Abstract
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.
Methods
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.
Results
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%.
Conclusion
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.
Keywords: Tattoo, Tattoo removal, Laser, Chemical removal, Allergy, Untrained practitioners, Pico-laser
Introduction
Tattoos are becoming more popular in modern society. Around 25% of tattooed persons have regrets at some point, resulting in a likely growing demand for tattoo removal [1]. The gold standard for tattoo removal is Q-switched lasers (nano- or picosecond), making use of selective photothermolysis [2, 3]. This allows selective targeting of the tattoo particles without destroying neighbouring tissues. Tattoo removal-induced complications account for up to 6% of all tattoo-related complications and are therefore important to investigate [4]. These include temporary blistering, haematoma, and oedema; however, more serious complications can also occur, such as dyspigmentation, scarring, infections, paradoxical darkening, and type I and IV allergies [5, 6]. It is essential that clients are informed about these complications and their incidence, enabling them to make well-considered decisions before beginning the tattoo removal process. Several tattoo-specific risk factors and patient characteristics may influence the effectiveness of tattoo removal and its risk of complications, such as Fitzpatrick skin type, tattoo setting (amateur/professional), tattoo ink colour, tattoo location, ink density/layering, initial scarring, and age of the tattoo [7–10].
To minimize the risk of complications and enhance the chance of removal, it is necessary to have a comprehensive understanding of laser and tissue interaction [5, 11, 12]. In the Netherlands, tattoo removal is most frequently performed by trained dermal therapists: registered healthcare professional specialized in evidence-based medical and cosmetic skin treatments. They are hereafter called practitioners. However, in some European countries, including the Netherlands, there is no official, accredited specific education for laser tattoo removal. The lack of specific accredited education and the high demand for tattoo removal have led to untrained practitioners, such as tattooists or cosmetologists, often performing treatments in beauty salons, tattoo shops, or at home-based offices [13–16]. Safety concerns are rising since it is unknown at what rate these untrained practitioners are treating tattoos and whether they cause more complications.
There are also non-laser options for tattoo removal, including dermabrasion, salabrasion, cryosurgery, electrosurgery, and surgical excision and chemical removal [17, 18]. The latter includes caustic creams or ointments and injectables containing different kinds of acids such as phenol, trichloroacetic, silver nitrate, salicylic, or lactic [19]. Their main purpose is to induce inflammation, causing ulceration. In the recovery process, tattoo pigments are disposed of along with the crusts when they fall off [18]. They may result in unwanted cosmetic outcomes, extensive scarring, chronic itching or pain, and hypo- or hyperpigmentation or infections [4, 19–22]. Moreover, the effectiveness and safety of these products have not been investigated. Remarkably, these products and treatments are widely available in the Netherlands, with numerous websites and clinics offering them [16]. They can be manufactured, sold, and applied by anyone, with limited restrictions.
Objective
The aim of this study was to report on practitioner-reported complications in laser tattoo removal, with a focus on the frequency and potential risk factors. Secondary objectives included identifying the observed use of alternative removal techniques, as well as tattoo removal by untrained practitioners and its reported complications.
Methods
This cross-sectional survey-based study was performed in accordance with the ethical standards of the institutional research committee. The study was carried out by the Tattoo Clinic of the Alrijne Hospital, the Erasmus Medical Center, the Hague University of Applied Sciences, and HU University of Applied Sciences Utrecht. A digital survey containing a maximum of 41 questions was distributed via social media (LinkedIn, Instagram) and email to Dutch dermal therapists, hereafter called practitioners. Inclusion criteria contained active practitioners who work in the Netherlands and have a mastery of the Dutch language. Practitioners who were still in training or who did not practice tattoo removal in the past 3 years were excluded. Only practitioners who fully completed the survey were included. The survey was completed using Castor EDC v2023.4.0.1. All practitioners gave informed consent.
The survey was pilot tested on several practitioners before distributing. It included questions on work experience and activities, types of clients and tattoo characteristics treated, treatment protocols, used lasers, and observed complications related to laser tattoo removal. Practitioners were asked to report complications related to laser tattoo removal treatments they had personally performed.
Each complication was assessed separately and reported independently if multiple occurred, and the order of occurrence was not recorded. Practitioners provided retrospective, self-reported estimates of complication frequencies based on recall of their own treatments. A primary 3-month reference period was used, with additional response options indicating lower frequencies (once per 6 months, once per year, or once in the past 3 years) for less frequently observed complications.
