Laser Treatment of Professional Tattoos With a 1064/532-nm Dual-Wavelength Picosecond Laser

Advancements in Laser Therapies for Dermal Hyperpigmentation in Skin of Color: A Comprehensive Literature Review and Experience of Sequential Laser Treatments in a Cohort of 122 Indian Patients

The heightened awareness of ethnic dermatology aligns with the growing prevalence of skin of color communities globally, where hyperpigmentation disorders pose a common dermatological challenge. Effectively addressing dermal pigmentation is challenging due to its resistance to conventional therapies and its association with impaired quality of life. This underscores the need for effective treatments and a thorough grasp of laser advancements. A relevant literature search spanning the last 7 years across the PubMed database reveals core studies, challenges, and the evolution of laser technologies tailored for various forms of congenital and acquired dermal hyperpigmentation in skin of color. This comprehensive review explores the mechanisms, applications, and recommendations for pigmentary laser technologies, highlighting the key role of Q-switched lasers in their established millisecond/ nanosecond forms and emerging picosecond lasers, fractional non-ablative and ablative lasers, Intense Pulsed Light, etc. The summary of evidence includes studies on dermal melanocytosis (nevus of Ota and Hori's nevus), tattoos, acquired dermal macular hyperpigmentation, etc., and also entities with mixed epidermal-dermal components, such as melasma and post-inflammatory hyperpigmentation. The review offers valuable insights for clinicians to make informed decisions based on diagnosis, skin type, and the latest technologies to optimize results and minimize complications, especially in darker Fitzpatrick skin types. In their five-year study with 122 Indian patients, the authors applied specific laser combinations for diverse dermal melanoses, including tattoos, dermal/mixed melasma, acquired dermal macular hyperpigmentation, and dermal nevi. Substantial pigmentation reduction, subjectively assessed by both physicians and patients, was observed across all groups. A one-way ANOVA indicated a significant difference in mean improvement scores across various pigmentary conditions (F = 3.39, p = 0.02), with melasma patients exhibiting a significantly higher improvement score than tattoos (p = 0.03). The results affirmed the safety and efficacy of sequential laser therapy for dermal pigmentation in skin of color, advocating for flexibility in approach while maintaining the rationale behind the laser sequences. Despite advancements, challenges persist, and gaps in the current literature are identified. In conclusion, this summary highlights the ongoing pursuit of optimal protocols in dermatological laser treatments for dermal melanoses, offering valuable insights for future research and clinical practice.

[Picosecond lasers in dermatology]

BACKGROUND

The picosecond laser is one of the latest laser systems in dermatology and was originally developed to optimize tattoo removal. Advances in this technology has expanded the use of the picosecond laser to numerous other indications.

OBJECTIVES

This article provides an overview of the technical background as well as the indications of the picosecond laser in dermatological laser medicine and elucidates the possibilities and limits of this laser system.

MATERIALS AND METHODS

The article is based on a review of the current literature as well as experience from clinical practice in a university laser department.

RESULTS

The picosecond laser enables a particularly gentle and effective treatment due to ultra-short pulses and the principle of laser-induced optical breakdown. Compared to Q‑switched lasers, the picosecond laser has fewer side effects and is associated with lower pain intensity and shorter downtime. In addition to the removal of tattoos and pigmentary disorders, it is also used in the treatment of scars and rejuvenation.

CONCLUSIONS

The picosecond laser has a wide range of indications in dermatological laser medicine. The current data indicate that the laser is an effective method with few side effects. Further prospective studies have to be conducted to assess the efficacy, tolerability and patient satisfaction in an evidence-based manner.

Outcomes of 1064-nm picosecond laser alone and in combination with fractional 1064-nm picosecond laser in tattoo removal

BACKGROUND

Removal of the unwanted tattoo was initially focused treatment of picosecond laser in the setting of the unfractionated beam, whereas the fractionated 1064-nm picosecond lasers (Fr-Pico) has been successfully utilized in various skin conditions, including scar and benign pigmented lesions. However, no studies compare the combination of Fr-Pico and unfractional 1064-nm picosecond laser (UFr-Pico) and UFr-Pico alone in tattoo removal.

OBJECTIVE

This study aims to compare the efficacy and safety of the combination of Fr-Pico and UFr-Pico and the UFr-Pico and in tattoo removal.

