Considerations include possible future removal

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

A tattoo is art that some people use to assert their personal style, but it's also a bit of a medical procedure. The tattoo artist inserts ink beneath the skin using a needle.

Today I'll talk with a doctor who specializes in skin care about what's important to consider about tattoos. Dr. Ramsay Farah is chief of dermatology at Upstate.

Welcome back to "The Informed Patient," Dr. Farah.

Ramsay Farah, MD: Thank you. It's nice to be here.

Host Amber Smith: For the person who's thinking about getting a tattoo, let's talk about some of the things they need to decide beforehand. Are there areas of the skin on the body that ought to be avoided, either for medical or practical reasons?

Ramsay Farah, MD: I wouldn't say that physiologically there's a particular area of skin that needs to be avoided. I think all areas of skin can probably take receiving the tattoo ink. it's just that in terms of removal, if that ever becomes an issue in the future, there are certain areas that are more tricky to remove, or, I should say, certain areas that are less responsive to removal of tattoos.

And basically, the farther away you go from the heart and the less drainage there is of blood supply and lymphatic supply, the harder it is to get the tattoo to go away, even with laser therapy.

So, in particular, I would say around the feet or the ankles. I should say I've never really removed tattoos from the palms and soles, but I imagine, as I'm discussing with respect to the ankles, it would be difficult to remove it from that area, but apart from the removal issue, and apart from the issue of how much on display the person wants the tattoo to be, you can pretty much get a tattoo anywhere on the skin that you wish.

Host Amber Smith: Are there pros and cons of getting a tattoo in a fleshy area versus a spot where the skin is thinner?

Ramsay Farah, MD: Again, I'm not a tattoo artist, so I can't comment on the pros and cons of inserting the tattoo pigment in those areas.

Off the top of my head, I would say it doesn't really matter much. What I will say is if there is an area that's kind of more over bone than over a fatty area, I think it would probably hurt more to get the tattoo in those areas, just like it would hurt more to remove the tattoos in those areas. But I don't think there is, other than that, a pro or a con between fleshy or non-fleshy areas.

Host Amber Smith: I definitely want to talk to you more about tattoo removal, but before we get to that, in terms of getting a tattoo, people have to choose between black ink or colored ink. Does that make a difference in how hard it might be to remove later on?

Ramsay Farah, MD: It does. So the red ink is very hard to remove.

Paradoxically, the black ink, even though it's the darkest ink, is actually the easiest to remove. So I would say red ink is among the most difficult, and then, other shades of color become also more difficult to remove than black. So for example, blue and yellow and so forth. Those are harder to remove than the black, but probably easier to remove than the red.

The other issue with the red is that the chemicals that make up the red color tend to make for more allergies for people. So sometimes, if you get a lot of red ink and you're allergic to it, you can wind up getting an allergy in the areas of the red ink, even without removing the tattoo. So just generally speaking, allergic reactions, whether it's the red ink or other inks, is something to consider.

Host Amber Smith: Now, will the shape or the size of the tattoo change as a person's body changes over time?

Ramsay Farah, MD: I would say yes. And to the degree that there are changes in the skin surface area, either by weight gain or weight loss, or even sun damage and loss of elasticity, all of those will, of course, affect the way that the tattoo looks like.

So, I mean, if you imagine that the skin is like a parchment, and when you get the tattoo, the skin is young and the parchment is nice and tight and clean and all of that stuff, the tattoo is going to look far different than if the parchment has been aged for 30 years per se.

And so the outlines of the tattoo may become less distinct. The vibrancy of the colors may become less distinct. If you wind up getting sun damage and pigmentation from the sun and all of those changes associated with sun exposure, that overlay on top of the tattoo, again, that can change the way the tattoo looks. I would say that it's mostly about the vibrancy, and it's mostly about the sort of the division between tattooed skin and non-tattooed skin, the sharpness of the lines and of the artistic work. That potentially can change quite a bit over the years.

Host Amber Smith: Is it safe for people with rosacea or acne or eczema to get tattoos?

Ramsay Farah, MD: They can. I mean, if you're talking about them getting a tattoo on the face, I think their face would almost certainly be more reactive, but people with rosacea, I don't think it's going to matter much if they get a tattoo on their arms.

