Rebellion and remorse
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More Americans getting — and getting rid of — tattoos

What do Otzi the Tyrolean Iceman and Tokidoki Barbie have in common? Tattoos — lots of them. The 57 tattoos that were found on the mummified remains of tzi, who lived in the Alps near the border of Austria and Italy about 5,300 years ago, were created with fireplace soot, according to a study in the Journal of Archaeological Science (2009;36(10):2335-2341). Because several of the tattoos appear over typical acupuncture points for treating back and leg pain, researchers believe they may have had more of a therapeutic than a decorative purpose. In contrast, the tattoos adorning Tokidoki Barbie, who also sports pink hair and leopard print leggings, are purely decorative, a nod to fans of the Japanese-inspired lifestyle brand.

Although the tattooed Barbie raises the ire of some parents, it also points to a growing acceptance of body art as a legitimate form of self-expression, particularly among younger Americans. “Tattoos are far more prevalent than they were 20 years ago, and there are far more in the current younger generation than there are in people 50 and over,” said Scott A. Norton, MD, MPH, staff dermatologist at Georgetown University and chief of dermatology at Children’s National Medical Center. And just as more tattoo parlors are springing up to serve a growing market, tattoo removal clinics are proliferating as well. While removal is often practiced by non-dermatologist physicians (and even by non-physicians in some states), it is dermatologists who are advancing the science of tattoo lightening, as evidenced by recent studies using Q-switched and picosecond lasers. 

From margins to mainstream

The modern history of tattoos dates back to the 18th century Pacific island voyages of Captain James Cook and a handful of other European explorers, according to Dr. Norton, who maintains a strong anthropological interest in the topic. “The word tattoo’ is a pan-Polynesian word meaning to tap,’” he noted. “As Cook and his crew stopped on the islands of Polynesia and Melanesia, they observed an abundance of tattoos and saw that they were not simply decorative, but also conveyed essential information about the individual and his or her place in society. Cook’s scientist and a few of the sailors got tattoos, and when they returned to England, the whole concept of having tattoos became quite exotic, associated with these Eden-like South Sea islands.” As time went on, tattoos became more prevalent among lower socioeconomic classes in Europe and were associated with the “marginalized populations” throughout the 19th century, Dr. Norton said.

Similarly, Americans with tattoos in the early 1900s were widely regarded as part of a “fringe population” with unsavory reputations: prostitutes, circus sideshow performers, and the like, Dr. Norton remarked. “All that changed with World War I, when very respectable people went off to war and came back with tattoos. The same thing happened in World War II; we can say that much of our greatest generation obtained tattoos as a memento of their experiences in the war.” But tattoos also remained popular among certain fringe elements, such as white supremicist groups. “Law enforcement groups recognized certain designs as pretty obvious markers of antisocial behavior and created a field guide to these tattoos,” Dr. Norton explained. “In the late 1980s, the Department of Defense issued a directive prohibiting the enlistment of soldiers with particular hate-based markings.”[pagebreak]

Tattoos among women in the military caught the attention of an Army nurse who would become a leading expert in the sociology of tattoos. “Around 1989, as I was performing a lot of physicals, I began to see tattoos on enlisted women and officers,” said Myrna Armstrong, EdD, RN, professor emerita at the Texas Tech University Health Sciences Center School of Nursing. “I was so surprised, and the more I talked to them, the more interested I became in the phenomenon of women getting tattoos.” Ten years later, Dr. Armstrong and a few of her colleagues at Texas Tech formed a small research group “looking at sociology, religion, studies for decision-making, complications, and trends” relating to tattoos (and more recently, body piercing).

Twenty-first century trends

Tattoos can easily be observed on business professionals, college students, parents and grandparents, as well as on athletes, entertainers, bikers, and military personnel. In some areas, tattoo parlors have morphed into upscale studios with spa-like ambiance. But the increase in tattoos among the general population is difficult to document precisely. The most recent nationwide survey of tattoo prevalence, published in the Journal of the American Academy of Dermatology (2006;55(3):413-21), found that 24 percent of the 500 respondents (aged 18 to 50) had a tattoo, and 65 percent had considered getting one. Co-authored by Anne E. Laumann, MBChB, and Amy J. Derick, MD, the study examined the association of tattoos with age, sex, level of education, jail time, and recreational drug use. Respondents with tattoos were also asked about local medical problems within two weeks of getting tattooed, and about the impact of their decision on work and social settings. Among the key findings:

  • Half of respondents with tattoos had multiple tattoos, and younger respondents were more likely to have more than one.
  • Men were slightly more likely to have tattoos (26 percent) than women (22 percent).
  • Thirty-six percent of respondents born between 1975 and 1986 had tattoos, compared with 24 percent of those born between 1964 and 1974, and 15 percent of those born between 1953 and 1963.
  • Recreational drug use and the current or past high consumption of alcohol was significantly more common among the tattooed than the nontattooed.
  • No one had had a tattoo removed, although 17 percent had considered it.

