Laser Surgery for Skin Problems and Tattoo Removal: Frequently Asked Questions

Laser surgery for tattoos was the main focus of the title of the talk. I expect a lot of the questions to focus on tattoo removal, but there are also lasers for wrinkles of skin (resurfacing), hair removal, vascular lesions and birthmarks, so I expect there will be some questions about those things as well. There may be a few questions about laser vein surgery. It is becoming a little more common now, but not quite as effective for treatment as conventional therapy. When we speak about lasering blood vessels, people might want to ask how effective sclerotherapy is, which is a relative newcomer.

What is the recovery time after having a tattoo lasered off? Will there be a scar?
The recovery time per treatment is usually several days. It depends on the type of laser system that is used to remove the tattoo. There are three main types of lasers that are used to remove tattoos. They are all called Q-switched lasers. That basically is a fancy way of saying 'very high energy.' There is the Alexandrite, Ruby and NdYAG. There tends to be a little bit more blistering and scabbing with NdYAG than the other two lasers. What the patient will notice is that the skin turns white immediately which is just some superficial heating of the upper surface of the skin. That lasts less than a day. They may have a little bit of flaking of the skin that lasts for a couple of days. There usually is not a lot of bleeding. There may be pinpoint bleeding. What people should realize is that laser tattoo removal isn't a one-time treatment no matter which of the three systems is used. Let me explain why that is because everyone ought to know. The lasers do not remove the pigment from that tattoo, what they do is break up the ink into smaller pigment particles which the body digests from the inside out. The analogy that I like to use is that it is like taking a sledgehammer to a large boulder and breaking it up so the pebbles can be washed away. You wait a couple of months between each treatment to give the body a chance to do its job, then the person has another treatment. It is not a one-time treatment, it is a two- to three-day recovery after each and every treatment. By way of additional background, it depends on whether the tattoo was amateur or professional as to how many treatments it takes to fade the tattoo. If it is amateur, it takes four to six and if it is professional, it is eight to ten on average. With any of those three procedures, the risk of scarring is very low, between one to two percent.
Is it dependant on size and color?
Size is not much of an issue although color is to some extent. The Ruby and Alexandrite lasers treat most colors very well except for red. The NdYAG does red very well but doesn't do blue and black as well as the other two lasers. The size of the tattoo is not a problem, except it is a longer procedure, and the cost is more for the procedure, but the size is not a factor.
What other skin conditions can be treated with lasers?
The main things in the skin treated with laser surgery are red lesions and birth marks, small spider veins, tattoos, excessive hair, wrinkles and some brown birth marks. Those are the main indications for laser surgery right now. In addition to removing lesions that 'stick out' from the skin, what is used for that is called a carbon dioxide or erbium laser. Those are more vaporizing or destructive lasers. They basically remove things or vaporize them; they are not as specific as the other categories of lasers; they are less specific in terms of what they target.
What are the risks associated with using lasers on the skin?
It depends on the type of laser that is being used. For the nondestructive lasers, the risk of scarring is generally low, a few percent or less. For the destructive lasers, meaning carbon dioxide or erbium or blends of those two, the risk of scarring is higher. The main risks to the other lasers are the pigmentary changes, either slightly lighter or darker skin that is usually temporary, swelling for a few days or superficial flaking of the skin or sometimes blistering. For some of the lasers, you will get temporary bruising of the skin and occasionally superficial scabbing. Sometimes they don't work for the problem they were intended to work for. They don't remove hair as well or completely get rid of the tattoo as much as you hoped. I would say that is a variation in what lasers can and can't do.
I have severe psoriasis—are lasers an option for me?
There was a brand new investigational study presented at the National Laser Meeting in April that spoke about an Excimer laser for psoriasis. It was somewhat promising but is still investigational. That laser is being developed in the Harvard system hospitals. The questioner might want to check and see what is coming out of the Harvard Dermatology Labs called the Wellman Labs. It is a very interesting question and a potentially new indication for lasers. Like the questions, I am interested to see what is going to come of that over the next 6 to 12 months. The trick to treating psoriasis with lasers is going to be, I think, cover enough area with the beam in a short enough period of time to make it practical, especially if the patient has extensive involvement. The first step would be to show that it works and see how many treatments might be required and see that it is safe. Before we talk about the practicality in how extensive an area can be treated, we really need more follow-up, to see how effective it is and how long the effectiveness lasts.
Do all dermatologists offer laser treatment?
No. Not all dermatologists do. I cannot come up with a percentage of how many dermatologists nationwide do, but not all dermatologists are trained in laser surgery. Some have access to lasers and some don't.
Is there any coverage (insurance) for this process?