So if we're talking about the face, then yes, I think there would be quite a bit more reaction and potentially more problems in that area, but not if it's at distant sites from the activity of the rosacea.

Host Amber Smith: You talked a little about the allergic reaction possibility. Are there other risks associated with tattoos, and how often do you hear about people that have bad outcomes?

Ramsay Farah, MD: So I would say that the worst outcome, so to speak, it tends to be related to people not liking the tattoo once it's on their skin, for various reasons. Maybe it wasn't quite what they expected, or they didn't review in detail with the artist exactly what was going to be part of the artistic tattoo, the endeavor.

And so they're kind of surprised because they say, "Oh, that's not really what I had in mind." That's far more common, I would say, in all honesty, than some of the physiologic problems I see. I would say that I see allergies, I wouldn't say commonly, but I see them, and that manifests kind of as bumps within the area of the tattoo.

You know, whenever you do anything on the skin that's somewhat invasive, and I would say the application of tattoo ink through a needle would constitute an invasive procedure, there's always the risk of hypertrophic scarring, or forming a scar, as a result of that trauma. I wouldn't say that I see that often, but potentially that can occur.

And then, of course, you have to consider that you're inserting something into the skin. So you want to make sure that the place where you're getting this procedure follows sterile or near-sterile technique, that there's no contamination of the instruments, there's as little chance of possible of getting a bloodborne disease like hepatitis through cross-contamination of equipment and things like that.

So I would say there's the allergy issue, there's the scar issue, and there's the infectious disease issue as the things to consider physiologically. And then just make sure you review with the tattoo artist exactly what's going on your skin and where, so you're not taken by surprise when it happens.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking to the chief of dermatology at Upstate, Dr. Ramsay Farah, about caring for tattoos.

Tattoo artists send people home with a dressing covering a new tattoo. What's the purpose of covering that?

Ramsay Farah, MD:

It's probably because they would consider the area that is just recently tattooed to sort of be a fresh wound, right? Because the skin has been compromised through the needle to get the tattoo ink. There's a lot of physiology going on with wound healing and inflammation and so forth. And when the skin is kind of in that fragile healing state, you need to consider it a wound and treat it like a wound, which for the skin would mean covering it up, keeping it moist, et cetera, until that inflammatory phase of the healing is over, and the skin is less fragile, and then therefore can be exposed to the environment, without any risk of infection or harm.

Host Amber Smith: So the skin may be sort of reddish or feel warm or itchy afterward, and that might be normal?

Ramsay Farah, MD: Yeah, sure. It could be, again, from the trauma of the needle insertion and then all of the inflammation that ensues afterwards. It can cause it to be a little tender, a little bit red, possibly a little bit warm. Sure, all of that's possible.

Host Amber Smith: Are there any ointments to use or anything to avoid with a new tattoo?

Ramsay Farah, MD: I would probably use very bland ointments, things that have very little chance of making people allergic. So Vaseline or Aquaphor, these are kind of moisturizing ointments. I would probably stay away from things like oils, and especially like nut-based oils or even aloe vera, because all of those materials, while they can in certain settings be soothing, that's true, but many people can also be allergic and sensitive to them. So I would use something that's less likely to cause that, just plain old Vaseline, Aquaphor, something very bland, but something that can moisturize.

Host Amber Smith: Now, once a tattoo is no longer new, what kinds of care do people need to follow, going forward?

Is there anything they can do to keep their tattoo from fading or drying out?

Ramsay Farah, MD: I would say, and this is not necessarily from a specific source that I'm getting, I'm just kind of speaking off the top of my head, the more you take care of your skin in that area, and the more you keep your skin physiologically normal, so using sunscreens, using moisturizers, not letting your skin get too dry, those kinds of general measures that you would follow for general skin health, I think would probably contribute to keeping your tattoo as vibrant as possible for as long as possible.

I must say, people, when they come to me for their tattoos, they kind of want them off, so I'm usually not engaged in a discussion about how you can lengthen the longevity of your tattoo.

On the contrary, they come to me and say, "I want this off. What can I do?" So that's more my area of expertise. But I think it's, probably correct to say that the more you keep your skin healthy, with all of what that entails, the more likely that your tattoo is going to remain kind of as young looking as possible.

Host Amber Smith: So what's involved? If someone regrets their tattoo, and they want it removed, how can that be done?