MATERIALS AND METHODS

Nineteen black tattoos in 11 patients were treated with UFr-Pico on one half and in combination with Fr-Pico on another half over three sessions with 4-week intervals and 4-week follow-up after the last session. Treatment efficacy was assessed using digital photographs, skin imaging analysis, and patient satisfaction.

RESULTS

After three treatments, tattoo clearance scores revealed that greater than 50% clearance was achieved in 11 (84.6%) tattoos treated with combination side and 9 (69.2%) tattoos with UFr-Pico alone. Significant differences were observed between the groups at 8 and 12 weeks. Skin textural changes also demonstrated significant improvements in the combination side at week 12. Adverse events, such as blistering and textural changes, were fewer in the combination side.

CONCLUSION

The combination of 1064 nm Fr-Pico and UFr-Pico may be more effective and safer in tattoo removal than UFr-Pico alone.

The effect of a dual-wavelength 532 nm and 1064 nm picosecond-domain laser with a fractionated holographic optic on photoaging and patient age perception: A pilot study

INTRODUCTION

This study evaluated the efficacy of a dual-wavelength 532 nm/1064 nm Nd:YAG picosecond-domain laser with a holographic lens array in treating facial photoaging.

METHODS

Thirteen subjects were enrolled with 10 completing the study. Receiving three-month treatments, subjects underwent full-face spot treatment of facial lentigines with the 532-nm non-fractionated handpiece, followed by two sequential facial passes of the 1064-nm and the 532-nm fractionated handpieces. Improvement was measured by treating physician evaluation of pigmentation and rhytids as well as blinded reviewer evaluation of pre- and post-treatment image sets taken 12 weeks after the final treatment. Participants completed treatment surveys to assess satisfaction.

RESULTS

Physician grading on a 5-point scale revealed an average improvement of 1.6 in pigmentation (p = 0.0042) and 0.9 in rhytids (p = 0.0196). Blinded physicians appropriately selected baseline images in 44 of 50 (88%) image sets (10 subjects; five reviewers). On an 11-point scale for overall facial photoaging (0 = no change, 1 = 10% improvement, 2 = 20% improvement, etc.) treating physicians scored mean improvement as 3.3 ± 1.83 (95% CI 1.99 to 4.61; range 1-6), while blinded reviewers scored mean improvement as 2.32 ± 2.62 (range % -4 to 8, 95% CI 1.57 to 3.07). The greatest majority (80%) of participants reported satisfaction with the treatment. Adverse events were mild; however, one patient developed hyperpigmentation, consistent with melasma that was successfully treated with topical agents.

CONCLUSION

This is the first study to show that picosecond-domain 532 nm/1064 nm laser treatments with combination non-fractionated and fractionated handpieces are well-tolerated, safe, and effective for the treatment of photodamage.

The efficacy and the adverse reactions of laser-assisted tattoo removal - a prospective split study using nanosecond and picosecond lasers

BACKGROUND

Laser pulses with nanosecond duration (NSL) have been the golden standard to destroy the pigment particles in skin. It is still controversially discussed whether picosecond pulses (PSL) are superior for tattoo removal.

OBJECTIVES

To compare the efficacy and the adverse reactions of nanosecond and picosecond laser pulses in a comparative study.

METHODS

The prospective study included 23 subjects with 30 black or coloured tattoos, which were split into two halves treated with either a new PSL (532, 1064 nm) or standard NSL (694 nm). The lasers were applied at regular time intervals of 4 weeks for up to eight treatments. Tattoo clearance (primary endpoint), pain and adverse reactions (secondary endpoints) were appraised by physicians, blinded observers, and by subjects. The extent and duration of adverse reactions were additionally assessed by using a questionnaire and photo-documentation after each treatment session.

RESULTS

The tattoo clearance appeared to be more effective for PSL compared to NSL but without statistical significance (P > 0.05). Pretreated tattoos responded better to laser treatments than previously untreated tattoos. Subjects felt significantly less pain with PSL than with NSL (P < 0.001). Transient adverse reactions were statistically less pronounced lasting shorter for PSL as for NSL, especially blistering, pruritus, and burning sensation. Hypopigmentation appeared after NSL treatments only, whereas hyperpigmentation was caused by both lasers. No scarring was detected with either laser.

CONCLUSIONS

Both laser systems enable acceptable clearance of most tattoos in the present study. PSL cause less collateral skin damage as compared to NSL.