The survey also included questions on experience with clients previously treated by untrained practitioners and on the use of alternative tattoo removal techniques. These questions asked whether practitioners had encountered such cases, how often this occurred, and which types of complications were observed.
Three practitioner groups were distinguished: (1) trained practitioners (dermal therapists) who actively perform laser tattoo removal; (2) trained practitioners (dermal therapists) who perform other forms of laser or dermal therapy (e.g., acne, vascular laser therapy, or oedema therapy) but do not perform tattoo removal; and (3) untrained practitioners who perform laser tattoo removal without training. Only trained practitioners completed the survey. Information on untrained practitioners was reported indirectly, based on clinical encounters with clients previously treated by such practitioners. Untrained practitioners are defined according to the study of Brody et al. [13] as providers of cosmetic dermatologic treatments, most frequently outside the medical setting, who typically do not have the necessary medical training and qualifications to perform the procedure or address adequately complications when they arise.
Questions regarding alternative tattoo removal techniques were answered by all participating practitioners (N = 173). Questions regarding complications following treatment by untrained practitioners were answered only by practitioners who actively performed laser tattoo removal (N = 94). These data were collected descriptively.
The following potential risk factors were analysed for their association with reported complications following laser tattoo removal: Fitzpatrick skin type (I–II vs. ≥III), presence of coloured tattoo ink (black only vs. non-black colours, including coloured tattoos and PMU), previous laser treatment (yes/no), tattoo age (<1 year vs. ≥1 year), practitioner work experience (categorized by interquartile range), and treatment interval between laser sessions. Patient and tattoo characteristics were collected at the practitioner level.
Risk factors were analysed at the practitioner level. Each practitioner’s overall patient population and treatment characteristics were applied to all complications they reported. These associations therefore describe differences between practitioners’ clinical practices, rather than risks at the individual patient level.
For dichotomous variables, Mann-Whitney U tests were used. For non-dichotomous variables, the Kruskal-Wallis test was applied. Complications with very low frequencies (keloid, infection, haematoma, and ink blow-out) were not included in risk factor analyses due to insufficient non-zero observations. Statistical analysis was performed using SPSS version 28.0.1.0. p values <0.05 were considered statistically significant.
Results
A total of 173 practitioners completed the survey, of whom 94 (54.3%) actively performed laser tattoo removal. Overall, practitioners had a median work experience of 8 years (IQR 2–12) and worked a median of 32 h per week (IQR 27–39). Lasering practitioners had a median of 6 years of work experience (IQR 2–10), worked a median of 32 h per week (IQR 30–40), and performed a median of 17 laser tattoo removal treatments per month (IQR 5–44). Practitioners were employed across a range of work settings, most commonly small practices, national chains, practices with multiple establishments, and multidisciplinary clinics; some practitioners worked in more than one setting.
Based on practitioner-reported data, complications were reported in an estimated 8.1% of laser sessions. This estimate was calculated by dividing the total number of reported complications per month by the total number of laser tattoo removal treatments performed per month by participating practitioners. The mean estimated number of complications per practitioner per month was 2.62 (SD 5.44), with a median of 0.64 (IQR 0.17–3.47), indicating substantial variability between practitioners.
Among the estimated total number of practitioner-reported complications following laser tattoo removal by trained practitioners, oedema accounted for 3.0% of treatment sessions, blistering for 1.9%, haematoma for 0.7%, hypopigmentation for 0.6%, hyperpigmentation for 0.5%, hypertrophic scarring for 0.2%, and paradoxical darkening for 0.2%. Keloid formation, allergic reactions, ink blow-out, and infection were each reported in approximately 0.1% of treatment sessions (Table 1).
Table 1.
