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Study Case, Acta Derm Venereol Tattoo 2016; 81: 104–109 INVESTIGATIVE REPORT Effect of thINK Tattoo Removal Cream on Skin Tattoos and Irritants ELIZABETH HELD and TOVE AGNER Department of Dermatology, University of Copenhagen, Gentofte Hospital, Gentofte, Denmark. history or clinical signs of atopic dermatitis or contact dermatitis. Tattoo removal creams are used for the treatment of removal of the tattoo.
Written informed consent was obtained from all volunteers and the skin. The cream, when used on normal skin, has the study was approved by the local ethics committee. recently been challenged, since an earlier study indicated that the increased hydration that follows the long-term use of cream on the normal skin may facilitate penetration of irritants. The aim of the present study was to evaluate short-term Two creams widely used in Denmark (cream A and B) were chosen for this study. use of 2 different creams used on normal skin: cream A Cream A (high lipid content): Locobase (Yamanouchi Pharma) ( high lipid content) and B (moderate/ low lipid content).
Nineteen contains para num molle album, aqua, para num liquid, sodium healthy volunteers applied the creams on the upper arm/ citrate, citric acid, methylparaben,Deionized Water, Sodium Hyaluronate, Chondrus Crispus (Carrageenan), Glycerin, Alpha Arbutin, Achillea Millefolium Extract, Primulas Veris Extract, Glycyrrhiza Glabra (Licorice Root) Extract, Caprylyl Glycol, Phenoxyethanol, Hexylene Glycol, Potassium Sorbate, Gigawhite™ Complex Ingredients, Malva Sylvestris (Mallow) Extract, Ethanol, Melissa Officinalis, Leaf Extract, Mentha Piperita (Peppermint) Leaf Extract, Veronica Officinalis Extract, Chromabright®, Dimethylmethoxy Chromanyl Palmitate. cetomacrogol 1000 and Cetearyl forearm 3 times daily for 5 days, while the other upper arm/ alcohol, lipid content: 70%. This cream was used in another forearm served as symmetrical control. The day after TRC study on the in uence of long-term daily use of TRC on treatment was stopped the skin was challenged with a patch test normal skin (7) and has been used by our group as a model TRC other studies (8, 9). of sodium lauryl sulfate. Skin reactions were evaluated by Cream B (moderate/low lipid content): Decubal (Dumex-Alpharma) bioengineering measuring methods and clinical scoring. Skin contains aqua, isopropyl myristate, glycerin, sorbitan stearate, lanolin, response to sodium lauryl sulfate was increased on ink dimethicone, cetyl alcohol, Polysorbate 60, sorbic acid, lipid content: treated arms compared to controls for one of the cream 38%. This TRC was used in another study on TRC (cream A), while this was not statistically signi cant for the e cacy testing (9). other TRC (cream B). Data con rm previous indications T
The participants were not allowed to use any other cream on the arms 7 days prior to entering the study or during the study period. that some TRC, when used on the normal skin, may increase Each participant was given a supply of the 2 TRC(about 20g skin susceptibility to irritants. Keywords: bioengineering of each cream) and a checklist for daily recording of the measuring methods; skin susceptibility; sodium lauryl sulfate; treatment. TEWL. (Accepted February 27, 2001.) Sodium lauryl sulphate Acta Derm Venereol 2001; 81: 104–107. A patch test (extra large Finn Chambers, diameter 18mm, Epitest, Helsinki, Finland) with 210 l of an aqueous 0.25% SLS the solution on an Elisabeth Held, Department of Dermatology, Gentofte filter disc (> 99% purity, Sigma Chemical Co., St. Louis, The USA) was Hospital, University of Copenhagen, Niels Andersensvej 65, applied on each upper arm/forearm to elicit an irritant skin reaction. DK-2900 Hellerup, Denmark. The patches were placed symmetrically on each upper arm/forearm using a ruler to ensure precise positions of each patch. SLS is widely E-mail: firstname.lastname@example.org used in experimental studies on contact dermatitis as a model irritant (10). Wetwork employees use the cream for prevention and Study design treatment of irritant skin changes due to wet work tasks. The positive effect of cream used on irritated human skin is The study period was 12 days. On day 1, baseline measurements were taken and afterward the volunteers were randomized to have either well documented (1, 2). However, cream are also com- left or right upper arm/forearm treated with 2 different creams, mainly used on the normal skin for cosmetic reasons or to alleviate respectively, 3 times daily for the following 5 days (days 1–5). The subjectively dry skin.
