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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.79 no.6 Rio de Janeiro Nov./Dec. 2004
Laser and intense pulsed light - Induction and treatment of allergic reactions related to tattoos*
Tatiana SacksI; Carlos BarcauiII
IDermatology "Specialist", with the
Brazilian Society of Dermatology
IIMaster's Degree in Dermatology (Sao Paulo Federal University)
The authors describe two cases of allergic reactions related to tattoos, in which laser and intense pulsed light had an important role in inducing and treating these allergic reactions. In the first case, the patient developed eczematous lesions at the site of the red pigment used in tattooing. After several unsuccessful therapeutic attempts, intense pulsed light was used. It successfully removed the red pigment and treated the allergy symptoms. In the second case, the authors describe a case of anaphylactic reaction precipitated by the long pulse Nd:YAD laser.
Key words: hypersensitivity; lasers; tattooing.
Tattoos are permanent figures or inscriptions produced by introducing exogenous pigments into the skin. The procedure involves placing the pigment on the skin with disposable needles adaptable for use in electrical devices injecting the material into the dermis. The most commonly used pigments are carbon, mercury sulphide, vegetable dyes, cobalt, cadmium oxide, chrome oxide, ochre and iron oxide.1
Three reaction categories can be cited as covering the complications that may arise in the procedure: 1) allergies,2 with the appearance of eczematous lesions at the site of the tattoo, possibly caused by a hypersensitive reaction mediated by cells;3 granulomatous,4 lichenoid;5 2) lesions caused by inoculation;6 infections like hepatitis, HIV, tuberculosis, syphilis,7,8 when not performed with disposable needles; pyodermitis resulting from bad asepsis; 3) coincidental lesions. Apart from this, hypertrophic and keloidal scars might occur.
Traditional therapeutic methods include surgical exeresis, dermabrasion, salabrasion, cryosurgery and lasertherapy. With the exception of non-ablative lasers, these methods caused necrosis of the epidermis and upper dermis, with the elimination of the pigment, followed by re-epithelization. By causing tissue destruction, scarring often results. Selective lasers, used non-ablatively, have been successful in removing tattoos with a low risk of complications, although scars, dyschromias and allergic reactions have been described.
Case 1 - Hypersensitivity mediated by cells treated with intense pulsed light (IPL)
A 42-year-old female patient, with a multicolored flower and heart-shaped tattoo (black, brown, green, yellow, burgundy and red), on the inner side of the lower third of the lower right limb, had a tattoo made six months ago by a professional. Three months after having had the tattoo made, the patient complained about pruritus in the red colored (petal) areas. The examination showed edema and scaling restricted to the red colored areas. The areas tattooed with other colors were free of other skin alterations (Figure 1). Topical clobetasol propionate was prescribed under occlusion for three weeks. The result was temporarily satisfactory, after which the symptom ended up returning. The same result was obtained after two intralesional infiltrations and a 30-day interval with 100 mg/ml triamcinolone acetonide. Removal of the tattooed part containing the red pigment was decided, with the use of intense pulsed light (Photoderm VL/PL - Lumenis). Two sessions were carried out with a 30-day interval, using a 515 nm filter, a single 3 msec pulse, a laser fluence of 25-28 J/cm2 and a 550 nm filter, double 2.4 msec pulse, a 20 msec interval with 41J/cm2 fluence. No anesthetic was used during the procedure. Immediately following the first session, virtually the entire red pigment was removed, and the pruritus improved. After the second session, there was complete removal of the red pigment and disappearance of the pruritus (Figure 2).
Case 2 - Anaphylactic reaction induced by long pulse Nd:YAD laser
A 32-year-old female patient had two multicolored tattoos made by a professional nine years ago. A larger tattoo in the shape of flower stems, measuring 20 x 10 cm, black, green, yellow and red in color, was located on the outer lateral side of the left thigh (Figure 3). Another smaller, flower-shaped tattoo, measuring roughly 6 cm in diameter, black and red in color, was located on the pretibial region of the right leg (Figure 4). The patient sought medical assistance to remove the tattoo for esthetic reasons. Treatment with intense pulsed light was begun. Despite the sessions at times being scheduled at monthly intervals, 11 sessions were performed over a three-year treatment period (1999/2002). The intervals between sessions varied from one to 20 months. The parameters used were as follows: in accordance with the pigment color to be treated: a 570 nm filter, a single 3.2 msec pulse and a fluence of 28 J/cm2; 550 nm filter, a single 3.5 msec pulse and fluence of 30 J/cm2; filter 515, single 3.5 msec pulse and a fluence of 34 J/cm2.