Practitioner-level associations between risk factors and estimated complication probability per treatment, expressed per 10,000 laser tattoo removal treatments (N = 94)
| Complication | Reported by practitioners, N (%) | Probability/treatment (%) | Risk factor (groups) | Group A median [IQR] | Group B median [IQR] | p value |
|---|---|---|---|---|---|---|
| Blistering | 63 (67.0) | 1.9 | Skin type (I–II vs. ≥III) | 0.09 [0.00–0.37] | 0.55 [0.00–3.30] | 0.045 |
| PMU (no vs. yes) | 0.00 [0.00–0.82] | 0.37 [0.00–2.75] | 0.012 | |||
| Tattoo color (black vs. non-black) | 0.00 [0.00–0.02] | 0.55 [0.02–3.02] | <0.001 | |||
| Tattoo age (<1 year vs. ≥1 year) | 0.00 [0.00–0.27] | 0.55 [0.00–3.23] | <0.001 | |||
| Oedema | 43 (45.7) | 3.0 | Skin type (I–II vs. ≥III) | 0.00 [0.00–0.00] | 0.09 [0.00–2.20] | 0.026 |
| Hypopigmentation | 49 (52.1) | 0.6 | Skin type (I–II vs. ≥III) | 0.00 [0.00–0.00] | 0.27 [0.00–0.55] | <0.001 |
| PMU (no vs. yes) | 0.00 [0.00–0.00] | 0.09 [0.00–0.55] | 0.012 | |||
| Tattoo color (black vs. non-black) | 0.00 [0.00–0.00] | 0.18 [0.00–0.55] | 0.005 | |||
| Previously treated (no vs. yes) | 0.00 [0.00–0.00] | 0.09 [0.00–0.55] | 0.015 | |||
| Tattoo age (<1 year vs. ≥1 year) | 0.00 [0.00–0.00] | 0.09 [0.00–0.55] | 0.007 | |||
| Hyperpigmentation | 30 (31.9) | 0.5 | PMU (no vs. yes) | 0.00 [0.00–0.00] | 0.00 [0.00–0.55] | 0.010 |
| Tattoo color (black vs. non-black) | 0.00 [0.00–0.00] | 0.00 [0.00–0.55] | 0.027 | |||
| Tattoo age (<1 year vs. ≥1 year) | 0.00 [0.00–0.00] | 0.00 [0.00–0.55] | 0.040 | |||
| Hypertrophic scarring | 28 (29.8) | 0.2 | Tattoo age (<1 year vs. ≥1 year) | 0.00 [0.00–0.00] | 0.00 [0.00–0.27] | 0.023 |
| Allergic reaction | 20 (21.3) | 0.1 | PMU (no vs. yes) | 0.00 [0.00–0.00] | 0.37 [0.00–0.05] | 0.047 |
| Paradoxical darkening | 20 (21.3) | 0.2 | Skin type (I–II vs. ≥III) | 0.00 [0.00–0.00] | 0.00 [0.00–0.09] | 0.030 |
| PMU (no vs. yes) | 0.00 [0.00–0.00] | 0.00 [0.00–0.05] | 0.047 | |||
| Tattoo color (black vs. non-black) | 0.00 [0.00–0.00] | 0.00 [0.00–0.07] | 0.038 | |||
| Tattoo age (<1 year vs. ≥1 year) | 0.00 [0.00–0.00] | 0.00 [0.00–0.09] | 0.024 | |||
| Haematoma | 16 (17.0) | 0.7 | X | X | X | X |
| Ink blow-out | 15 (16.0) | 0.1 | X | X | X | X |
| Infection | 12 (12.8) | 0.1 | X | X | X | X |
| Keloid | 3 (3.2) | <0.1 | X | X | X | X |
Values are presented as median [IQR] estimated complication probability per treatment, expressed per 10,000 laser tattoo removal treatments for readability. Percentages indicate the proportion of practitioners who reported having observed the complication at least once. p values were derived from Mann-Whitney U tests comparing practitioner-level aggregated estimates between groups. Associations reflect practitioner-level practice patterns rather than patient-level risk estimates. Risk factor analyses were not performed for rare complications due to insufficient non-zero observations. Non-black tattoos included coloured tattoos and permanent make-up (PMU).
Practitioner-level associations between patient, tattoo, and treatment characteristics and reported complication probabilities are summarized in Table 1. Complications were more frequently reported by practitioners treating clients with higher Fitzpatrick skin types, coloured tattoos, permanent make-up, previously treated tattoos, and tattoos younger than 1 year. No significant associations were observed for practitioner work experience or treatment interval between laser sessions.
Among practitioners performing laser tattoo removal, 87.2% reported encountering clients who had previously been treated by untrained practitioners. Of these, 81.7% reported observing complications. Thirty-one percent of all practitioners reported clients who had attempted tattoo removal using alternative techniques, with 56.7% reporting complications. These findings are presented descriptively in Table 2.
