Laser Tattoo Removal: How Many Sessions, Which Colours Are Difficult, What Are the Risks?

What is laser tattoo removal and how does it work?

Tattoo ink consists of particles that settle in the middle layer of the skin and are too large for the body to clear on its own. The lasers used in tattoo removal deliver extremely short, high-energy pulses of light. This light is absorbed by the ink particles and breaks them into smaller fragments.

The smaller fragments are gradually cleared by cells of the immune system over weeks and months. This is why a tattoo fades gradually over the course of sessions rather than in a single session. The time left between sessions is needed both for the skin to heal and for the body to clear the particles.

The lasers used for this purpose are generally divided into two groups according to pulse duration: “Q-switched” lasers, which deliver pulses in the nanosecond range, and picosecond lasers, which deliver even shorter pulses. Both groups include different wavelengths, and each wavelength works better on different ink colours.

It has been reported that picosecond lasers may give results with fewer sessions for some tattoos; however, the evidence is not yet sufficient on whether they have a clear advantage over Q-switched lasers.

What is it used for?

• Removing or lightening professional or amateur tattoos
• Lightening an old tattoo before a new tattoo is done over it
• Correcting permanent make-up on the eyebrows, lips and around the eyes (requires special care)
• Marks caused by particles such as dirt, dust or gunpowder that entered the skin in an accident (where the physician considers it appropriate)

Who is it suitable for?

Tattoos considered easier to remove are usually black or dark blue, contain less ink and are located on areas of the body closer to the trunk. On lighter skin, because the colour contrast between the ink and the skin is marked, the procedure can often be done more safely.

Who is it not suitable for, and what should you watch out for?

• Postponing the procedure during pregnancy and breastfeeding is recommended.
• Diseases or treatments that suppress the immune system
• Active infection, an open wound or an active cold sore in the treatment area
• Recently sun-exposed or tanned skin: The risk of pigmentation and burns increases.
• A tendency to keloids (excessive scarring)
• A history of an allergic reaction to the ink, such as redness, swelling or itching in the tattoo area: Be sure to tell the physician beforehand.
• Use of medicines that cause light sensitivity and of oral vitamin A–derived acne medicines
• Having been treated in the past with gold-containing medicines: Tell your physician because of the risk of permanent skin discolouration after laser.
• A mole within or around the tattoo that has not been examined or that is changing colour or shape: A physician's assessment is needed first.

At the consultation, mention the medicines you use, when and how the tattoo was done, and whether removal has been tried before. Suitability and the plan can only be decided after a physician's assessment.

Who should perform it, and where?

Tattoo removal lasers are very high-energy devices. Treatments with the wrong wavelength or unsuitable settings can lead to burns, permanent scarring and colour change. It is recommended that the procedure be performed under the responsibility and supervision of a physician who can assess skin type and the characteristics of the tattoo.

Eye protection suitable for the device must be available at the treatment site, and your eyes must be protected during the procedure. At-home removal creams and methods such as rubbing with salt are not recommended; these methods can leave burns, infection and scarring on the skin.

Preparation before the procedure

• Protect the treatment area from the sun in the weeks before the procedure; tanned skin must not be treated.
• Do not apply self-tanning products to the area.
• If you have a history of cold sores and the tattoo is on the face, ask whether preventive medicine is needed.
• Have a photo taken of the tattoo; it is useful for tracking the change over a long process.
• If eyebrow or lip permanent make-up is to be removed, ask whether a test will first be done on a small area.
• Discuss beforehand what can be used for pain control.

The day of the procedure, step by step

1. Your medical history, medicines and the characteristics of the tattoo are discussed; your skin type and the colours of the tattoo are assessed.
2. The informed consent form is read; realistic results, the number of sessions and the risks are discussed, and the form is signed.
3. The area is cleaned. If needed, an anaesthetic cream is applied beforehand or the area is cooled.
4. You and the practitioner put on eye protection suitable for the device.
5. Pulses are delivered with a wavelength chosen to suit the colours of the tattoo. Each pulse may feel like a rubber band snapping against the skin or a splash of hot oil.
6. Immediately after a pulse, brief whitening may be seen on the tattoo; this usually goes away within minutes.
7. At the end of the procedure, the area is cooled, a soothing product is applied and, if needed, it is covered with a sterile dressing.

After the procedure: the first 24 hours and the first week

After the procedure, redness, swelling, tenderness and pinpoint bleeding are common. Blistering followed by crusting can occur in the first days; this can be part of healing and usually goes away within one to two weeks.

• Follow the dressing and aftercare instructions your physician gives you; keep the area clean and dry.
• Do not burst blisters or pick off scabs.
• Avoid hot baths, saunas, Turkish baths and swimming pools in the first days.
• Do not irritate the area with tight clothing.
• There may be itching; do not scratch.
• Protect the area from the sun during and after healing.

Expected side effects

• Redness, swelling and tenderness
• Blistering and crusting
• Pinpoint bleeding
• Itching
• Temporary colour change: Lightening or darkening of the skin; this often improves within months, but it may not always improve.

There are also rarer but important risks: permanent colour change, scarring, changes in skin texture, infection and burns. These risks increase on darker skin, with treatments using unsuitable settings and in inexperienced hands.

Skin-coloured, white, pink and some red inks, as well as some pigments used in permanent make-up, can darken permanently with laser. This is why a test on a small area first is a commonly used precaution for such tattoos and for permanent make-up. In people allergic to the ink, an allergic reaction after laser has been reported, although rarely.

When is the result seen and how long does it last?

After each session, the tattoo fades a little more over the following weeks. The number of sessions needed varies greatly depending on the colour, size, amount of ink and location of the tattoo and the person's skin type; most tattoos require many sessions, and the process can take more than a year.

Usually a few weeks or longer are left between sessions for the skin to heal and for the body to clear the ink. Having sessions too often does not speed up the result and can increase the risk of side effects. Ink cleared by the body usually does not come back; however, a faint shadow may remain with some tattoos.

Realistic expectations: what can laser not do?

• Not every tattoo can be removed completely; sometimes only marked fading can be achieved.
• A faint shadow, colour difference or texture change may remain where the tattoo was.
• No result is achieved in a single session; the process usually takes months, sometimes years.
• Some colours, especially green, light blue and yellow, may not respond or may fade very slowly.
• Some inks may darken instead of being removed.
• Results can differ even between two similar tattoos.

Alternatives