Tattoo removal among Ethiopian Jews in Israel: Tradition faces - CMS

Tattoo removal among Ethiopian Jews in Israel:
Tradition faces technology
Moshe Lapidoth, MD, and Gali Aharonowitz, MD
Herzelia Pituach, Israel
Background: Many Jews in Ethiopia adopted the Christian custom of tattooing various parts of the body,
either after conversion or to hide their Jewish origin. After emigrating to Israel, they sought to remove these
foreign symbols to better blend with society. The aim of this study was to describe the use of laser
technology for tattoo removal in a high-risk dark-skinned population and to highlight one way in which the
interaction of modern medical communities with people from developing countries can open new avenues
of research.
Patients and methods: The study sample consisted of 401 women and 3 men of Ethiopian origin with
Fitzpatrick skin type V or VI. Ages ranged from 15 to 53 years. All tattoos were blue/black and had been
made by injecting charcoal into the skin. Most (n = 392, 97%) were located on the forehead or the forehead
and temples (n = 312); 69% were cross-shaped. Patients underwent 3 to 6 laser treatments (average 3.6)
with the Q-switched Nd:YAG (n = 380, 94%) or ruby (n = 24) laser at intervals of at least 8 weeks. The
percent of clearing was scored by two independent investigators as follows: 1 = 0%-25%; 2 = 26%-50%;
3 = 51%-75%; 4 = 75%-100%. Pigmentary and textural changes were classified as none, mild, moderate, or
severe. The duration of follow-up after the last treatment was 6-8 months.
Results: At the last follow-up, the clearance score was 4 in 92% of the patients and 3 in the remainder.
Transient (2-4 months) mild hyperpigmentation was noted in 177 (44%) patients, and mild textural changes
in two, both treated with the Q-switched laser. There were no cases of scarring or permanent pigmentary
changes.
Conclusion: Laser removal of carbon-based tattoos in an Ethiopian population yielded an excellent to
good aesthetic outcome with no complications, similar to results in light-skinned patients. These findings
have important implications for improving the quality of life of Ethiopian immigrants in Israel. ( J Am Acad
Dermatol 2004;51:906-9.)
Under the Law of Return, Israel has absorbed
millions of Jews from all over the world.
Between 1977 and 1991, the country witnessed
the mass immigration of almost the entire
Jewish population of Ethiopia, numbering about
50,000. Today there are approximately 85,000
Ethiopian Jews in Israel, 20,000 of whom are
Israeli-born. 1
From the Dermatological Laser Unit, Herzelia Medical Center.
Funding sources: None.
Conflicts of interest: None identified.
Accepted for publication July 19, 2004.
Reprint requests: M. Lapidoth, MD, Dermatological Laser Unit,
Herzelia Medical Center, Herzelia 46851, Israel. E-mail:
alapidot@netvision.net.il.
0190-9622/$30.00
ª 2004 by the American Academy of Dermatology, Inc.
doi:10.1016/j.jaad.2004.07.028
906
In Ethiopia, the Jews lived primarily in villages in
the north and northwest of the country, distant from
their Christian neighbors, in order to maintain
autonomy over their social and economic institutions.
About 100 years ago, Christian missionaries
began attempting to convert the Jews. Although the
majority spurned these advances, some left their
faith, whether from belief or from social and economic
pressure, or from fear of persecution. 2,3
Tatooing is a common practice among Ethiopian
Christians, mostly in women. The tattoo, usually a
cross shape, is placed on the forehead, chest, neck,
or arms. It serves as a mark of beauty and is believed
to protect against illness and other misfortunes.
Many converted Jews used the tattoo as an external
sign of their new faith, although it did not necessarily
indicate a voluntary conversion. 4
The absorption and integration of the Ethiopian
Jews into Israeli society has been a long road of

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VOLUME 51, NUMBER 6
challenges, successes, and difficulties. Besides the
practical problems in moving from a developing
nation to a modern, industrialized one, the immigrants
also had to adapt to new social, cultural,
and bureaucratic rules. There was also the problem
of religion: the state religious institutions do not
recognize their status as Jews 1 and many Ethiopians
have been required to undergo conversion. 1 Under
these circumstances, the tattoo stands out as a mark
of their different background.
Since the arrival of the Ethiopians in Israel, our
laser unit has treated 404 Ethiopian Jews for removal
of a tattoo. This procedure is a major medical
challenge in patients with dark skin owing to the
high risk of side effects. 5 The aim of the present study
was to describe our experience with laser tattoo
removal in this population.
