Purpose Increasing numbers of people are having professional, permanent tattoos placed on their bodies. Currently, the most widely used methods of tattoo removal are laser treatment and Intense Pulsed Light (IPL). These modalities require multiple treatment sessions with varying degrees of successful tattoo removal. A new medication class of immune response modifiers initiated by imiquimod (Aldara®, 3M, St. Paul, MN), has been shown to activate the innate and cell-mediated immune pathways resulting in improved treatment of certain cutaneous lesions. We hypothesize that the combination of IPL and imiquimod would result in faster and more complete removal of tattoos than IPL alone.

Methodology An IRB approved, double-blind, randomized, controlled trial was performed using 24 patients separated into two groups. All patients had a professional tattoo present for at least one year and free from any previous treatment. Both groups had their tattoos treated with the Vasculight IPL (Lumenis®, Santa Clara, CA) on standard tattoo removal settings. Immediately post-IPL treatment either medication or vehicle control was applied to the treated area. This was reapplied each night before bed and washed off each morning for four weeks. Standard antibiotic ointment was applied during the day to the treated area. This was repeated for a second treatment after three months if the patient desired. All tattoos were photographed using a standardized digital photography technique before and after treatment. The amount of clearance was judged by five experienced plastic surgeons in a blinded fashion using a scale from 1-5 (1 = <25%, 2 = 26-50%, 3 = 51-75%, 4 = 76-95%, 5 = >95%). Side effects were assessed at each visit and characterized by the patient as mild, moderate, or severe.

Results Twenty-three of 24 patients completed the study. One patient was lost to follow-up after a single treatment. A significant difference was noted in tattoo ink clearance between the medication and control groups (p<0.05, Chi-squared <0.05). Eight of 11 imiquimod patients had complete or excellent clearance of their tattoo after two sessions, while only 4 of the control patients obtained similar results. All patients in the control group had moderate to severe pigmentary and/or scarring changes to obtain clearance, while only 1 imiquimod patient had moderate hypopigmentation and no scarring. Other side effects were minor and similar between the two groups.

Conclusions Combined use of Aldara with Intense Pulsed Light significantly increases the amount of tattoo ink clearance per treatment session. Most tattoos can be removed in 2 sessions, which is considerably less than the usual 6 to 8 sessions other lasers and IPL alone have historically taken. In addition, imiquimod reduces the side effects of scarring and pigmentary changes seen with tattoo removal.

References Kilmer, SL. Laser Eradication of Pigmented Lesions and Tattoos. Dermatologic Clinics; 20(1):37-53, 2002. Trying S., et al. Imiquimod; An International Update on Therapeutic Uses in Dermatology. International Journal of Dermatology; 41:810-816, 2002. Solis, RR, et al. Experimental Nonsurgical Tattoo Removal in a Guinea Pig Model with Topical Imiquimod and Tretinoin. Dermatologic Surgery 28(1):83-87, 2002. Leuenberger, ML, et al. Comparison of the Q-Switched Alexandrite, Nd:YAG, and Ruby Lasers in Treating Blue-Black Tattoos. Dermatologic Surgery 25(1):10-14, 1999.