It depends on what is being treated. Some of the birthmarks are covered by insurance in many instances. If the person's condition is disfiguring, then it is sometimes covered by insurance. For certain medical conditions that have broken blood vessels, for example, as a part of the disease process, sometimes insurance will cover that. Let me give several examples, acne rosacea, which is an adult form of acne and may have a lot of broken blood vessels, or for people who have lupus that involves the skin—they might have broken blood vessels and sometimes that might be covered. Also port wine stain birthmark. In some instances, I have had patients who have had a traumatic tattoo that is covered, what I mean is someone who is an accident and gets asphalt in their skin, the black pigment in their skin, and I have seen that covered. In most instances, such as trying to improve leg veins, wrinkles or removing hair from the underarms, bikini lines, legs/back, in most instances, those are not treated by insurance.
I had a tattoo removed and there are still bluish bumps on my arm—will these go away?
It is unusual in my experience for 'bumps' to occur, it depends on the type of laser that was used and how many treatments used. For example, it is not unusual after one or two treatments to notice that there is still pigment there because multiple treatments are required. Some people who go between treatments, longer than a couple of months, will notice continued improvement in color even though they don't get additional treatment because the body continues to digest what the laser has broken into smaller pieces.
Are there alternative methods to diminish stretch marks other than surgery?
Stretch marks have been a problem for dermatologists and others to treat for a long time. There is no perfect treatment, or what I would consider a 'gold standard' treatment for stretch marks. For newer stretch marks that are pinker or light red in color, the Pulse-Dye laser is sometimes effective in fading the color of the stretch marks. For older stretch marks that are more silvery-white, I know of no very effective treatments for that including things that you can rub on the skin. Some people think that creams such as Renova or Retin-A can improve stretch marks. They may, to some extent. This improvement is often subtle. To get the texture of stretch marks to change is particularly difficult; we have more success improving the color of stretch marks than we do the texture of them.
I was wondering about a tattoo that I got 4 days ago. It's really sore and has a rash on it. Is that normal and what do I need to look for in an infection?
Without a thorough examination, it is really hard for me to comment on this.
I had a cyst removed from my left cheek that was found to be a cyst with solar keratosis. It has left a scar on my face about the size of a small eraser. Can this be removed with laser surgery? What is the approximate cost? Does this increase my risk of skin cancer?
Revising scars with lasers is very much dependent on the height and the size of the scar. In most instances, it is the carbon dioxide, or erbium laser that is used to smooth scars. But, whenever a scar is revised, whether a laser is used or scalpel surgery, you trade the original scar in for another. Sometimes it's an improvement, sometimes it is not. If the scar that the person is talking about is a small round scar and he/she wants it to be more of a lined scar instead of a circular, round bump, in most instances, that is better revised with scalpel surgery than a laser. It seems 'lower tech' but is often a better choice because it creates a narrower scar. With regard to the solar keratosis, that is another word for a sun damaged spot or a "precancer." People that have solar keratoses are at somewhat higher risk for skin cancer because they are a reflection of long-term sun exposure in the past. Sun exposure is the main risk factor for getting skin cancer. Now, a single solar keratosis does not increase the person's risk dramatically. However, if there are many solar keratoses, the risk goes up, especially if there has been a prior history of skin cancer in that person. The cost depends on the region of the country, whether inpatient or outpatient setting, a whole host of factors that come into play with regards to the cost. Typically this would be in the hundreds of dollars (not thousands of dollars), lots of different factors are involved (how many sutures, inpatient, outpatient).
If a melanoma was removed, what is the increase in recurrence of a melanoma?
Lasers are not typically used to treat melanomas. However, with regard to melanoma, the chance of recurrence is most dependent on the thickness of the cancer at the time of diagnosis. This thickness is typically described in millimeters. For example, the guest that speaks of the staging at 3.75 may be referring to the thickness of millimeters of her friend's cancer. The recurrence of a cancer in that thickness is different for different patients. If you look at large groups, it would be somewhere between 40 and 60 percent. In comparison, melanomas diagnosed at less than .76 mm recur on average of less than 5 percent of the time. There are intermediate percentages between .76 and 1.5, 1.5 and 3, 3 to 4 mm and higher. But, in general, the thicker the tumor, the more likely a melanoma might recur in the future. In no way do I mean to imply that for your particular friend, that these percentages apply, because these are simply group statistics obtained over many years time with a variety of patients.
Does location play a part in recurrence—this was on the leg?
It plays a minimal role.

My closing comments would be that lasers can be used to treat a variety of skin conditions, most commonly they are used to treat broken blood vessels or reddish birth marks/skin lesions, excess hair or unwanted hair, tattoos and some brown or tan birth marks, and wrinkles and other surface signs of photoaging. Traditional scalpel surgery, or topical therapy, among other forms of therapy, should also be considered when a person seeks care for these conditions. Laser surgery is not always the answer for every skin condition, a person should leave their options open and realize that lasers are one tool used by the doctor to treat these conditions and that a thorough discussion with their health care provider, their dermatologic surgeon, would give them additional information as to whether laser surgery might be helpful for them.

Christopher Arpey, MD
University of Iowa Hospitals and Clinics