PATIENTS AND METHODS
Patients
The study sample consisted of 404 patients, 401
women and 3 men, of Ethiopian origin, who
presented for laser therapy for cosmetic tattoo removal.
All had Fitzpatrick skin type V or VI. Age
range for the women was 15 to 53 years (average
24.2), and for the men, 26 to 30 years (average 27.1).
Lapidoth and Aharonowitz 907
Fig 1. A typical cross-shaped tattoo on the forehead of a 22-year-old female before (A) and
after (B) treatment with a Q-switched Nd:YAG laser.
Fig 2. Cross-shaped tattoo on a 19-year-old woman before (A) and after (B) treatment with
a Q-switched ruby laser.
Tattoo characteristics
All tattoos were blue/black and were made by
injecting charcoal into the skin (Figs 1 and 2). Most
(n = 392, 97%) were located on the forehead or the
forehead and temples (n = 312). Other sites, alone or
combined with the forehead, were the neck (n = 96,
24%) upper limbs (forearms and hands), and cheeks.
Sixty-nine percent of the tattoos were cross-shaped,
and the remainder were in the form of a sun, circle,
or chain.
Tattoo removal
In most cases (n = 380, 94%), we used the
Q-switched Nd:YAG laser (Continuum Biomedical,
Livermore, Calif) at 1064 nm, with a pulse width of 10
nsec, spot size of 3 mm, and fluences ranging from
4.2 to 7.0 J/cm 2 . The other patients (n = 24) were
treated with the Q-switched ruby laser, (Wavelight
Laser Technologie AG, Erlangen, Germany) at 694
nm, with a pulse width of 20 nsec, spot size of 4 mm,
and fluences ranging from 5.0 to 7.0 J/cm 2 . No
anesthesia was used. Patients underwent between
3 and 6 laser treatments (average 3.6) at intervals of at
least 8 weeks. They were instructed to apply
antibiotic ointment (mupirocin) after each session.
Photographs were taken before treatment and 3
months after the last session (Figs 1 and 2). The

908 Lapidoth and Aharonowitz
Fig 3. Self-scarification in a 45-year-old woman following
an attempt to remove the tattoo.
percent of clearing was scored by two independent
investigators on a quartile scale: 1 = 0%-25%; 2 =
26%-50%; 3 = 51%-75%; 4 = 75%-100%. Pigmentary
and textural changes were classified as none, mild,
moderate, or severe. The duration of follow-up after
the last treatment was 6 to 8 months.
RESULTS
Good clearance (90%-100%, score 4) was
achieved in 92% of the patients (n = 372) after the
last laser treatment. In the remaining 32 patients, 75%
to 90% clearance was documented (score 3). Most of
the patients showed no changes in skin pigment or
texture after treatment. Transient (2-4 months) mild
hyperpigmentation was noted in 177 (44%) patients,
and mild textural changes in two, both treated with
the Q-switched Nd:YAG laser. There were no cases
of scarring or permanent pigmentary changes.
DISCUSSION
The interaction of the medical community in
a developed country with a population from a developing
country opens a broad range of areas of
study and research. Our sample included 404 Jews of
Ethiopian origin who sought to remove tattoo marks,
mainly cross-shaped. Tattoos are only one of the
many differences that characterize Ethiopian and
Israeli culture and customs, and they exemplify the
often problematic and complex relationships between
immigrants and the social, educational, and
religious authorities in our country. Most of the
tattoos of the Ethiopian population in Israel were
made in their homeland under Christian influence.
Traditional Jewish law, however, adheres to the
admonishment in Leviticus 19:28, ‘‘You shall not
make any cuttings in your flesh on account of the
dead or tattoo any marks upon you: I am the Lord.’’
Jews believe that human beings are created in the
image of God, and tattooing is an interference with
His original design. It was apparently in response to
this negative attitude, and a wish to better integrate
JAM ACAD DERMATOL
DECEMBER 2004
into Israeli society, that prompted many of our
patients to remove their tattoos, particularly the
cross-shaped ones, sometimes even by themselves
(Fig 3). This assumption is supported by the study of
Armstrong et al 6 who investigated the motivation for
tattoo removal among 105 patients. Their subjects
expressed strong feelings of dissociation from the
past and sought to improve their self-identity.