Ramsay Farah, MD: One could probably find various methods that have been described on the internet, but I would kind of stay away from all of them. I think the laser tattoo removal is probably the safest method and the method that has the most scientific study behind it.

I've seen lots of scarring and some pretty bad aftereffects of some very bizarre kind of home remedies that have been recommended. So I would definitely stick with the laser tattoo removal as the preferred method of treatment. And what I would say to people is, you should find a physician who does this, who's familiar with lasers and has done laser tattoo removal and get a consult, because, probably the reality, process, of getting your tattoo taken off is different than what people think. They may think, "Oh, I'll just go in a couple of times, get the tattoos zapped, and it'll be gone, and my skin will be completely normal after that."

And unfortunately, that's not the case.

I mean, there's a lot to consider, and it's a pretty long process, to be honest. It's not one or two treatments.

Host Amber Smith: Does it matter if it's a recent tattoo or if it's a tattoo from decades ago? Are they equally challenging to remove?

Ramsay Farah, MD: So that's a good question, and I'm not sure we have a great answer for that.

The thinking used to be that if the tattoo is very old, that means over the years the body has tried to kind of degrade the tattoo and sort of break up the tattoo, and therefore the tattoo would be easier to remove with lasers. More recently, there's been a suggestion that actually if it's a very fresh tattoo, and the ink hasn't sort of gotten a chance to settle in as much into the skin, that that might be easier.

So I don't know exactly what the right answer is. I guess what I would say from my experience that they're equally challenging. they will both take a large number of treatments, over many, many months. So I don't know what the answer is, but I think they're both hard on a practical level

Host Amber Smith: In general, does it cost more to remove a tattoo than it probably did to get it in the first place?

Ramsay Farah, MD: I would say, as a general rule, yes. To be honest with you, I don't know what the going rates are for getting a tattoo. And the going rates for removal of a tattoo can also vary from practice to practice, the type of laser that is offered in the practice. So, I can't give you a definite answer. I can just kind of give you a general gestalt (overview).

I think it's going to cost more to remove the tattoo than to get it, if, for nothing else, the number of treatments that are required to remove the tattoo, whereas getting a tattoo is basically one and done.

Host Amber Smith: So once it's removed, and I understand it may be more than one visit to get it removed, will there be any sort of, like, a ghostly image of it left on the body, or will it be invisible?

Ramsay Farah, MD: That depends a lot on the tattoo, the colors, the location, and to a certain extent, the technique used. And so the answer is there are really, I would say, three possibilities of what can happen when you start the process of tattoo removal.

The first possibility is that the best you can do is just fade the tattoo, such that people will look at it, it will look very faded, but they can still make out that a tattoo was there. I don't think that happens very often to be honest with you, but it is possible. So that's one possibility.

The other possibility is that the tattoo can be almost completely gone, but some tattoo pigment remains in the skin, maybe it's even sort of caught in a little microscopic scar that could develop as the process continues. And so, what that means is that the tattoo, the area of the tattoo, might look, like, a little smudgy or even a little dirty. People might look at that area and say, "Hmm, what is that? Is that like a birthmark? I can't tell what that is, but there's something on the skin." So that's another possibility.

And then the third possibility is that the tattoo is completely removed and the skin looks completely normal, and that's obviously the home run, and that's what we aim to get.

And then there is a fourth possibility. The fourth possibility is that the tattoo is completely removed, but in the process of removing it and all of that physiology that takes effect after the tattoo is zapped with the laser and the healing and the number of treatments that are done, you can leave microscopic scarring in the skin, which you can't see with the naked eye, other than it looks a little white. And that is called ghosting. So basically you remove the tattoo, but you leave a whitish outline of the tattoo, and that is also a possibility.

Now, that tends to be more common in darker-skinned individuals, so someone like from a Mediterranean or Southern European background, it's more likely to occur in that setting than someone who's of Northern European descent and has very, very white skin. Now, if that happens, that ghosting happens, there are some lasers you can use to try and blend that in somewhat, although it may not be perfect.

So you can have a fading, you can have a smudging, you can have a ghosting, or you can have it gone completely with no residual whatsoever.

Host Amber Smith: Well, if it goes as planned, and the skin returns to normal, does the hair grow back? Does it return to like what it used to be before the tattoo?

