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Nitrous oxide linked to less pain in tattoo removal


– The results of a small, single-site study suggest that nitrous oxide (NO) can play a significant role in reducing pain during laser tattoo removal.

“Nitrous oxide is a safe and effective option for patients, particularly those who have large tattoos that can’t be adequately numbed with injections or topical numbing,” the study’s lead author, Jared Mallalieu, DO, said in an interview. “NO has allowed us to treat larger tattoos – full sleeve or large back tattoos – in a single setting, which has made treatment more convenient for patients.”

Patients fared better on pain measures when they received NO, compared with topical and injectable anesthetics, according to Dr. Mallalieu, a cosmetic surgeon at the Laser Center of Maryland, Severna Park. The results were so dramatic that EMLA cream is now rarely used for patients in his clinic, although injectable lidocaine is used on smaller tattoos (smaller than 5 inches by 5 inches), he said.

The use of NO comes with challenges, however, in terms of the extra time and patient monitoring required, he said.

Dr. Mallalieu and his associates reported the results in an e-poster at the annual meeting of the American Society for Laser Medicine and Surgery.

Laser tattoo removal can be an agonizing process. “Patients describe it as being significantly more painful than getting a tattoo,” Dr. Mallalieu said. “The intense pain only lasts during the treatment,” he said, “though many patients will note some discomfort for a few hours after a treatment session.”

Most clinics use a topical cream, such as lidocaine/prilocaine (EMLA) or topical benzocaine/lidocaine/tetracaine (BLT), as an anesthetic for these procedures. “Our center has also used 1% lidocaine with epinephrine in small doses of up to 7 mg/kg,” he said. “The injections are much better than the cream.”

Sometimes the clinic uses a device that blows cold air on the skin, which “helps a little,” he added.

For the study, conducted in 2014, 23 laser tattoo removal patients were surveyed about their pain levels using a 1-10 scale, after undergoing a total of 41 single-location procedures.

Dr. Jared Mallalieu, Severna Park, Md.

Dr. Jared Mallalieu

The average pain rating during the procedure was 9.1 for those treated only with lidocaine/prilocaine, 5.4 for injections of lidocaine with epinephrine alone, and 6.8 for both lidocaine/prilocaine and lidocaine with epinephrine injections.

The average pain rating for NO alone was 2.6, and was 3.6 for those who received both the injection treatment and lidocaine/prilocaine. Three of 12 NO patients reported anxiety.

Another benefit is that patients can drive after receiving NO, unlike other anesthetics, which leave patients sedated, he said. “Levels of NO are titrated to keep the patient sedated, but breathing on their own,” and patients can be easily woken up within moments of stopping the NO.

However, the use of NO requires more time to set up and more monitoring, he added. The average treatment time for procedures with NO was 27 minutes compared with 4 minutes for the other procedure, and “the patient is put on a monitor that measures pulse rate and oxygenation levels,” which not only takes more time, but requires additional staff to watch the patient. “Also, it takes about 3-5 minutes to slowly the titrate the NO to a perfect level.”

The study points out that physicians at the clinic are the only ones who perform the procedures that use NO, but at many clinics, nonphysicians perform tattoo removals.

As for cost, “NO and oxygen tanks are rather inexpensive to purchase and maintain, and there are various small units which serve to titrate the gas,” Dr. Mallalieu said. “We do charge our patients a small fee because of the added personnel and time cost associated with the procedure. As tattoo removal is considered a cosmetic procedure, insurance doesn’t come into play.”

Training to administer NO brings up the issue of what is allowed in the state, he said. Physicians can give sedation to patients, “but some states may limit the degree to which a patient can be sedated in an office. If the physician has a certified operating room, this is not a problem,” he added. “Because dentists commonly use NO, we followed the American Dental Association guidelines ... As we employ an anesthesiologist, we were quite familiar with it. That said, the administration of NO is not complex and [is] easily mastered.”

Dr. Mallalieu reported no relevant disclosures.

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