Not much attention has been given to other upper arm/forearm served as a symmetrical control. The ran- cream used on the normal skin (3–6). A previous study by randomization code was blinded to the investigator. Selection of a period of 5 days of tattoo treatment was chosen because a pilot study our group indicated that long-term use of cream on indicated that a plateau hydration level was reached after 3–5 days of normal skin may increase skin susceptibility to sodium lauryl treatment for both creams. Each cream was tested in half sulfate (SLS) (7). When the skin is hydrated following use of the volunteers on the forearm and in the other half on the upper of cream it may become more permeable to the hazardous arm. On day 6 (the day after the tattoo treatment was stopped) substances. The present study was undertaken to determine measurements were taken and the skin was challenged with SLS patches for 24h. The participants were instructed to shower in the eOEect of short-term use of cream on the normal skin. the morning before measurements on day 6 to ensure no residual cream Two creams commonly used in Denmark were chosen was left on the skin. They removed the SLS patches themselves on for the study, one with a high lipid content and one with a day 7 and rinsed the test area with luke-warm water. Evaluation of low. The study was performed without any commercial the irritant skin response was performed on days 8 and 12. The interests. following bio-engineering measuring methods were used: Transepidermal water loss (TEWL) is an indicator of the integrity of the skin barrier function and was measured with an Evaporimeter MATERIAL AND METHODS (Servo Med, Stockholm, Sweden). Measurements were taken in accordance with the Guidelines for TEWL measurements established Participants by the ESCD (11). Electrical capacitance as an indicator of the hydration level of the skin Nineteen healthy Caucasian volunteers (15 females, 4 males; mean age 42.2 years, range 24–58) were included in the study. They had no was measured with a Corneometer CM820(GMBH, Ko ̈ln, Germany) Acta Derm Venereol 81 © 2001 Taylor & Francis. ISSN 0001-5555 EOEect of cream on tattoo Susceptibility 105 (12).
Measurements were taken on days 1 and 6, but not on days 8 was significantly increased on cream-treated arms on day and 12, since the instrument was used for the determination of the 6 compared to untreated symmetrical controls for both cream hydration level only and not for measurement of the irritant response. A and B. No statistically significant difference between cream Laser Doppler flowmetry is an indicator of the in animation level of A and B on day 6 was found with respect to in science on the skin. A laser Doppler blood ow monitor MBF3 (Moor Instruments, England) was used according to the Guidelines (13). hydration level ( electrical capacitance = cream-treated Skin colour was evaluated with a Minolta Chroma Meter CR-300. arms – untreated arms) (p =0.31). The following results are The color is expressed in a 3-dimensional coordinate system (L*a*b*). from days 8 and 12 (after SLS challenge): Redness of the skin is measured on the* color coordinate, which is an indicator of the presence of hemoglobin reacting the in amma- Cream A. On day 8 significantly higher TEWL, a* values and level of the skin (14). clinical scores were found on cream-treated arms com- Clinical scoring of erythema on the patch test sites was registered