By John Evans, Assistant Editor, The Chronicle
In a recent news article published online in the Canadian Medical Association Journal (Apr. 13, 2015), Canadian Dermatology Association president Dr. David Zloty said that the CDA would prefer if all directed-energy dermatology devices, including tattoo-removal laser systems, were operated exclusively by physicians or physician-designated staff. However, there are arguments both for and against making laser tattoo removal a restricted medical procedure, according to two Canadian dermatologists who spoke with THE CHRONICLE OF SKIN & ALLERGY.
Strongly agreeing with Dr. Zloty that laser tattoo removal should be a restricted procedure, dermatologist Dr. Lisa Kellett of Toronto says that formal medical training is needed to adequately assess and screen candidates before laser tattoo removal.
“There are people who would not be good candidates for the procedure,” says Dr. Kellett. “If you have had an allergic reaction to the ink, there is a chance that by lasering the ink you can actually have an anaphylactic reaction, which is potentially life-threatening.”
As well, she says, if a patient has a cancerous or pre-cancerous lesion in the tattooed area that has not been identified, the tattoo-removal procedure can obscure it. This could make it more challenging for a dermatologist to diagnose the lesion when the patient does present with it or, perhaps more worryingly, to assume the lesion is ‘treated’ and not seek out a dermatologist until it has progressed into a serious, potentially life-threatening melanoma, she says.
She also noted that some non-physician laser operators do not restrict themselves to tattoo removal. She has seen non-medical operators in Toronto advertise that they treat moles and other pigmentation issues. Even if the operator restricts their laser use to removing tattoos, “it is still a [medical] procedure, we still end up breaking the surface of the skin,” she says.
Lack of knowledge of how to deal with complications, including scarring and pigment changes, should they occur, is also a concern when non-physicians carry out laser tattoo removal, says Dr. Kellett.
While agreeing that there is some risk involved with laser tattoo removal procedures, Dr. Jaggi Rao, a dermatologist and cosmetic surgeon in Edmonton and a member of the Canadian Standards Association committee on laser safety, says it is unreasonable to restrict tattoo removal to physicians while tattoo application—often a riskier procedure—is not so restricted.
Tattoo-removal lasers “are relatively safe compared to what they used to be,” says Dr. Rao. The original tattoo procedure itself is often more risky, and other directed-energy treatments such as laser hair removal are not restricted in spite of not necessarily being benign. The question arises, when there is a call to restrict one procedure—laser tattoo removal—where is the line drawn and using what criteria, he says. The CSA committee Dr. Rao sits on has drafted a standards document on laser safety, and he says they deliberately omitted a call for medical restriction of laser tattoo removal for this reason, he says.
There are certainly advantages to performing laser tattoo removal in a medical setting, says Dr. Rao, including the availability of a wider array of anesthetic options and potentially a faster response to complications, but those also apply to laser hair removal, photo-rejuvenation, and tattoo application.
“What I would say is there should be some kind of standard so anywhere that a laser is being operated, they maintain that certain safety standard,” says Dr. Rao. “I do agree [laser operators] should have some type of standard of certification if they want to use any type of lasers.” An unbiased, comprehensive third-party course—rather than one offered by a laser manufacturer—along with laser registration and an accreditation process would be ideal, he says.
“If you look at the tattoo industry, it is very well regulated, more so than laser hair removal. They are held to a very high standard that, unfortunately, we don’t see in the laser world. But that’s what we want to see [implemented for laser treatments],” Dr. Rao says.
“That’s why the CSA has come out with guidelines for safe application of laser,” says Dr. Rao. “In those guidelines we do recommend people take a course, and in that course they’ll learn to recognize complications and act on them quickly—either directly or referred to somebody who can do it.”
Alberta Health Care has talked about creating a standardized course to teach the fundamentals of laser therapy, and the Canadian Association of Aesthetic Medicine had developed a course on the fundamentals of laser safety and laser science that they plan to introduce this year which will be open to physicians as well as to physician-delegates, says Dr. Rao. These courses could serve as a template to develop a program for training non-physician operators, he adds.