Table 2.
Practitioner-reported encounters with complications following tattoo removal by untrained providers or alternative methods (descriptive data only; not incidence rates)
| Complication | Alternative methods – ever observed among all practitioners, n (% of 173) | Untrained practitioners – ever observed among lasering practitioners, n (% of 94) |
|---|---|---|
| Practitioners reporting any complication | 53 (30.6) | 82 (87.2) |
| Complications | 30 (56.6) | 67 (81.7) |
| Incomplete removal | 23 (43.4) | 64 (78.0) |
| Hypopigmentation | 21 (39.6) | 59 (72.0) |
| Hypertrophic scarring | 18 (34.0) | 57 (69.5) |
| (Burn) wounds | 17 (32.1) | – |
| Atrophic scarring | 15 (28.3) | – |
| Blistering | – | 46 (56.1) |
| Hyperpigmentation | 10 (18.9) | 34 (41.5) |
| Erythema | 10 (18.9) | – |
| Paradoxical darkening | – | 21 (25.6) |
| Oedema | – | 16 (19.5) |
| Infection | 5 (9.4) | 16 (19.5) |
| Blow-out ink | – | 14 (17.1) |
| Keloid | 4 (7.5) | 8 (9.8) |
| Allergic reaction | – | 8 (9.8) |
| Haematoma | – | 5 (6.1) |
| Completely bleeding tattoo | – | 1 (1.2) |
Percentages for individual complications are calculated among practitioners who reported ever encountering complications related to alternative methods (N = 53) or untrained practitioners (N = 82), respectively. Survey questions regarding alternative methods were answered by all practitioners (N = 173), whereas questions regarding untrained practitioners were answered only by lasering practitioners (N = 94). Data are descriptive and do not represent incidence per treatment or per patient. N, number of clients; IQR, interquartile range.
Discussion
Although complications of laser tattoo removal have been reported in previous patient-based observational studies, this is the first study to focus on practitioner-reported complications. Practitioner-based data provide an important contribution to understanding complication patterns in routine clinical care. It provides valuable, real-world insight directly from experienced professionals, offering a comprehensive and practical understanding of complications that may otherwise be underreported or overlooked in patient-based studies.
Zhang et al. [6] performed a retrospective analysis like the present study, although patient-based. They reported a higher overall incidence of complications (24.1% versus 8.1%) but similar incidences of blistering (1.5% versus 1.9% in this study), hypertrophic scarring (0.3% versus 0.2% in this study), and allergic reactions (0.4% versus 0.1% in this study). Rates of hyperpigmentation and hypopigmentation were lower in the present study compared to most other patient-based studies. These lower rates may reflect incomplete patient follow-up, recall bias, or differences in reporting thresholds. However, patient-based studies also show considerable variability in the incidence rates of complications, such as hypo- and hyperpigmentation (2–50%), blistering (0–50%), or scarring (0–12%), depending on laser type and patient and tattoo characteristics [5, 23, 24]. In the present study, no distinction was made between the types of lasers used, as the wide variety of lasers precluded identifying significant differences.
Complications were more frequently reported by practitioners treating higher-risk tattoos, which may partly explain why some practitioners reported more complications than others. Blistering and hypopigmentation were associated with multiple risk factors. Although longer wavelengths are typically selected for higher Fitzpatrick skin types to reduce epidermal injury, practitioners in this study reported blistering more frequently in skin types ≥III [5]. This apparent discrepancy may be explained by the higher number of treatment sessions typically required in darker skin types and in coloured or newer tattoos, resulting in increased cumulative tissue exposure [25].
Paradoxical darkening, a phenomenon where instead of fading, certain tattoo pigments darken immediately after treatment, was also reported [26]. This effect is most common in ink containing titanium dioxide and iron oxides, such as white, beige, and flesh-toned inks. Correspondingly, in this study paradoxical darkening was reported significantly more often in practitioners treating clients with Fitzpatrick skin types >II, coloured tattoos and in PMU, where such inks are commonly used.