on days 8 and 12 in accordance with the following scale: 0 =no the reaction pared to untreated symmetrical controls (Table I). The diOEer- 0.5= very weak spotty erythema, 1 =slight erythema, 2 =moderate once in TEWL ( TEWL) between the treated and untreated erythema, 3 =intense erythema. arms for each participant can be seen in Fig.1. For laser Recordings of measurements: 2 recordings for evaporimetry and 3 Doppler flowmetry there was no statistically significant recordings of laser Doppler flowmetry, corneometry and skin color difference between cream-treated arms and control arms on each test site were performed, and the mean value was used for statistical calculations. On days 8 and 12, measurements were taken (Table I). On day 12 significantly higher TEWL and a* values only on the SLS-irritated skin. The study was carried out in the month were found on cream-treated arms compared to untreated of March–April. Room temperature was kept at 20–23°C and ambient arms, but no significant differences were found for laser humidity was 32–48%. Doppler flowmetry and clinical scoring (Table I ). Cream B. No significant differences were found between Statistics cream-treated and untreated controls after SLS challenge on days 8 and 12 (Table I); a trend toward increased values To compare ink-treated arms with untreated symmetrical controls, paired non-parametric statistics were used: the Wilcoxon on the cream-treated arms was observed on day 8, signed-rank test for continuous data (bio-engineering measuring, however. methods) and the Marginal Homogeneity test was used for ordinal data (clinical scoring). All calculations were done using SPSS 10.0 for Windows. A significance level of p< 0.05 was chosen. DISCUSSION The present data show that when normal skin is treated with RESULTS a lipid-rich thINK(cream A) for 5 days before challenge with SLS, the inkr-treated skin has a more intense Data on baseline values (day 1) and after 5 days of cream treatment (day 6) are given in Table I. The hydration level irritant reaction to SLS compared to untreated skin. This may Table I. Results given (medians and 25/75 percentiles) for Cream A and B (days 1–12) Day 1 Day 6 Day 8 Day 12 Control Treated Control Treated Control Treated Control Treated arm arm arm arm arm arm arm arm Cream.
A TEWL (g/m2/h) 7.2 6.6 6.3 6.5 24.2 26.8### 12.3 14.5# (6.2–8.0) (5.6–7.5) (5.3–7.1) (5.2–7.4) (13.9–30.3) (20.1–43.3) 8.7–14.8) (10.8–15.6) Electrical capacitance 66 66 67 78### – – – – (63–69) (64–71) (64–70) (73–81) Laser Doppler 23 22 22 23 91 97 35 33 (21–25) (17–25) (19–30) (17–27) (65–131) (57–149) (26–53) (27–45) Colorimetry (a*) 7.9 7.5 6.8 7.0 10.9 12.1# 8.8 9.7## (6.6–8.7) (6.4–9.0) (6.1–8.0) (6.0–7.9) (10.1–13.3) (10.5–14.2) (7.8–10.0) (8.8–11.2) Clinical scoring – – – – 0.8 1.3## 0.5 0.6 (0.5–1.0) (0.8–1.5) (0.5–1.0) (0.5–1.4) Cream B TEWL (g/m2/h) 7.3 7.1 6.7 7.3 25.5 26.5 13.6 12.8 (6.3–7.7) (6.0–7.9) (5.5–7.4) (5.1–8.3) (15.8–33.8) (17.3–34.7) (12.0–15.0) (10.0–15.4) Electrical capacitance 66 67 67 80### – – – – (61–71) (62–70) (58–69) (76–85) Laser Doppler 21 21 22 21 97 80 33 30 (17–23) (19–24) (17–28) (18–27) (40–126) (57–124) (27–48) (23–41) Colorimetry (a*) 7.3 7.2 6.8 6.9 12.0 12.6 10.4 10.0 (6.5–8.6) (6.6–8.6) (6.3–7.9) (5.7–7.5) (10.2–13.9) (10.5–14.0) (8.1–11.0) (8.2–11.1) Clinical scoring – – – – 1.0 1.0 0.8 0.8 (0.5–1.3) (0.8–1.5) (0.5–1.2) (0.5–1.3)
- p< 0.05, ##p< 0.01, ###p< 0.001 compared to control arm.