In 1996, Grevelink et al 5 investigated the efficacy
and side effects of laser tattoo removal in 5 darkly
pigmented patients (4 of them Ethiopian women)
and concluded that Q-switched laser treatment can
be performed successfully in this population. Further
evidence was provided by Jones et al 7 who applied
the Q-switched laser in 8 darkly pigmented patients
and found it to be an excellent therapeutic option for
tattoo removal.
Comparisons between different types of tattoos
showed that the Q-switched laser is more effective in
removing amateur, carbon-based tattoos than professional,
densely colored tattoos, 8,9 probably because
of the selective absorption of the 1064 nm and
694 nm wavelengths by the carbon particles. The resulting
photopyrolysis and photoacoustic disruption
of the phagocytized particles allows them to be transported
away in lymphatic vessels, eliminated transcutaneously,
or rephagocytized in macrophages. 10,11
The present study included a relatively large
population of patients with Fitzpatrick skin types V
and VI and carbon-based tattoos. In agreement with
earlier studies, the aesthetic outcome was excellent—90%
to 100% clearance in 94% of cases, with
only limited and transient side effects, similar to
results in light-skinned patients. 12
These findings highlight the usefulness of laser
technology for tattoo removal in Ethiopians. Given
the data on the motivation for tattoo removal in
this population, our study may have important
implications for improving the quality of life of
Ethiopian immigrants in Israel and easing their social
integration in their adopted country.
We became aware through verbal reports of our
patients that one of the main obstacles to tattoo
removal among Ethiopian immigrants is the financial
consideration. Therefore, we decided to provide the
service at a symbolic fee, and thereby contribute to
their acceptance in Israeli society.
REFERENCES
1. Israel Association for Ethiopian Jews. History. Available at:
http/www.iaej.co.il. Accessed July 10, 2003.
2. Archbishop Yesehaq. The Ethiopian Tewahedo Church: An
Integrally African Church. Winston-Derek Pub; Nashville, TN:1997.
3. Ford E. Children of the lost tribe of Dan. Photographs of
Ethiopian Jewry. On view at the Yeshiva University Museum,
Bronx, New York, January 28-August 3, 2003.

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VOLUME 51, NUMBER 6
4. University of Pennsylvania Museum of Art. Body modification
ancient and modern. Available at: http/www.Museum.
upenn.edu. Accessed 10 July 2003.
5. Grevelink JM, Duke D, van Leeuwen RL, Gonzalez E, DeCoste
SD, Anderson RR. Laser treatment of tattoos in darkly
pigmented patients: Efficacy and side effects. J Am Acad
Dermatol 1996;34:653-6.
6. Armstrong ML, Stuppy DJ, Gabriel DC, Anderson RR.
Motivation for tattoo removal. Arch Dermatol 1996;132:
412-6.
7. Jones A, Roddey P, Orengo I, Rosen T. The Q-switched Nd:YAG
laser effectively treats tattoos in darkly pigmented skin.
Dermatol Surg 1996;22:999-1001.
8. Kilmer SL. Laser treatment of tattoos. Dermatol Clin 1997;15:
409-17.
9. Ferguson JE, Andrew SM, Jones CJ, August PJ. The Q-switched
neodymium:YAG laser and tattoos: A microscopic analysis of
laser-tattoo interactions. Br J Dermatol 1997;137:405-10.
10. Kilmer SL, Lee MS, Grevelink JM, Flotte TJ, Anderson RR. The
Q-switched Nd:Yag laser effectively treats tattoos. Arch
Dermatol 1993;129:971-8.
11. Ferguson JE, August PJ. Evaluation of the Nd/YAG laser for
treatment of amateur and professional tattoos. Br J Dermatol
1996;135:586-91.
12. McBurney EI. Side effects and complications of laser therapy.
Dermatol Clin 2002;20:165-76.
DERMATOLOGY LEXICON PROJECT OPEN COMMENT PERIOD
Dermatologists have the unprecedented opportunity to apply their expertise to a comprehensive
dermatology terminology to improve communication, image indexing, computerized medical records,
and research.
The Dermatology Lexicon Project needs your help to:
—Ensure that all skin diseases are included—
—Suggest synonyms—
—Identify rare/orphan diseases—
Open comment period:
September 1, 2004-December 31, 2004
www.dermatologylexicon.org
For more information, e-mail
jennifer_byrnes@urmc.rochester.edu
Lapidoth and Aharonowitz 909
This project has been funded in whole or in part with Federal funds from the National Institute of
Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Department of Health and
Human Services, and with funds from The Carl J. Herzog Foundation, Inc. under Contract No. NO1-AR-
1-2255.