Practitioner-Reported Complications in Tattoo Removal

Introduction: Q-switched laser treatment is the gold standard for tattoo removal; however, complications such as blistering, scarring, dyspigmentation, infections, and allergic reactions can occur. Potential risk factors include the client's skin type, tattoo age, and ink colour. Moreover, untrained practitioners performing laser tattoo removal and the increasing use of non-evidence-based alternative removal products have raised safety concerns. This study aimed to document practitioner-reported complications in laser tattoo removal, focussing on frequency and associating factors. Secondary objectives were to explore practitioner-reported encounters with alternative removal techniques and treatments performed by untrained practitioners.

A digital survey containing up to 41 questions was distributed among Dutch dermal therapists. The survey addressed treatment protocols, complications of laser tattoo removal, and observations regarding alternative techniques and untrained practitioners in tattoo removal.

Of 173 practitioners, 94 (54.3%) actively practiced laser tattoo removal. Complications were reported in an estimated 8.1% of laser tattoo removal treatment sessions, most commonly oedema (3.0%), blistering (1.9%), and haematoma (0.7%). Hypo- and hyperpigmentation were reported in approximately 0.6% of treatments, while hypertrophic scarring and paradoxical darkening were reported in 0.2%. Keloid formation, allergic reactions, ink blow-out, and infection were each reported in 0.1%. Complications were reported more frequently by practitioners treating clients with Fitzpatrick skin types ≥III, coloured tattoos, permanent make-up, previously treated tattoos, and tattoos younger than 1 year. Among practitioners performing laser tattoo removal, 87% reported treating clients previously treated by untrained practitioners, and 81.7% of these practitioners observed complications. Additionally, 31.0% of all practitioners reported clients who had used alternative removal techniques, with complications observed in 56.7%.

This is the first study to systematically report practitioner-reported complications in laser tattoo removal. Although laser tattoo removal is generally safe, complications were more frequently reported in the presence of known risk factors. The widespread involvement of untrained practitioners and the use of alternative removal techniques highlight ongoing safety concerns and underscore the need for further research and consideration of regulatory measures.