Safety and Efficacy of Tattoo Removal Using a Dual-Wavelength 1064/532-nm Picosecond Laser in Patients With Fitzpatrick Skin Type III and IV

BACKGROUND AND OBJECTIVES

To investigate the safety and efficacy of a dual-wavelength 1064/532-nm picosecond-domain laser for tattoo removal in Vietnamese patients.

STUDY DESIGN/MATERIALS AND METHODS

This prospective clinical study enrolled 30 subjects with 52 decorative tattoos treated with up to six treatments of laser removal at intervals of 6-8 weeks. Safety and efficacy were assessed at each treatment session and at 4 weeks after the final session. A "good" response was defined as at least 75% clearance of tattoo pigments.

RESULTS

A significant reduction of tattoo appearance was achieved in all subjects. 88.5% of tattoos exhibited a "good" response to treatment by the end of the six sessions and more than 36% of tattoos exhibited better than "good" responses. Adverse events were common in the early period after treatment but did not persist in most patients. Only one case of prolonged hypopigmentation was reported.

CONCLUSIONS

Treatment using a 1064/532-nm picosecond laser is an effective approach for removal of decorative tattoos, which poses a minimal risk of long-term adverse events in patients with Fitzpatrick skin type III or IV. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Treatment of facial and non-facial lentigines with a 730 nm picosecond titanium: Sapphire laser is safe and effective

Objective

A 730 nm picosecond‐domain laser was developed to improve the clearance of pigmented lesion and reduce adverse events. This study assessed the safety and efficacy of this system for the clearance of lentigines and explores how the short picosecond pulses interact with tissue via histology.

Study Design and Methods

Twenty subjects with Fitzpatrick skin types II–IV were enrolled in this prospective, IRB‐approved study. Four treatments were administered using a 730 nm picosecond‐domain laser. Pre‐ and posttreatment photos were assessed by blinded reviewers at 4‐ and 12‐week follow‐up visits, using a 5‐point clearance scale. Subject satisfaction was measured using a 5‐point scale. Investigator Global Improvement Score (IGIS) was performed at the 4‐ and 12‐week follow‐up visits, using an 11‐point clearance scale. Subject pain level was measured using an 11‐point scale (no pain [0], extreme pain [10]). Histology of 730 and 532 nm picosecond pulses was compared with 755 and 532 nm nanosecond pulses.

Results

Sixteen subjects with a total of 118 discontinuous treatment areas, each comprised of 1–20 lesions, completed all study visits. Thirty body regions were studied, including arms (6), hands (16), scalp (1), forehead (2), face (3), and back (2). Spot sizes ranging from 2 to 5 mm diameters were used with fluences ranging from 0.8 to 4.0 J/cm². Mean pain score was 3.6 of 10 for all four treatments. Ninety‐nine percent of randomly paired 4‐week posttreatment images and 100% of 12‐week posttreatment images were correctly identified from their respective baseline images by three blinded reviewers. Mean IGIS demonstrated scores of 6.7 and 7.0 at 4‐ and 12‐week follow‐up visits, respectively. At the 4‐ and 12‐week follow‐up visits, 76% and 73% of subjects, respectively, were satisfied to highly satisfied. The mean clearance score for all 118 treatment areas was 3 of 4 in follow‐up visits. At 12‐week follow‐up, 36% of 118 treatment areas had a clearance score of 4, and 38% had a clearance score of 3. Post treatment, there was typical erythema, edema, dryness, crusting, and itching but negligible purpura, no pinpoint bleeding, blistering or scarring, and no significant hyperpigmentation or hypopigmentation. Histology showed diffuse, focal epidermal vacuolization ~5–10 µm in diameter and mild extravasation of erythrocytes with 730 nm picosecond pulses, while diffuse epidermal vacuolization was observed with coalescence of vacuoles (~20–100 µm), junctional clefting and mild extravasation of erythrocytes with 755 nm nanosecond pulses. Picosecond pulses of the wavelength of 532 nm produced diffuse, focal epidermal vacuolization and larger dermal vacuoles to depths of 500 µm, while 532 nm nanosecond pulses produced diffuse epidermal vacuolization with coalescence of vacuoles and marked dermal hemorrhage.

Conclusion

This study demonstrated the potential of a new 730 nm picosecond‐domain laser for the clearance of lentigines. The results showed good clearance with no adverse events and good subject satisfaction in patients with skin type II–III. Additional studies need to be conducted on darker skin types. The histopathologic findings demonstrate that the picosecond 730 nm laser produces excellent selectivity for pigment with minimal disruption of the dermal–epidermal junction and may therefore reduce healing times and the risk of adverse events.

