A New Simple Technique (PDF)

Refer to: Manchester GH: Tattoo removal-A new simple technique.
Calif Med 118:10-12, Mar 1973
Table salt applied by salabrasion, tattooing
or dermabrasion was used in
the treatment of unwanted tattoos in 25
cases. With removal of the eschar at
the treated site, the unwanted pigmentation
was reduced by half, and there
was further dimming to virtual disappearance
during further healing.
Tattoo Removal
A New Simple Technique
GARY H. MANCHESTER, MD
San Diego
THE PROBLEM OF TATTOO REMOVAL has been
with man a long time. History records the Egyptians
in 4000 B.C. to be the first to use tattoos
for identification of their social classes.1 This practice
was revived by Hitler to recognize the enemies
of the Third Reich, while inmates of our penal
institutions use the self-inflicted ink tattoo for initiation
of a new prisoner.
Tattooing as a decorative and artistic form first
foun'd expression in Europe at the end of the 19th
century. Lady Randolph Churchill is said to have
had a snake placed around her arm. This art form
found great acceptance with the American service
man as an expression of his manhood during the
past century.
After World War II, the incidence of tattoos
began to decline. Social pressures were brought
to bear in the large cities, and health departments
began closing down the "art parlors." The medical
literature was busy reporting the transmission
of syphilis, tuberculosis, and infectious hepatitis
through the use of the tattoo needle.1-3 In 1948
Bromberg published his psychiatric study of the
tattooed personality.4 Dr. Bromberg concluded
that emotional instability was the underlying cause
for this self-embellishment. He felt that the tattoo
was either a form of exhibitionism or the means
for a weak neurotic to associate himself with a
strong group of people-soldiers. With this report
and the public awareness of a problem, employers
began refusing positions of responsibility on the
basis of a previous indiscretion. In 1969 the
Submitted September 21, 1972.
Reprint requests to: G. H, Manchester, MD, 7910 A. Frost
Street, Suite 205, San Diego, Ca. 92123.
United Kingdom passed a law restricting the use
of tattooing in minors.5
Recently requests for tattoo removal have increased
greatly in the United States due to the use
of these markings in the initiation rites of the
various Hippie-Yippie cults. With the increased
demand, I found myself without a means of removing
tattoos quickly and inexpensively. Approximately
two years ago, I began experimenting,
with the patients' permission, on new methods for
tattoo removal.
The basic problem is that the accepted methods
of treatment-serial excision or excision, and grafting-either
cause a spread or an unsightly scar,
or trade one blemish for two defects. Since 54
A.D., physicians have tried to remove tattoos without
leaving a scar. Aetius (543 A.D.) was the
first to describe the use of salt and chemicals for
the purpose.5 Klovekorn (1935) described the
abrasion of skin with table salt in order to remove
tattoo pigment;6 and Crittenden recently confirmed
these results and named the process salabrasion.7
Salabrasion, the removal of tattoos by
superficial abrasion of the skin with table salt, is
merely one means of delivering sodium chloride to
the underlying dermis. I have found that salabrasion,
dermabrasion,' and tattooing with table salt
or a salt solution give equally good results with
minimal scarring.
Technique
The area to be treated is first shaved and prepared
with Phisohex®. A local anesthetic is then
infiltrated into the skin when a dermabrador or
10 MARCH 1973 * 118 * 3

*:l^E..S
k-A
1/~~~~~~~~~~~~~~~~o
Figure 1.-A. a six-year-old multicolor tattoo before treatment. B. 72 hours after abrasion with table salt, the
treated area has the characterstics of tanned leather. C. on the eighth day the eschar separated from the underlying
dermis, taking about half the pigment with it, and, D. the appearance of the site 38 days after treatment.
tattoo machine is used. Anesthetic is not necessary
if the patient abrades the skin himself, since the
salt acts as a local anesthetic.8 The patient is then
instructed to wrap a moist 4x4 gauze sponge impregnated
with salt around his index and middle
fingers and to begin rubbing the tattoo he wishes
to remove. The abrasion continues till the skin
becomes "blood" red and appears like good granulation
tissue. This usually takes 30 to 40 minutes.
At this point, the treated area is covered with antibiotic
ointment and a sterile dressing which is left
in place for three days.
When a dermabrador or tattoo gun is used, the
skin is either superficially abraded or punctured
in the desired areas and then covered with a layer
of table salt. The insult to the dermis must be very
superficial. The mixture of blood and plasma will
carry the sodium chloride to the dermis. At this
point, when the treated area will look raw but
not blood red, it is covered with a layer of salt
for four hours. The dressing is then changed and
the wound cleaned and redressed with an antibiotic
ointment for an additional three days.
On the third postoperative day the treated area
is dry and has the appearance of tanned leather.
This salted area separates between the seventh
and twelfth postoperative days. With eschar separation
one may see that about half of the ink has
been removed. Still more ink leaves the treated
area in exudate while the skin is healing. The
abraded area remains erythematous for approximately
six weeks and has a tendency to become
hyperpigmented if exposed to sunlight. The skin
heals quickly and with virtually no scarring. A
second treatment can be administered six to eight
weeks after the first.
Results
CASE 1. A 25-year-old white man who six
years earlier had had a multi-colored tattoo professionally
applied to his forearm (Figure 1),
removed about ninety percent of the tattoo pigment
by use of salabrasion for 35 minutes. Fortyeight
hours after treatment the skin at the site had
taken on the characteristics of tanned leather.
Eight days after salabrasion, the eschar had separated,
taking with it approximately half of the tattoo
pigment. The skin had completely healed by
the 38th day. At this time, hair was already growing
from the treated area and there was mild
hyperpigmentation secondary to sun exposure.
CASE 2. The patient, a white man 22 years of
age, had had a "homemade" tattoo with india ink
applied to his left arm two years before treatment
(Figure 2). On instruction, he used salabrasion
for 30 minutes on one area of the tattoo. After
21 days the treated area had lost about nine-tenths
of its ink content. There was an eczematous eruption
at the site, secondary to the antibiotic dressing
used.
CASE 3. A 24-year-old white man with a professionally
applied black ink tattoo that had been
on his forearm for five years was treated with a
tattoo gun whose needles were set at 1 mm of
penetration. The treatment was applied for four
or five minutes at the center of the tattoo. The area
was then wiped dry and covered with a layer of
CALIFORNIA MEDICINE 11
The Western Journal of Medicine

