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

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JAM ACAD DERMATOL 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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