High power Q-switched 1064 nm / 532 nm Nd:YAG Laser in tattoo removal: A systematic review

Q-switched 1064 nm/532 nm Nd: YAG Lasers present important characteristics which can contribute toward the removal of tattoos, for having the ability to reach only specific targets with minimal damage to the tissue. Despite reports of their clinical benefits, only a few scientific studies demonstrate the efficacy and safety of these types of lasers in the short and long term. To substantiate the effects, benefits, and safety of the application of Q-switched 1064 nm/532 nm Nd: YAG lasers, a systematic review was carried out from September to December of 2019, about the studies which report their use in the removal of tattoos, published in the last 20 years. Randomized clinical trials in humans were considered, as long as they evaluated the efficacy, safety, and benefits of the application of Q-switched 1064 nm/532 nm Nd: YAG lasers in the removal of black and color tattoos in different skin phototypes. One hundred and twenty-two articles were identified after the titles, abstracts were read, and duplicates were removed; six articles were left, which were included in the research (188 individuals). The Q-switched 1064 nm/532 nm Nd: YAG lasers seem promising in the short term, with minimal adverse effects; however, the efficacy and safety in the long term still present limitations. Consequently, future research is necessary, with better methodological standardization applied and with a follow-up for a longer period of evaluation of possible permanent adverse effects, to determine the standardization and safety of the therapy with the lasers Nd: YAG de 1064 nm/532 nm Q-switched.

Treatment of pigmentary disorders using picosecond laser in Asian patients: A meta-analysis and systematic review

There were many studies evaluating the effect of picosecond (PS) lasers, but no meta-analysis examined the effects of PS laser in the treatment of pigmentary disorders in Asians. The aim of this article was to review the before-after effect of PS laser in Asians for the treatment of pigmentary disorders. PubMed, Embase, and Cochrane library were searched for articles published up to May 2020. The evaluations were summarized into a 4-point scale that ranged from <25% (poor), 25%-50% (fair), 50%-75% (good), and 75%-100% (excellent). Effect sizes (ESs) were calculated according to laser wavelengths and lesion types. There were two randomized controlled trials, three single-arm trials, and three case series, with 200 patients. At 3 months after treatment, of all included patients, 3% (95%CI: 1%-6%) were evaluated as poor or worse, 9% (95%CI: 2%-21%) as fair, 29% (95%CI: 12%-50%) as good, and 56% (95%CI: 28%-83%) as excellent. The 532 and 1064, and 755 nm PS lasers had similar ESs across all four response groups. This meta-analysis suggested that 56% of Asian patients who underwent PS laser for the treatment of pigmentary disorders were evaluated as "excellent" about the pigment clearance by a dermatologist at least 3 months after treatment.

Comparing the efficacy and safety of laser treatments in tattoo removal: A systematic review

BACKGROUND

Although lasers have been the criterion standard for tattoo removal, selecting the best modality can be challenging because of the varying efficacies and adverse effects.

OBJECTIVE

To evaluate all lasers used to remove tattoos and assess their efficacies and adverse effects.

METHODS

Our systematic review searched PubMed, MEDLINE, Embase, Scopus, CINAHL, Cochrane Central Register of Trials, and ClinicalTrials.gov for all laser treatments. The outcomes measured included laser parameters, treatment methods, patient and tattoo characteristics, clearance rate, and adverse effect rate. The quality of the included articles was appraised by using specific assessment tools and given a high, moderate, or low risk of bias.

RESULTS

Our search led to 3037 studies, with 36 being included in the systematic review (7 randomized controlled trials, 2 nonrandomized controlled trials, and 27 case series). Although quality-switched neodymium-doped yttrium-aluminum-garnet lasers are safe and effective, picosecond lasers have shown superiority with blue, green, and yellow tattoo pigments. Both are safe and effective for black tattoos.

LIMITATIONS

Variability among studies.

CONCLUSIONS

Picosecond lasers show superiority when treating blue, green, and yellow tattoos. The R20 and R0 novel techniques can effectively reduce treatment time. Further randomized controlled trials are required to make a more definitive recommendation.