Ramsay Farah, MD: Yes. I mean, if all goes well, then it would go back to what it was before the tattoo. The hair should grow back again because the depths of the penetration and so forth of the laser may not quite be where the hair follicle is to get rid of the hair. There's always a little bit of a chance of that, by the way. But generally, alopecia, or hair loss, is not much of an issue, and most people don't necessarily have tattoos in hair-bearing areas, unless women choose to tattoo their eyebrows. But even in that setting, even though the hair growth may be slowed, the hair generally does come back. So it's not really a hair-removal procedure.

Host Amber Smith: Well, if you remove a tattoo from someone's body, and then they decide they want to get a new one, would they be recommended to get it in the same place, or would you tell them to avoid that area?

Ramsay Farah, MD: Generally, I tell them to avoid the area. So even though visually it looks like it's perfectly normal, right, if all goes well in that fourth scenario, I think if you biopsy the skin and look at it under the microscope, you're going to see some changes in the structure of the skin. There's just too much energy kind of zapped into the skin and too much inflammation over and over and over again to remove a tattoo, in my opinion, to make the skin there completely normal.

So, as a general rule, I would tell them to maybe avoid that area.

But I do sometimes have people come and say, "You know, remove this part of the tattoo. Don't remove the whole thing, just this part that I don't like. And then I'm going to have another tattoo kind of done over it." So they come and ask me to remove it as much as possible, so then they can camouflage the area they didn't like with yet another tattoo.

And people do that, and I haven't heard from them that. something terrible has happened with that strategy, but it's just that the more you traumatize the skin, the less the skin is likely to remain completely normal.

Host Amber Smith: I guess some people put a tattoo to kind of camouflage a mole. Does the mole change colors; does it accept the ink? Or does it stay as a mole?

It kind of depends what the tattoo artist does. If they ink around the mole, then the mole won't necessarily change color.

If they put ink over the mole and deposit the ink even above some of the mole cells, then potentially it could change color, and could kind of look weird and be sort of a diagnostic challenge for the physician looking at it. What is that? That's an unusual morphology (form), an unusual color. So it makes ambiguity enter into an arena that is already ambiguous enough.

I mean, mole checks are hard enough on their own, without having to add these other factors to complicate it.

Well, as tattoos seem to be getting more popular with people and some people have many, many tattoos covering a lot of their body, if they had a tattoo over a mole or other skin blemishes, how would you be able to, or would you be able to, do a skin cancer screening if they're covered?

Ramsay Farah, MD: Yeah, so that's a very good question. And actually there have been some studies that have shown that moles in the area of tattoos can be sufficiently camouflaged that sometimes if they turn malignant, it's more difficult to recognize them.

So that is true, and what I do when someone comes in for a skin exam and they've got a tattoo, a large one, I turn my light on, I turn my magnifiers on, and I look very, very carefully within the tattoo to see if I can identify a mole. And then if I can, I use my dermatoscope, which is a device that can make me see even more.

So I'm very careful when examining skin that has been tattooed, for that reason. Now, the other question I think that you asked is: Can you remove a tattoo if there's a mole there? And the answer is yes, but do we know exactly what all of that energy does to the mole that's there?

I mean, I don't know that anyone knows for sure. I haven't really seen any studies that would suggest that the lasers will make a mole turn into cancer. and I don't think that that's probably true. The question is whether there was a mole there that would have turned to cancer anyway happens to be in an area of a tattoo. That's a more difficult question and a more difficult mole to identify.

The other thing I'll comment is, if people come in with a -- I'll call it like a bathing trunk tattoo, something really large, like over their chest or their entire arm, I wouldn't be able to remove that in one sitting because, again, there's a lot of biology that's activated with these treatments. There's a lot of inflammation, and people can actually wind up feeling sick if I do way too much of a surface area.

So for someone with a very large tattoo, I kind of do it piecemeal. I do a certain section at one sitting and another section at another sitting. But I wouldn't do the whole thing because they can actually get systemic effects of feeling joint pains and muscle aches, and almost like they have a flu or a virus.

Host Amber Smith: That's very interesting to know. Dr. Farah, I thank you so much for making time for this interview.

Ramsay Farah, MD: My pleasure. Thanks for asking me to speak.

Host Amber Smith: My guest has been Dr. Ramsay Farah. He's the chief of dermatology at Upstate.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

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