Standard guidelines of care: Lasers for tattoos and pigmented lesions

Introduction: Lasers have revolutionized the treatment of pigmentary disorders and have become the mainstay of therapy for many of them. Machines: Though different laser machines are used, Quality-switched (QS) lasers are considered as the gold standard for treatment of pigmented lesions. Proper knowledge of the physics of laser machine, methodology, dosage schedules, etc., is mandatory. Physician Qualification: Laser may be administered by a dermatologist, who has received adequate background training in lasers during postgraduation or later at a center that provides education and training in lasers, or in focused workshops which provide such trainings. He should have adequate knowledge of the machines, parameters, cooling systems, and aftercare. Facility: The procedure may be performed in the physician's minor procedure room. Indications: Epidermal lesions: Cafι au lait macules (CALM), lentigines, freckles, solar lentigo, nevus spilus, pigmented seborrheic keratosis, dermatosis papulosa nigra (DPN). Dermal lesions: Nevus of Ota, Blue nevus, Hori's nevus (acquired bilateral nevus of Ota-like macules). Tattoos: Amateur, professional, cosmetic, medicinal, and traumatic. Mixed epidermal and dermal lesions: Postinflammatory hyperpigmentation (PIH), nevus spilus, periorbital and perioral pigmentation, acquired melanocytic nevi (moles), melasma and Becker's Nevus. Contraindications: Absolute: Active local infection, photo-aggravated skin diseases and medical conditions, tattoo granuloma, allergic reactions to tattoo pigment, unstable vitiligo and psoriasis. Relative: Keloid and keloidal tendencies, patient on isotretinoin, history of herpes simplex, patient who is not co-operative or has unrealistic expectation. Patient selection: Proper patient selection is important. Investigations to identify any underlying cause for pigmentation are important; concurrent topical and systemic drug therapy may be needed. History of scarring, response to previous injuries, degree of tanning needs to be considered. Detailed counseling about the need for multiple sessions is required. Informed consent should be taken in all cases. Treatment sessions: Epidermal lesions need an average of 1−6 sessions, while dermal lesions need average of 4−10. Some tattoos may need up to 20 sessions. All lesions may not clear completely and only lightening may be achieved even after multiple sessions in many cases. Future maintenance treatments may be needed. Hence, a realistic expectation and proper counseling is very important. Epidermal lesions are likely to recur even after complete clearing. Therefore, there is a need for continued sun protection. Dermal lesions and tattoos tend to remain clear after treatment (except conditions as dermal melasma). Laser parameters: Laser parameters vary with area, type of pigmentation and machine used. Complications and their management: Postinflammatory pigmentation changes are common in dark skin patients. Textural changes and scarring occur rarely.