“It is clear that people of lower socioeconomic class and people who have been in jail for three days or more are more likely to have tattoos,” said Dr. Laumann, who is professor of dermatology and chief of general dermatology at Northwestern University’s Feinberg School of Medicine. Her findings also indicated that the more highly educated respondents were far less likely to have tattoos than those who did not finish high school. Some notable exceptions are profiled in a book cited by Dr. Norton. Published in 2011, Science ink: Tattoos of the science obsesssed, by acclaimed science writer Carl Zimmer, features more than 350 color photographs of tattoos worn by scientists and scholars, including those depicting Darwin’s finches, the uranium atom, physics equations, and the neural network of the brain.[pagebreak]

A 2010 Pew Research Center report on the “Millennials” (those between ages 18 and 29 at the time of the survey) found that nearly 40 percent have tattoos — a higher percentage than in the youngest group surveyed by Dr. Laumann in 2004 — and about half of those with tattoos have two to five. In a study of college students and tattoos, published in the Journal of Psychosocial Nursing (2002;40(10):20-29), Dr. Armstrong cited a “tattoo renaissance in people of all ages, social classes, and occupations.” She noted that despite the physical risks, which include infections and transmission of blood-borne diseases such as hepatitis B and C, tattoos remain popular among college students (19 percent of students in her study had tattoos, which she called “the highest recorded amount in a civilian group”). Dr. Laumann pointed out that an acceptance of body art may now start in childhood. “All young people I know take their children to parties, and the child comes home with a temporary tattoo,” she said. “Mom thinks it’s alright — you’ve told that child that decorating the skin is OK. That never would have happened at a party when I was a child.”

“We know that one of the reasons people obtain body art is that it makes them feel good, feel special and unique,” Dr. Armstrong said. “It’s so interesting to step into the lobby of a tattoo parlor and see who’s there. It’s a cross section of individuals, from the 15-year-olds to the 60-year-olds. But it’s important not to lump them together; the people with one tattoo aren’t like the ones with five. We have found that the higher the amount of tattoos or piercings, the higher the risk of deviant behavior, such as marijuana use and cheating on exams.”

While Dr. Armstong has written extensively about the risks of infection and hepatitis associated with tattoos, she said the incidence of these complications is difficult to quantify. “You would have to test the individual before and after they went into the studio to establish tattooing as the cause of hepatitis, and we have no data on a direct link,” she said. “Infection will usually occur during the procedure, either from the artist, from the individual, or from a previous individual. For all the tattoos created, I believe there have been very few problems with infections, especially as compared to body piercings.” Consumer health information from the Food and Drug Administration published in 2009 warned that the agency had received reports of adverse reactions to tattoo ink and noted that many pigments used in the inks are industrial-grade colors suitable for printers’ ink or automobile paint.[pagebreak]

Taking it off

While tattoos may be entering the mainstream of society, they are not universally accepted, particularly in the workplace environment (see sidebar). In a study examining the motivations for tattoo removal, published in Archives of Dermatology (2008;144(7):879-84), the authors note that women “had experienced significantly more negative comments and stigma problems in public, workplace, or school settings than had the men with tattoos. Problems with clothes were also significant and led them to use cosmetics, creams, and adhesive bandages to cover their tattoos.” For many, the symbols of their individuality and identity had become a barrier to fitting into a corporate culture.

Tattoo removal with lasers was revolutionized in the 1980s when R. Rox Anderson, MD, professor of dermatology at Harvard Medical School and director of the Wellman Center for Photomedicine, developed the theory of selective photothermolysis as applied to the Q-switched ruby laser. “He basically figured out that different colors preferentially absorb different waves of laser energy, so each color could be targeted by a specific wavelength,” said Allan Izikson, MD, a dermatologist in private practice who conducts clinical research at the Wellman Center. “He also found that for optimal destruction of pigments, the duration of the laser pulse has to be less than the thermal relaxation time of the target — that’s the amount of time in which a particle loses half its heat.”

Modern conventional laser therapy for tattoo removal may involve the use of different lasers to achieve the optimal wavelengths, Dr. Izikson said. Results of the treatment will depend on a number of factors, including whether the tattoo was done by an amateur or professional (the latter is more difficult to remove); whether it is a new or an old tattoo; and the color and chemical composition of the ink. While the laser treatments can lighten tattoos significantly, some pigment is likely to remain. In addition, the treatments are expensive, require multiple visits, and can be painful. “It’s important to understand the capacities of the technology and also the limitations,” Dr. Izikson said. “And you have to know how to speak to patients realistically about expectations. That’s paramount.” (See sidebar, "Managing patient expectations.")

Recent research conducted in Greece and supervised by Dr. Anderson may lead to better results with fewer treatment sessions. Greek dermatologists treated 18 tattoos on 12 adults. Each tattoo was divided into two approximately equal parts, which were randomized to receive either conventional therapy (a single treatment pass) or four consecutive passes separated by 20-minute intervals (called the “R20” method). A Q-switched alexandrite nanosecond laser was used for both groups. With the R20 method, 61 percent of the sites cleared completely. Among the tattoos treated with conventional therapy, none cleared completely, and lightening was much less than with the R20 method. On a self-assessment questionnaire, 97 percent of subjects said they would recommend the R20 treatment to others. (The study has been accepted for publication by the JAAD.)

