Reasons for requesting laser removal of unwanted tattoos

S.VARMA AND S.W.LANIGANDepartment of Dermatology, Bridgend General Hospital, Quarella Road, Bridgend, Mid Glamorgan CF31 1JP, U.K.

Accepted for publication 22 October 1998

Summary Laser removal of tattoos is not generally or readily available on the National Health Service andremoval in privately run clinics is expensive. For those seeking removal of their tattoo this can createsignificant financial hardship. We investigated the psychological, social and financial impact oftattoos on the lives of those patients requesting laser removal. Sixty-eight patients with a mean age of36 years participated. Twenty-seven (40%) had one tattoo, whereas eight (12%) possessed 10 ormore; 54% had an amateur tattoo. Only 18% had received an explanation of the procedure or side-effects. The mean age at application of the first tattoo was 16 years; 48 (71%) were tattooed belowthe legal age limit of 18 years. Most tattoos were applied for the sake of fashion. The median durationof regret was 14 years before seeking removal. The main reasons for removal were enhancement ofself-esteem and social, domestic and family reasons. In those patients attending for removal, mosttattoos are applied impulsively and inexpensively in youth. They are often regretted for decades andcreate significant psychological, social and financial burdens.

Keywords: demographic survey, Nd:YAG laser, removal of tattoo, tattoo

In Western society, approximately 3–5% of the populationhas at least one decorative tattoo; the number ofapplications of new tattoos is increasing.1,2 Informationis limited regarding the demography of tattooed indivi-duals, the motivation for application and removal, andthe impact of tattoos on their lives and functionalbehaviour. We undertook a questionnaire survey toinvestigate the characteristics of patients attending atattoo removal clinic to document the psychological,social and financial burden that tattoos had created. Weaimed to identify potential groups considering a tattooand methods of educating them regarding prevention,safety and improving the management of those alreadytattooed.

Subjects and methods

Sixty-eight consecutive patients requesting tattooremoval between November 1995 and December1995 by the Q-switched Nd:YAG laser at a private

clinic were requested to complete an anonymous andconfidential questionnaire prior to their initial consulta-tion. Patients detailed their age, sex, number and loca-tion of tattoos, whether amateur or professional, age atapplication, cost of application, whether under theinfluence of alcohol or drugs at the time of application,whether the procedure or side-effects were explained,reasons for application, motivation for removal, theimmediacy and duration of regret and an estimate ofthe cost of removal.

Results

All 68 patients (44 male) completed 80% or more of thequestionnaire. The mean 6 SD age was 36 6 11 years(range 18–69). Twenty-seven patients (40%) had onetattoo and eight patients (12%) had 10 or more (Fig. 1).Most tattoos were located on the arms (67%) with 14%on the face, 6% on the hands, 6% on the legs and 4% onthe chest; 3% of patients had their entire body surfacearea covered with tattoos. Most patients possessed anamateur tattoo (54%), 38% a professional one and 8%had a combination. Ten patients volunteered that theyalso had self-inflicted tattoos. Of those who reportedbeing tattooed solely by another person, only 18% hadreceived any sort of explanation of the procedure or itsside-effects.

British Journal of Dermatology 1999; 140: 483–485.

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Correspondence: Dr Sandeep Varma, Department of Dermatology,University Hospital of Wales, Cardiff CF4 4XW, U.K. E-mail: varma@-cardiff.ac.ukPart of this study was presented at the annual meeting of the BritishAssociation of Dermatologists, July 1996. Varma S, Lanigan SW. Thepsychological, social and financial burden of tattoos. Br J Dermatol1996; 135 (Suppl. 47): 37–8 (Abstr.).

Most patients (n ¼ 48) were tattooed below the legalage limit of 18 years. Of these, 18 patients were tattooedby a professional artist. The mean age at application ofthe first tattoo was 16 years (range 10–27; Fig. 2). Nine(13%) were under the influence of alcohol or drugs.Most patients acquired tattoos very cheaply. Among thepatients who recalled the original cost of application(n ¼ 64), 50% paid less than £1. One patient estimatedthe cost of his whole body tattooing to have cost £1000.

Tattoos were applied for a variety of reasons, mostcommonly for the sake of fashion (45%), followed bypeer pressure (22%), rebelliousness (15%), romance(6%) and other (12%). Ten per cent of patients imme-diately regretted their tattoo and an additional 18%felt remorse within the first month. The duration ofregret before requesting removal ranged from2 months to 48 years, median 14 years; 32 patientswaited for 1–10 years before requesting removal; 18 for11–20 years; 11 for 21–30 years; 3 for 31–40 yearsand 1 for 41–50 years. Patients quoted one or morereasons for removal: improvement of self-esteem (48patients), followed by social reasons (24), family pressure

(13), improving potential for employment (12) and achange of partner (four).

