Multiple color changes following laser therapy of cosmetic tattoos

OBJECTIVE. To emphasize the wisdom of small test areas when treating cosmetic tattoos and the need for multiple laser systems. METHODS. A 48-year-old woman requested removal of permanent makeup (cosmetic tattoos) of her eyebrows and around her lips. Physical examination revealed a brown tattoo of both eyebrows and dark red lip liner around both lips. A test area was performed on the red tattoo of the lips. A frequency-doubled Nd:YAG laser (532 nm, 2.0 J/cm², 2 mm spot size) was used for the lip area, while the same laser at 1064 nm, 3.9 J cm², 2 mm spot size was utilized for the eyebrows. The lip area immediately turned black. The patient returned for follow-up 1 month later; the black ink on the lip was treated with the same laser at 1064 nm, 3 mm spot size, 4.2 J/cm², with satisfactory resolution in two monthly treatments. Both brown eyebrow turned bright orange and were treated with 532 nm, 3 mm, 3.0 J/cm². One month later the eyebrows were a mixture of yellow ink and dark green. The yellow area was treated with 532 nm, 3 mm, 2.3 J/cm², while the dark green was treated with the 1064 nm, 3 mm spot size, 4.2 J/cm². One month later little improvement was noted, so Q-switched ruby laser at 694 nm, 6 mm spot size, 16 J/cm² was utilized. An additional four monthly treatments were given utilizing a combination of both ruby and 532 nm ND:YAG lasers for green and yellow pigment, respectively. RESULTS. Significant but incomplete resolution of the tattoo ink was achieved. CONCLUSION. Multiple laser systems are needed to remove cosmetic tattoos. Test areas must be done before treatment.