Figure 2. Left, a two-year-old "homemade" india ink
tattoo. Right, three weeks after the first treatment to
the hat area only. The eczematous reaction was secondary
to a topical antibiotic.
table salt for four hours. The salt was removed
and a sterile dressing applied. At the end of four
weeks, the center of the flower showed decided
loss in pigmentation (Figure 3).
Discussion
How salt acts to remove pigment-impregnated
skin is not known. Success may be attributed to
the initial tanning which removes the majority of
superficial epidermal and dermal pigment, with
an increased phagocytic response in macrophages
following. At the end of the first week, only about
half of pigment is removed with the initial eschar
but during the following 14 days additional fading
occurs.
Boo-Chai reported that superficial dermabrasion
of tattoos creates an inflammatory response
and thus promotes the "biologic removal" of pigment
through the lymphatics and the sloughing
of superficial macrophages.9 Clabaugh postulated
that the pigment-laden phagocytes may become
mobile and migrate to the wound surface where
they are removed by daily dressing changes.'0 The
treatment of tattoos with salt may enhance this
phagocytic response.
From a review of the literature it appears that
most early techniques owe their success to the
inflammatory reaction of salt or a caustic substance.
Aetius, in his treatise, directed, "On the
sixth, remove the mixture and prick the area with
a sharp-pointed instrument, wipe off the blood
Figure 3.-Left, a five-year-old professionally applied
tattoo, before treatment. Right, four weeks after treatment
by superficial penetration of the skin with a tattoo
gun and topical application of salt at the site of densest
pigmentation, the treated area is almost entirely depigmented.
with a sponge, and powder the punctures with a
thin layer of salt."5 Scutt recently reported on the
the Variot method of over tattooing with a 50
percent tannic acid solution.5 I have used a strong
solution of phenol.
In the treatment of 200 tattoos in a two-year
period I became dissatisfied with most methods because
of the expense in time and money. With
superficial dermabrasion, although it has enjoyed
great success over the past ten years',9"-1 there is
occasional atrophic scarring or poor result.
In a more recent series I have used salt in
treatment by light dermabrasion in ten cases, tattooing
in two cases and salabrasion in 13. In all
cases there was uniform removal of pigment in
the treated areas with virtually no scarring.
REFERENCES
1. Roenigk HH: Tattooing-history, techniques, complications,
removal. Cleve Clin Q 36:179-186, 1971
2. Rook AJ, Thomas PJB: Social and medical aspects of tattooing.
Practitioner 169:60-66, 1952
3. Smith BF: Occurrence of hepatitis in recently tattooed service
personnel. JAMA 144:1074-1076, 1950
4. Bromberg W: Psychologic motives in tattooing. Arch Neurol
Psychiatr 33:228-232, 1948
5. Scutt RWB: The chemical removal of tattoos. Br J P Surg
25:189-194, 1972
6. Kloevekorn GH: Eine einfache methode der entferlung
von taetowierungen. Dermatologische Wochenscrhrift 101:1271,
1935
7. Crittenden FM: Salabrasion-removal of tattoos by superficial
abrasion with table salt. Cutis 7:295-300, 1971
8. Personal observation
9. Boo-Chai K: The decorataive tattoo-Its removal by dermabrasion.
Plastic Reconstr Surg 32:559-563, 1963
10. Clabaugh W: Removal of tattoos by superficial dermabrasion.
Arch Dermatol 98:515-521, 1968
11. Loria PR: Dermabrasion-Principles of planing. J LA Med
Soc 112:401-405, 1960
12 MARCH 1973 * 118 * 3