A Systematic Review of Picosecond Laser in Dermatology: Evidence and Recommendations

BACKGROUND AND OBJECTIVES

The use of picosecond laser in dermatology was originally focused on optimizing the removal of unwanted tattoos. Subsequent advances in this technology have broadened its clinical indications to include treatment of benign pigmented lesions, photodamage, melasma, and scar revision. In this systematic review, evidence-based recommendations are developed for the use of picosecond laser in dermatology.

STUDY DESIGN/MATERIALS AND METHODS

A comprehensive search of the English language literature was performed up to and including November 2019. Relevant citations were individually evaluated, synthesized, and categorized based on the Level of Evidence. With the addition of the authors' combined clinical experience, clinical recommendations were developed.

RESULTS

After application of inclusion and exclusion criteria, a total of 77 unique studies were evaluated. Treatment of benign pigmented lesions was associated with level I-IV evidence; rejuvenation was associated with level II evidence; melasma was associated with level II evidence; scar revision was associated with level II-III evidence; tattoo removal was associated with level I evidence.

CONCLUSION

Picosecond laser is a safe and effective treatment modality for an increasing range of dermatologic indications. Further development of this technology is warranted. Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

The First Commercial 730 nm Picosecond-Domain Laser is Safe and Effective for Treating Multicolor Tattoos

Background and Objectives

Laser‐pumped lasers enable driving a secondary wavelength through pumping with a primary device. Here we investigate the first 730 nm laser‐pumped laser for efficacy in tattoo removal.

Study Design/Materials and Methods

Fifteen subjects with 20 tattoos were enrolled to investigate the effect of a new 730 nm, titanium‐sapphire laser‐pumped laser at removing decorative tattoos. A total of four treatments were administered and photographic improvement of pre‐ and post‐treatment cross‐polarized digital images was evaluated by four blinded physician observers using an 11‐point scale.

Results

Blinded assessment of pre‐ and post‐treatment images found 70%, 77%, 83%, 83%, 26%, and 8% clearance from baseline images for black, green, blue, purple, red and yellow pigments, respectively. Side effects were limited to pinpoint bleeding and erythema immediately after treatment and some crusting and scale up to 1–2 weeks following treatment, and a localized allergic reaction in a single subject. There was no scarring or pigmentary alteration visible in any follow‐up images.

Conclusion

The new 730 nm, picosecond‐domain, titanium‐sapphire, laser‐pumped laser is safe and effective for removing multicolored tattoos. Green, blue, and purple pigments cleared the most as expected, but black ink cleared more completely than was predicted. Lasers Surg. Med. © 2020 The Authors. Lasers in Surgery and Medicine published by Wiley Periodicals LLC

Laser assisted tattoo removal – state of the art and new developments

Decorative tattoos including permanent make-up are very popular world-wide. As the trend for tattoo acquisition increases, the demand for tattoo removal will similarly rise. This article highlights the state of the art and new developments in laser assisted tattoo removal.

A novel titanium sapphire picosecond-domain laser safely and effectively removes purple, blue, and green tattoo inks

BACKGROUND

Green, blue, and purple tattoo pigments are often the colors most resistant to laser removal. Recently, the first ever production picosecond-domain laser with a 785 nm wavelength was developed to improve the rate of clearance of green, blue, and purple tattoo inks.

METHODS

Twenty-two tattoos from 15 subjects with skin phototypes II-IV were enrolled in the study. A total of four treatments were administered using a single 785 nm picosecond-domain laser wavelength. Blinded assessment of digital, cross-polarized photographs taken approximately 8 weeks following the last treatment was performed using an 11-point clearance scale.

RESULTS

Fourteen subjects with 21 tattoos completed all study visits. The 21 tattoos contained the following pigments: black (n = 15), green (n = 13), blue (n = 8), yellow (n = 5), purple (n = 4), and red (n = 3). Treatments were performed with a 2-4-mm beam diameter and fluences ranging from 1.1 to 3.1 J/cm2 . Blinded assessment of photographs found 85%, 81%, 74%, 61%, 11%, and 5% clearance from baseline photos for purple, blue, green, black, red, and yellow pigments, respectively. Treatments were well tolerated with typical erythema, edema and one case of pinpoint bleeding. No scarring was noted.

CONCLUSION

This first study of a new 785 nm picosecond-domain laser demonstrates safe and effective removal of multicolor tattoos. Although clearance was shown for a multitude of colors including black, the 785 nm laser wavelength has special affinity to purple, blue and green tattoo pigments. Lasers Surg. Med. 9999:1-7, 2018. © 2018 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.