Ruby Laser for Tattoo Removal
The Q-switched ruby laser (694 nm) is highly effective for tattoo removal and can be used successfully in patients with darker skin tones, though the longer wavelength Q-switched Nd:YAG laser is recommended as first-line for Fitzpatrick types V and VI to minimize pigmentary complications. 1, 2, 3
Mechanism and Effectiveness
The Q-switched ruby laser operates through selective photothermolysis, generating ultra-short pulses (25-40 nanoseconds) that cause extremely rapid heating and mechanical fragmentation of tattoo pigment particles without damaging surrounding tissue. 1, 2, 4 This technology is particularly effective for:
- Blue-black and green pigments - the ruby laser wavelength (694 nm) is optimal for these colors 1, 2, 5
- Amateur tattoos - require fewer treatment sessions than professional multicolored tattoos 6
- Professional, accidental, cosmetic, and traumatic tattoos - all respond to treatment, though professional tattoos require more sessions 2, 5, 6
Treatment Protocol
Maintain a minimum 4-week interval between sessions - this is critical to allow complete phagocytosis and clearance of fragmented pigment particles, and longer intervals may reduce the risk of permanent pigmentary changes. 1, 2, 4
Key technical points:
- Immediately after the laser pulse, the epidermis appears white due to water vaporization in the skin 1
- Free pigment becomes intracellular again within 4 weeks, necessitating the waiting period 1
- Multiple sessions are always required - one documented case required 47 treatments for large multicolored tattoos 1, 2, 4
- Power densities in the range 1200-2800 GW/m² are most suitable 7
Special Considerations for Darker Skin Tones
For Fitzpatrick types V and VI skin, the Q-switched Nd:YAG laser (1064 nm) is recommended over the ruby laser as first-line treatment to minimize the risk of adverse pigmentary changes and keloidal scarring. 3 However, clinical evidence demonstrates that:
- Q-switched ruby laser treatment can be performed successfully in darkly pigmented patients without scarring or permanent pigment changes 3
- A test treatment is advised before treating large skin areas in darker-complected persons 3
- The longer wavelength Nd:YAG laser has a lower incidence of hypopigmentary changes compared to the ruby laser 6, 3
Safety and Complications
Proper training in Q-switched laser use is essential - significant burns can occur within tattoos after improper treatment, leading to scarring and poor outcomes. 1, 4
Common adverse effects include:
- Transient hypopigmentation - reported in up to 50% of patients, though usually temporary 6
- Textural changes - occur in approximately 12% of patients 6
- Scarring - rare when proper technique is used 5, 6
- Hyperpigmentation - less common with ruby laser than with other modalities 6
Additional safety considerations:
- Tattoo particles can be found in regional lymph nodes following treatment 1, 4
- Toxicologic risks exist with cleavage products formed during laser-assisted removal 8, 1, 4
- Patients with history of keloid formation should be advised of potential scarring risks 1
Patient Counseling and Cost
Counsel patients upfront that tattoo removal is expensive, time-consuming, and may not achieve complete clearance. 1, 2
Specific counseling points:
- Treatment costs range from $49-$300 per square inch per session, with multiple sessions required, making total costs substantial 1, 2, 4
- The Kirby-Desai score can help estimate the number of sessions needed based on skin type, tattoo colors, and complexity 1, 4
- Complete removal may require multiple sessions over many months due to the mandatory 4-week intervals 1, 2
- Tattoo removal is only partially effective in many cases 1
Clinical Algorithm for Laser Selection
For lighter skin (Fitzpatrick I-IV):
- Q-switched ruby laser is excellent for blue-black and green pigments 1, 2, 5
- Combine with Q-switched Nd:YAG 532 nm for red pigments if needed 6
For darker skin (Fitzpatrick V-VI):