Accelerated tattoo removal with acoustic shock wave therapy in conjunction with a picosecond laser

Conventional tattoo removal consists of single-pass treatments, spaced 7-8 weeks apart, for a total of 7-10 sessions. A major limiting factor of this procedure is the development of cavitation bubbles and vacuoles within the epidermis and dermis that result from the rapid heating of tattoo particles by the laser. While multiple-pass methods using the R20 protocol or the PFD patch enhance tattoo removal through epidermal clearance, they have no effect on deep-intradermal pigment associated vacuoles that arise from treatment with lasers such as the Q-switched laser.

A 28-year-old female with Fitzpatrick skin Type V presented for treatment of a 6-year-old professional black tattoo on the left ventral wrist. She underwent three treatment sessions at 6-8 week intervals using a commercial 1,064-nm picosecond Nd:YAG laser (PicoWay; Candela, Wayland, MA) and a perfluorodecalin (PFD) patch (Merz; Raleigh, NC). At each treatment session, she received two passes with 1,064-nm, 4-mm spot size, a fluence ranging from 2.8 to 3.2 J/cm² and a laser repetition rate of 2 Hz. Between laser passes and following the final laser pass, the medial portion of the tattoo was treated with acoustic shock wave therapy (ASWT) using the Zwave device (Zimmer Medizin Systems; Irvine, CA) with 90 mJ, 22 Hz, and 1,200 pulses.

After three treatment sessions, there was 80% clearance of the medial portion of the tattoo that received the ASWT compared with 60% clearance of the lateral portion of the tattoo that was treated with the picosecond 1,064-nm Nd:YAG laser and PFD patch alone. In the days following each treatment session, the patient noted consistently less edema, erythema and epidermal crusting on the portion of the tattoo that received the ASWT.

We report a case of 80% tattoo clearance with ASWT in a patient with Fitzpatrick type V skin compared with 60% clearance with the picosecond 1064-nm Nd:YAG laser and PFD patch alone. The concurrent use of the PFD patch, which facilitated multi-pass treatments, may have also increased tattoo fading in this patient. ASWT may enhance tattoo clearance by increasing lymphatic drainage and increasing metabolic activity in the treated area, thereby accelerating the clearance of dermal pigment vacuoles produced by the picosecond laser and minimizing epidermal side effects such as erythema, edema, and crusting. Lasers Surg. Med. 50:890-892, 2018. © 2018 Wiley Periodicals, Inc.