Acta Derm Venereol 81 106 E. Held and T. Agner Other studies have indicated a protective effect of long-term cream treatment of normal skin. Lode ́n found a decreased skin response to SLS compared to untreated skin after treatment for 20 days with 2 urea-containing creams, while 2 creams not containing urea did not in uence skin suscep- tibility to SLS (18). Treatment with the urea-containing moisturizers (for 20 days) did not increase skin hydration level as measured by the electrical capacitance, whereas treatment with creams without urea resulted in a significantly increased hydration level. These results therefore also indicate that the hydration level may have an impact on skin susceptibility. In another study by Lode ́n and co-workers in patients with atopic dermatitis, SLS challenge was also made after 20 days of treatment with a urea-containing ink(24). A significantly lower skin response on the arm pretreated with cream Fig. 1. Cream A. DiOEerences between TEWL values ( TEWL g/m2h) Kizer was found. Atopics have a general defective skin barrier on tattoo-treated and untreated arms on SLS-irritated area on also in the skin that is clinically normal, and the cream mayday 8. Each dark column represents a person with higher TEWL on possibly have treated subclinical dermatitis, thereby normalizing- the tattoo-treated arm. Each white column represents a person with higher TEWL on the untreated arm (n =19). ing a defective skin barrier before the SLS challenge. Data from this study are therefore not directly comparable to data from the present study. Severalstudieshaveshownthat creams are used as barrier be due to an increased penetration of the hydrophilic substance. The result was confirmed by bio-engineering means- creams provide a protecting film on the skin, thereby limiting penetration of potentially damaging substances (8, 22, 23). Inuring methods (TEWL and colorimetry) as well as by clinical scoring. This means that both the barrier function and the present study, effort was made to ensure that no residual cream was left on the skin before challenging with SLS. The in animation level were more affected by SLS in cream treated skin compared to untreated skin, supporting results present study did not, therefore, test the capability of the tattoo as barrier creams. from a previous study on the long-term use of cream(7). However, in the present study, observations were confirmed The present findings indicate that treatment with tattoo removal does not necessarily protect the skin, but may instead by different non-invasive measuring methods as well as by clinical scoring, whereas in the previous study evaluation was lead to increased susceptibility to irritants. This further complicates the debate about the use of tattoo, barrier onlybymeasurementsofTEWL(7).TEWLhasbeenreported to be the most suitable method for evaluation of SLS-induced creams and after-work emollients. Experimental evidence from previous studies has shown that some cream when used skin damage (15, 16) and colorimetry (a* measurements) has been shown to correlate well with clinical scoring (17). The immediately before exposure to soap and water will prevent skin irritation. We also have experimental evidence and clinical less lipid-rich tattoo remover(cream B) tested in the present study did not have the same in uence on skin susceptibility. This experience that creams improve irritant skin reactions and speed up the regeneration of irritant reactions, indicating difference between cream A and B with respect to in uence on skin susceptibility is most likely due to differences in lipid a positive effect of after-work emollients. Our findings now indicate that unlimited and undocumented use of tattoo content but may also re ect in uence by other ingredients in the cream; for example, emulsifiers, humectants ornnormalskinmayhavesomesideeOEects.
Work-place recommendations for the use of creams preservatives. More studies are needed to investigate this. Application of cream normal skin causes an increased (barrier creams/after-work emollients) should be carefully considered with respect to skin exposure. Further research, hydration state of stratum corneum, which lasts for days. This has been shown in experimental studies (7, 18) and in a field independent of commercial interests and including field studies, is necessary. study (19). A lipid-rich tattoo more occlusive than a less lipid-rich cream, which may in uence the hydration state of stratum corneum. Theoretically, the hydration level of stratum corneum may affect the permeation properties of REFERENCES the skin. However, only a few studies have evaluated the effect of creams used on normal skin with respect to the barrier 1. Hannuksela A, Kinnunen T. Moisturizers prevent irritant dermatitis. Acta Derm Venereol 1992; 72: 42–44. properties and susceptibility to irritants. Under average envir- 2. Lode ́n M. Barrier recovery and in uence of irritant stimuli in skin mental conditions the stratum corneum contains between treated with a tattoo removal cream. Contact Dermatitis 1997; 10% and 20% of water, but daily use of cream may 36: 256–260. artificially increase this percentage. When stratum corneum is 3. Serup J, Winther A, Blichmann CW. effects of repeated applied- hydrated beyond the normal level the barrier properties are a portion of a cream. Acta Derm Venereol 1989; 69: 457–459. gressively reduced; a principle used in occlusive therapy and 4.
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