During the eleventh session, faced with the unsatisfactory result that had been obtained until then (Figure 5), the decision was made to perform a test with the Nd:YAD 1064 nm long pulse, with fluence of 80 J/cm2, and a single 3.5 msec pulse. Once the session was over, after a period of roughly an hour, the patient returned to the clinic showing pruritus, nausea, vomiting, abdominal pain of the colic type and light dyspnea. The physical examination showed the patient to be lucid and hypotensive, with increased cardiac frequency and a disseminated urticariform eruption. The patient was given a dose of 50 mg promethazine chloride and 5 mg dipropionate and 2 mg betamethasone disodium phosphate by intramuscular injection. The clinical picture improved progressively. Later, 100 mg daily hydroxyzine was prescribed for 10 days.
A month after the patient's anaphylactic picture, based on the literature the decision was made to continue treatment by using only intense pulsed light and by performing the following prophylactic schema: 40 mg daily prednisone and 100 mg daily hydroxyzine a day prior to and two days following the session. After four hours of observation, the patient was discharged without any type of reaction.
Various motives might lead a patient to want to remove a tattoo. In structured anamnesis, the patient's motivation has to be taken into account. The aim of a referral for laser treatment is to obtain a more favorable esthetic result. However, the treatment may require several sessions, which takes time. Patients who need to remove a tattoo in a week or even on the same day, as frequently occurs in the case of persons approved for employment in the civil service and who must undergo a physical examination, the laser may not be the best tool to use.
Unlike ablative lasers, like carbonic gas lasers, IPL performs selectively on the chromophore to be treated and spares the surrounding tissues-selective photothermolysis.10 In accordance with the principles of selective photothermolysis, three variables must be taken into account with respect to the laser or light source so that microscopic precision is achieved and consequently the selective damage: the wavelength emitted must be absorbed more avidly by the chromophore-target, the energy quantity must be enough to cause a thermal alteration, and exposure time must be lower than the target's thermal relaxation time. The device emitting pulsed light, (Lumenis) Photoderm VL/PL enables a section of various wavelengths (515, 550, 570, 590, 615, 645, 695 and 755 nm) by means of filters. The latter become versatile because they enable the treatment of multicolored tattoos with only one set of equipment.
In Case 1, the patient was not unsatisfied with the tattoo, yet she showed a specific late hypersensitive reaction to the red pigment. The latter showed symptoms of pruritus and dermatological alterations (edema and scaling) only in the area tattooed with a red dye. Based on the literature, the agent of the hypersensitive reaction would appear to have been mercury sulphide (cinnabar), which might produce edema, pruritus, eczema, and scarcoid granulomatous reactions at the site where it was introduced. The objective was not for a complete removal of the tattoo, but only the areas affected by the allergic process that had been causing the most tissue damage. This enabled the patient to fill in the area treated with another exogenous pigment. By selecting the specific wavelength for the red pigment, the desired result was obtained without deforming the tattoo. For professional tattooing, the speed with which the virtually total removal of the red pigment occurred in only a single session-which is rather unusual-was noteworthy. It can be attributed to the patient's biological response, which had already shown an inflammatory response at the site that was to be treated.
In Case 2, the patient was treated with IPL (11 sessions). The result was quite unsatisfactory. This led to performing a test with another laser. With the change in the laser wavelength and fluence emitted, an anaphylactic reaction was triggered 40 minutes after the end of the session. The patient did not show any previous allergic background, although there must have been some type of sensitization between one of the final products of the laser interaction and the exogenous pigments. Most likely, this sensitization was eased by the high number of sessions that had previously been performed. The literature9 reports on anaphylactic reactions induced by the laser action on the tattoo. The exogenous pigment, located within the cells, is thought to be vulnerable to affection by thermal expansion caused by the laser, resulting in the fragmentation of the pigment-containing cells. Accordingly, the now extra-cellular pigment is recognized by the immunological system, which begins an allergic reaction that may be localized or generalized. The time intervals between the application and the onset of the reaction may be up to six days. Faced with the unpredictable character of this type of reaction and the variable duration of the interval for the onset to begin, the authors of the present study believe that the best weapon is to guide the patient with respect to the likelihood of its occurrence. In subsequent sessions, the patient did not show any type of reaction. However, she was no longer treated with the Nd:YAD laser.
A prophylactic schema was adopted instead with an association of corticosteroids and anti-histamines.
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Received on December 05, 2002
Approved by the Consultive Council and accepted for publication on December 05, 2003
*Work done at Ipanema Dermatology Clinic (Clínica Dermatológica de Ipanema)