While picosecond lasers and other advances continue to boost tattoo clearance rates, said an expert at The Cosmetic Bootcamp, there's still a place for earlier-generation pigment-pummeling technologies.
Picosecond lasers improve physicians' ability to break up ink particles, including tough-to-treat green and blue inks, more effectively, said Paul M. Friedman, M.D., a dermatologist with offices in Houston and New York.
"The 1,064 nm should be your primary wavelength for a tattoo-removal laser. It allows you to treat all skin types, which is important to me, practicing in Houston, Texas." He showed photos of a patient with type VI skin and a black tattoo who achieved an excellent outcome after three treatment sessions with a 1,064 nm picosecond Nd:YAG laser — without the dyspigmentation that frequently occurs when treating darker skin types with shorter wavelengths.
More impressive, he said, was the laser's performance in removing red ink safely with the 532 nm laser light. "We've all seen hyper-or hypopigmentation when treating patients with skin of color because the melanin is a competing chromophore. The lower fluence required compared to Q-switched technology allows for safer treatment in skin of color."
For accelerated tattoo removal, the R20 method allows one to perform multiple passes on the same day by waiting 20 minutes between passes. This approach was published in the February 2012 Journal of the American Academy of Dermatology. The R20 method achieved excellent results in the original Harvard study, said Dr. Friedman. "But in reality, that's not very efficient to have the patient in our office for that length of time."
To streamline tattoo treatments, he uses the perfluorodecalin (PFD) patch. "I like it for several reasons – it provides a barrier, so that none of the tissue is splattering back." He also likes PFD's ability to serve as an optical clearing agent. Because heat is conducted from the epidermis into the patch instead of the skin, explains Dr. Friedman, the patch provides an extra layer of safety for darker skin types.
"More importantly, it clears out those little microbubbles that occur between passes. So it allows us to do multiple passes on the same session without having to wait 20 minutes in between. Therefore, we achieve more effective clearing per treatment session." In a 30-patient study published in Lasers in Surgery and Medicine in March 2017, using a PFD patch with a nanosecond Q-switched 755 nm alexandrite laser allowed investigators to perform 3.7 passes in five minutes (versus 1.4 passes with the laser alone) with less erythema and edema.
Experts are now considering the role of acoustic shockwave technology (ASWT), which is traditionally used to remove kidney stones, in tattoo removal. "ASWT has been shown to increase vascular endothelial growth factor, which increases local blood circulation. The theory is that it may enhance tattoo clearance by increasing lymphatic drainage and metabolic activity in the treated area."
Hours after laser treatment of tattoos, Dr. Friedman said, deep residual dermal vacuoles of pigment may still be present. In a case report he co-authored, applying ASWT between laser pulses allowed for 80% clearance of a black tattoo in a patient with type V skin after three sessions, versus 60% clearance with a picosecond 1,064 nm Nd:YAG laser plus PFD patch alone. The report appeared online June 25, 2018, in Lasers in Surgery and Medicine.
At multidisciplinary conferences, Dr. Friedman added, attendees may be so focused on fillers, neuromodulators and more invasive procedures that they overlook the importance of improving the surface of the skin. For a female patient who wanted to address her skin texture and pigmented lesions, Dr. Friedman said he could have chosen a Q-switched or picosecond laser. "But when I presented her treatment options, I discussed that we have the ability to vastly improve the overall texture as well as the actinic damage of her skin utilizing an ablative fractional resurfacing device, which was a very attractive option to the patient."
Most of Dr. Friedman's patients are unable take a week off from work to recover from more aggressive resurfacing. "So the workhorses in our practice are the 1,550/1,927 nm non-ablative fractional lasers. We typically use the 1,927 nm thulium wavelength when we are targeting superficial pigmentation, dyschromias and actinic damage where rhytids are less pronounced." This wavelength also can improve pores, he said.
He uses the 1,550 nm wavelength for deeper treatment of conditions such as acne scarring, as well as wrinkles. "Although the 1,550 nm is a shorter wavelength, there is deeper penetration because there is less water absorption compared to the 1,927 nm thulium wavelength."
The real value of the fractionated non-ablative device, he added, is its ability to treat all skin types and off-face areas such as the neck, chest and hands – areas he previously would not resurface due to the risk of scarring. "This has been a game-changer in the population of patients who do not want to have the significant downtime or risk associated with traditional resurfacing procedures."
When treating postinflammatory hyperpigmentation (PIH) associated with scars, he commonly chooses the 1,550 nm wavelength. For example, he used the 1,550 nm wavelength to treat a patient with type III skin who had burn scars and got excellent results after two sessions.
For a female patient with type IV skin with atrophic scarring and PIH following herpes zoster infection of the forehead, Dr. Friedman began with the 1,927 nm low-powered diode laser, which he uses for patients with PIH in all skin types. Subsequently, he performed non-ablative fractional resurfacing with the 1,550 nm wavelength to improve the patient's atrophic scarring.
Dr. Friedman frequently combines fractional and Q-switched lasers for same-day treatment. For a patient with minocycline hyperpigmentation, this approach achieved almost complete clearance after one session. "In this case, we did non-ablative fractional 1,550 nm, followed by Q-switched 755 nm laser. There seems to be a synergistic role for combining these treatment modalities on the same day for faster removal of the pigmentation."
To treat a woman with PIH, fine telangectasias and hemosiderin deposition following lipotransfer under the eyelids, Dr. Friedman chose a combination of pulsed-dye laser, non-ablative fractional resurfacing (to stimulate collagen remodeling) and a Q-switched alexandrite laser (to break up the hemosiderin). The patient improved dramatically after two treatment sessions.
For melasma, Dr. Friedman recommends a multimodality approach that includes low-energy and low-density non-ablative fractional resurfacing or picosecond technology. "It's part of a combination approach along with a topical antioxidant, retinoid and skin brightener with tranexamic acid, and for some patients, oral tranexamic acid."
In more challenging cases such as nevus of Ota, he typically combines technologies to reduce the number of treatment sessions required. "We often find that these patients plateau — in these cases I prefer combining non-ablative fractional resurfacing with Q-switched or picosecond laser technology on the same treatment session."