“The principal of R20 is very sound, and has a lot of foundation in biology and science,” Dr. Izikson said. “But of course, the only way to find out if it works on a mass scale is to do it on all kinds of colors and tattoos.” In his own research at the Wellman Center, Dr. Izikson tested the concept with fewer treatment passes and a different laser. “We took an ultrafast laser, in the picosecond range, and treated one part of the tattoo with one pulse and another part with two pulses separated by 20 minutes,” he explained. “We repeated the process one month later, and again after another month. We wanted to see if we could replicate the same kind of efficacy as the four treatments per session. And we did see some improved lightening, not quite as dramatic as with the four treatments. We’re still waiting for the final results at the three-month follow-up. But the patients were pretty happy with the results; some of these tattoos almost completely went away.”

Not surprisingly, laser tattoo removal is a booming business. A recent article in the Washington Post (“Rethinking the ink: Laser tattoo removal gains popularity,” Dec. 8, 2011) quotes an entrepreneur who took a two-week course to become a certified laser specialist, invested $90,000 in equipment, and now operates out of an office building. Regulations regarding who can operate a laser vary by state; Dr. Izikson noted that in New York it must be a physician but not necessarily a dermatologist. “You can have an opinion one way or the other, but I believe the patient who cares about getting the best results should probably go to the professional who’s best trained to do the procedure, who understands the limitations of the technology, and can medically manage the side effects,” he said. 

Tattoos in the dermatology office

Body art may be gaining acceptance in the workplace, but many dermatology practices forbid their employees from displaying visible tattoos, said Rhonda Holloway, president of the Association of Dermatology Administrators and Managers. “There are no guidelines set by our organization, though we have hosted speakers at our annual meeting who have addressed the issue. In the world of dermatology it’s a practice-by-practice choice,” Holloway said. “I certainly have gone into other [non-dermatologist physicians’] offices and seen employees with tattoos. But in our practice, and in those I’ve had this discussion with, the feeling is that when you’re in the business of promoting healthy skin, we as a physician’s office should not be promoting tattoos, just as we would not promote tanning.”

Holloway manages a Shreveport, La. practice with seven dermatologists and 50 employees. She compared the no-tattoo policy with the requirement for wearing a uniform, and said she makes both very clear to job applicants during the interview. “You have to be very upfront with them at the very beginning,” she insisted. “We don’t discriminate against people with tattoos, but our policy is that if you have a tattoo, it may not show when you’re working in the office. That normally means that you have to wear long sleeves, or socks, or whatever it takes. So far, that’s worked very well for us.”

Managing patient expectations

When counseling a patient about removing a tattoo, dermatologists should “underpromise and overdeliver,” said Allan Izikson, MD. “Make sure your patients understand that the technology is good, and it’s going to keep improving, but it also has its limitations. They have to go into the process knowing that they’re not going to have perfectly normal skin after tattoo removal. Not all the pigment will be gone, but it will definitely be better. I talk to people in terms of tattoo lightening, not tattoo removal. ”

Dr. Izikson starts by explaining to patients that every tattoo is unpredictable due to factors such as the pigment composition, the chemicals in the tattoo, how the inks were placed, and the patient’s own ability to clear the pigment particles. “Generally, if it’s a very simple black tattoo, we can make that disappear by about 90 percent quite easily,” he said. “But if it’s a more complicated tattoo, with black colors that are more difficult to treat, such as those made of iron oxide, or more challenging pigments such as red, yellow, and orange, we can’t say they will totally go away.”

Patients are advised that it will likely require five to 11 treatments to achieve optimal lightening, which can range from 50 to 90 percent, Dr. Izikson said. Costs per session can range from a few hundred dollars for a small tattoo to one or two thousand dollars for larger tattoos that require several different types of lasers and longer treatment times. “For the larger tattoos, the sky’s the limit; it takes a very long time,” he said.

Although tattoo lightening is reputed to be extremely painful, Dr. Izikson said discomfort can be managed by cooling, topical numbing creams, and lidocaine injections. Side effects include blistering and scabbing, which generally resolves within two to two-and-a-half weeks, he noted. “We do advise patients that they need to take meticulous care to make sure the treated area doesn’t become infected and to protect the area from the sun before and after treatment,” he said.

On the whole, if patients are prepared for less-than-perfect skin following treatment, they’re “quite pleased” with the result, Dr. Izikson noted. “If you enter the treatment cycle with realistic expectations, and you don’t promise something you can’t deliver, then most patients are quite satisfied with the lightening. They’re happy that they can’t see what they’re used to seeing.”

Advising patients with tattoos

As the number of patients with tattoos rises, dermatologists may want to offer those patients information about the special care tattooed skin requires. The American Academy of Dermatology has created information for these patients in the public section of its website. Patients who visit can learn all about how they can protect their tattooed skin and when they should turn to a dermatologist for treatment.



Tattoos in the dermatology office
Managing patient expectations
Advising patients with tattoos