Allergic reactions following laser treatment were also reported in this study. These reactions can manifest as either delayed type IV hypersensitivity or, in rare cases, type I hypersensitivity [27, 28]. In this study, allergic reactions were significantly more reported in PMU, which can likely be attributed to the frequent use of red pigments in tattoo inks for red full lip or brown eyebrow tattooing [29]. While type IV allergic reactions to tattoo ink are well documented, particularly those involving red ink, reports of type I allergic reactions occurring after tattoo removal remain scarce [4, 30, 31]. The exact mechanism behind these allergic reactions is not fully uncovered. In type IV allergies, the culprit allergen is suggested to be a breakdown product of the original tattoo azo pigments [32]. In type I allergies, it is suggested that the fragmentation of pigment-containing cells after laser treatment leads to an extracellular breakdown product, potentially triggering an immunological response [28, 30, 31].
Previous studies have reported laser-related complications caused by untrained practitioners in the cosmetic industry, predominantly in hair removal but also in cases of laser tattoo removal [13–16, 33–35]. In 2001, the American Association for Dermatologic Surgery (ASDS) conducted a survey investigating physician-reported complications arising from the performance of cosmetic dermatological surgeries by nonphysicians, who are in the current study called untrained practitioners [13]. These nonphysicians included cosmetologists, aestheticians, and salon owners, with treatments often carried out in spas or home-based offices. Reported complications included infections, dyspigmentation, and extensive scarring (shown in Fig. 1). The present study similarly highlights that the majority (87.2%) of practitioners treated clients who had previously been treated by untrained practitioners, leading to a range of complications. Our findings suggest that the implementation of mandatory training or certification requirements for laser tattoo removal practitioners could contribute to improved patient safety.
Fig. 1.
Hypertrophic scar due to (failed) laser treatment of a tattoo on the left shoulder with remaining tattoo pigment after treatment by an untrained practitioner (aesthetician).
Furthermore, the current study emphasizes the common use of alternative removal techniques. Similarly to the study of Hutton Carlson et al. [19], in the current study, various and severe observed complications were reported by the vast majority of the lasering practitioners (56.7%). These methods are not evidence based, not regulated or FDA approved, and should therefore be strongly discouraged as a first-line therapy for tattoo removal. Although descriptive in nature, these findings raise important safety concerns and underscore the need for prospective, patient-level research to systematically assess complication rates and inform potential regulatory measures.
This study has limitations. The survey relied on retrospective self-reporting and is subject to recall bias. Due to the open recruitment strategy, the denominator of invited practitioners could not be established, precluding calculation of a true response rate and potentially introducing selection bias. In addition, risk factors were collected at the level of practitioners rather than individual patients, which limits conclusions at the patient level. Despite these limitations, the study provides valuable real-world insight into complication patterns observed in routine clinical practice and offers a unique practitioner-based perspective that complements existing patient-based evidence.
Conclusion
This is the first study to systematically explore practitioner-reported complications in laser tattoo removal. Rather than providing patient-level incidence rates, this study describes practitioner-level patterns of observed complications in clinical practice. Although laser tattoo removal is generally safe, practitioners reported a range of complications. Practitioners treating darker skin types, coloured tattoos, permanent makeup, and younger tattoos reported a higher rate of complications. A substantial proportion of practitioners also encountered complications following treatment by untrained providers or alternative removal methods.
While these findings do not represent patient-level incidence rates, they underscore important safety concerns within current tattoo removal practices in the Netherlands. Improved practitioner education, standardized training, and consideration of regulatory measures may contribute to safer tattoo removal practices. Prospective, patient-level studies are needed to further quantify complication risks and evaluate outcomes of alternative techniques.
Statement of Ethics
This study was performed in accordance with the Declaration of Helsinki. This human study was reviewed and approved by the Institutional Research Committee of the Alrijne Hospital in Leiden – Approval No. ALR/RVB/2024/UIT44291. All patients in this manuscript have given written informed consent for participation in the study and the use of their de-identified, anonymized, aggregated data and their case details (including photographs) for publication.
Conflict of Interest Statement
The authors have no conflict of interest to declare.
Funding Sources
This study was not supported by any sponsor or funder.
Author Contributions
M. Poelhekken, S.A.S. van der Bent, D. Quant, E.P.M. Tjin, and P.J. Velthuis all contributed substantially to conception and design, or acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; and final approval of the version to be published.
Funding Statement
This study was not supported by any sponsor or funder.
Data Availability Statement
All data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author.
