Blasting Away Pigment: Targeting Hair, Tattoos, Brown Spots

Michael H. Gold, MD

The tattoo removal market is projected to grow significantly in North America. In 2004, there were 19,900 tattoo removal procedures at an estimated cost of $5.9 million and by 2009 there were 33,900 procedures estimating $14 million demonstrating a 21 percent increase in the market.  There are two major market drivers for the procedure, the first being tattoo popularity. A study at Northwestern University published in the JAAD in 2006 reported that 23 percent of people in the United States have at least one tattoo (69,000,000 people). This was a 30.4 percent increase over the 2003 Harris Interactive study that reported that 16 percent of the US population had at least one tattoo. The second market driver is “buyers remorse” coming from “tattoo regret”-driven by changes in life and/or circumstances. “Tattoo regret” ranges from a reported 15 to an estimated 50 percent of tattoo wearers.

There are multiple, low-cost treatment options for tattoo removal. These include:

  • Cryogenics, i.e., cryotherapy
  • Acids of various kinds
  • Topical retinoids
  • Hyfercation
  • Continuous Wave Lasers
  • Bleaching agents
  • Surgical excision
  • Abrasives with or without chemicals
  • Dermabrasion or salabrasion

However, these methodologies come with many complications such as scars, permanent pigmentation changes, residual tattoo pigment, wound infection, ineffective overall treatment, and can be a painful and slow process.

Laser Tattoo Treatment

There are several advantages to laser tattoo treatment. It is a non-invasive procedure with less pain that produces optimal clearing. With laser treatment, there is a lower risk of scarring and reduced hypo-pigmentation. There is also no change in skin texture, minimal post-operative care and the healing usually takes about one to two weeks. However, there are disadvantages to laser treatment.  Pain is the number one issue (it hurts a lot more to remove a tattoo than to get one), but topical and injected analgesia can be used in conjunction with the laser.  Realistically, it is important to let customers know that as many as 10-15-20 treatments may be required to “satisfactorily” remove a single tattoo (the tattoo will lighten 30-50 percent with each treatment). It is extremely important to set appropriate expectations with you customers and their patients. The treatments can result in hypo-pigmentation, routinely resulting in redness and swelling and punctate bleeding is also a possible (but “normal”) side effect.

As with ANY laser treatment, other more serious side effects are also possible, including–hypo-pigmentation, burns, blisters & scarring.

Pigmented Lesions

The market for pigmented lesion removal is also projected to grow significantly in the coming years. These lesions include epidermal lesions (sun spots, age spots, and melasma) as well as dermal lesions (nevus of Ota/Ito and blue nevi).

Treating Pigmented Lesions with Lasers

Dr Gold comments that both the alexandrite 755 nm lasers and the Nd: YAG 1064 nm lasers are both effective lasers for pigmented lesions. There are several advantages to treating pigmented lesions with lasers, these include the fact that it is a fast procedure; it is a simple treatment technique with minimal discomfort. DCD may or may not be required, depending on the device being used. It usually requires one to four treatments and the lesions darken for five to ten days before they exfoliate. There is improved efficacy with laser treatment because of the thermal effect and the photoacoustical effect.

Several lasers exist for the treatment of both tattoos and pigmented lesions. For pigment, long-pulsed alexandrite lasers are good; Q-Switched lasers are the treatment of choice for tattoos and most pigmented lesions.  It is important to remember that tattoos should NOT be treated with IPLs. Recently picosecond lasers have become available which show, in clinical studies, reduces the treatment time for the overall improvement of tattoos.

R20 Tattoo Removal

R20 involves performing three to four laser treatments in one session.  The result of the R20 method is 50 to 85 percent clearing in a single session without any additional side effects. Laser Tattoo removal treatments form tiny vapor bubbles in the skin (frosting) that looks like fine white powder. Ordinarily, this frost refracts the laser beam preventing it from penetrating the skin. After 15 to 20 minutes, the frost disappears making it possible to do another treatment or “pass”. Dr Gold states that the R20 Tattoo Removal method simply waits for this to happen and lets us treat clients three to four times in one visit. Combining three to four laser tattoo removal treatments during one office visit lets the laser reach deeper than with a traditional single-pass treatment. One R20 treatment would be sufficient to completely remove an amateur black tattoo or for lightening a tattoo for a new one.  For professionally applied black tattoos however, about 50 to 75 percent fading will occur. This is significantly more fading than expected from three to four conventional treatments.  Using the R20 method will cut the total time for removal by half or more.


In conclusion, we know that 25 million people in the US have a tattoo. There are 250,000 women being tattooed each year. Approximately 50 percent of people who have a tattoo look to have them either removed or augmented. The average age of procuring a tattoo is eighteen, often leaving the tattoo as a permanent reminder of their poor decision to get one in the first place. A clinical pearl that Dr Gold tells all of his patients is that it costs more money to remove a tattoo and it hurts more to remove a tattoo then it does to get one.