelskov.serup @ regionh.dk
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Serup J, Bäumler W (eds): Diagnosis and Therapy of Tattoo Complications. With Atlas of Illustrative Cases.
Curr Probl Dermatol. Basel, Karger, 2017, vol 52, pp 132–138 (DOI: 10.1159/000452966)