Discussion

Tattooing is widespread and continues to increase.Tattoos are inexpensive and easy to apply, and thelack of legal documentation provides scant discourage-ment against acquiring a tattoo. With the advent ofQ-switched lasers, the perception that removal of tattoosis relatively simple has enhanced the image of tattoos asbeing non-permanent and will do little to reverse theupward trend of applications. Once perceived to havenegative connotations such as delinquency and deviantbehaviour,3 tattoos now provide considerable appeal toimpressionable youngsters, being sported by ‘super-models’ and ‘pop stars’; in this study, most were appliedfor the sake of fashion or because of pressure to conformto a group. Our study confirms similar findings by othersthat tattoos are often applied impulsively4 with 28%of individuals voicing remorse within a month ofapplication.

Since 1969, it has been illegal to tattoo individualsunder 18 years.5 However, 71% of patients had tattoosapplied before the age of consent. Of these, 38% wereby a professional tattoo artist. Preventive educationtargeted at school children emphasizing scarring, dis-ease transmission, permanency, possible effects onemployment, social stereotypes and cost of removalmay reduce under-age applications. Although effectiveand safe,6–9 it should be stressed that treatment may bepainful, prolonged or incomplete. Alternative forms oftattooing could be encouraged as temporary substitutes.A signed document from customers recording age,knowledge of the procedure and possible side-effectsshould be obtained by tattoo artists. A 4-week‘cooling-off period’ after the first request may furtherreduce applications. Thirteen per cent of our cohortwere under the influence of alcohol or drugs during theapplication of one or more tattoos. Temporary mobiletattoo parlours are often present at concerts. Impulsiveadolescents under the influence of alcohol, widely avail-able at these events, may find the act of bravado in frontof friends or a desire to imitate the celebrity they revere,irresistible. Mobile tattoo parlours should therefore denya tattoo to those deemed to be under the influence of amind-altering substance.

The most common motivation for removal of a tattoowas enhancement of self-esteem. Patients now wantedto exorcise from themselves a stigmatizing lesion thathad been the source of years of regret. Other reasons for

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Figure 1. Number of tattoos possessed by patients. NR, non-responders.

Figure 2. Age at application of tattoos.

removal, such as eradication of a socially discreditinglesion, domestic pressure and improvement of employ-ment prospects, mirror the findings of a recent study inBoston, MA, U.S.A.10 Although the motives for applica-tion will vary between different cohorts, the reasons forremoval appear to be similar. Patients regretted theirtattoos for a median of 14 years before requestingremoval. Common reasons for enduring their tattoountil the present consultation were quoted as beingthe perceived high cost of removal and ignorance ofthe availability of the service. The cost of tattoo removal(up to four sessions for an amateur and up to 10sessions for a professional tattoo; £80 per session inBridgend) was overestimated by approximately half ofthe patients. With the cost of lasers falling and demandfor removal rising, appreciating the demography oftattooed patients may help health authorities to con-sider setting up a laser tattoo removal service. Furtherepidemiological work should therefore be encouraged toprovide more comprehensive information.

It should be noted that our study was performed onpatients attending a private laser tattoo removal clinicin South Wales, so our findings may not apply to othercohorts without further research. However, our studysuggests that tattoos represent significant morbidity inmany individuals. They may cause considerable perso-nal unhappiness, and impose significant psychological,social and financial burdens lasting many years. Typi-cally, tattoos applied impulsively in youth on visible siteswere a source of embarrassment to those now matureindividuals in stable domestic, social and employment

circles. While one cannot legislate against a person’sdesire to acquire a tattoo, education aimed at prevent-ing impulsive applications, stricter law enforcement todiscourage minors from being tattooed, better educationof tattoo artists, the enforcement of good standardpractice among tattoo artists, and a wider availabilityof services for removing tattoos will do much to alleviatethe substantial misery created by an unwanted tattoo.

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Skin Laser Today 1994; 2: 3–7.2 Tope W. State and territorial regulation of tattooing in the United

States. J Am Acad Dermatol 1995; 32: 791–9.3 Bekhor PS, Bekhor L, Gandrabur M. Employer attitudes

towards persons with visible tattoos. Australas J Dermatol 1995;36: 75–7.

4 Dupont C. Decorative tattoos: an analysis of 100 cases. (Letter.)Acta Derm Venereol (Stockh) 1994; 74: 236.

5 Hall-Smith P, Bennett J. Tattoos: a lasting regret. Br Med J 1991;303: 397.

6 Kilmer SL. Laser treatment of tattoos. Dermatol Clin 1997; 15:409–17.

7 Ferguson JE, August PJ. Evaluation of the Nd/YAG laser for thetreatment of amateur and professional tattoos. Br J Dermatol1996; 135: 586–9.

8 Kilmer SL, Lee MS, Grevelink JM. The Q-switched Nd: YAG lasereffectively treats tattoos. A controlled dose–response study. ArchDermatol 1993; 129: 971–8.

9 Alster TS. Q-switched alexandrite laser treatment (755 nm) ofprofessional and amateur tattoos. J Am Acad Dermatol 1995; 33:69–73.

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