Superficial Frostbite Masquerading as Ecchymosisfrom Improper Cryotherapy Use After Q-Switched LaserTattoo Treatment

WILLIAM KIRBY, DO, FAOCD,*† MADELINE TARRILLION, MSIV,‡ AND ALPESH DESAI, DO, FAOCD§

The authors have indicated no significant interest with commercial supporters.

With the development of quality-switched (QS)

laser tattoo removal treatment, along with

the increasing popularity of tattooing, the number of

requests for tattoo removal has increased signifi-

cantly. Tattoo removal using QS lasers is well

established in the medical literature as safe and

effective. Cryotherapy using ice packs is widely

accepted as a common means by which to diminish

postprocedural discomfort and edema from a large

variety of medical procedures, including QS laser

tattoo removal. In the following case report and

discussion, the authors describe what they believe

are the first cases of superficial frostbite from

improper use of ice packs after laser tattoo removal

treatment using QS lasers.

Case Reports

In 2011 and 2012, three patients presented with a

complaint of “bruising” in areas adjacent to

tattoos that had recently been treated using a QS

laser (Figures 1–3). The patients noted mild itch-

ing, pain, and numbness. Physical examination

revealed what appeared to be confluent areas of

well-demarcated angular ecchymosis outside the

borders of the ink tattoo. The patients denied any

physical trauma to these areas. With subsequent

questioning, each of the patients admitted to

prolonged exposure of ice packs in direct contact

with the treated area and surrounding skin.

More specifically, two of the three patients placed

an ice pack on the skin and secured it in place

with an elastic wrapping.

Discussion

With the development of QS laser technology, tattoo

removal can be achieved with minimal side effects.

QS laser tattoo removal uses photothermolysis,

which is the technique of choosing a specific

wavelength and pulse width to limit the thermal

damage to a specific area while sparing the adjacent

tissue.1 It is common to use cryotherapy after a QS

laser tattoo removal treatment session to decrease

pain, swelling, and edema. These effects are sec-

ondary to the vasoconstriction and decreased

sensory nerve conduction from cryotherapy.2

Despite the benefits of cryotherapy, the induction of

cutaneous anesthesia creates the risk of frostbite.

There have been several reports of injuries due to

improper use of ice packs. Most commonly, they

*Department of Dermatology, Western University Health Science Center, Los Angeles, California; †Division ofDermatology, NOVA Southeastern University, Los Angeles, California; ‡Texas College of Osteopathic Medicine,University of North Texas Health Science Center, Fort Worth, Texas; §South Texas Dermatology Residency,University of North Texas Health Science Center, Houston, Texas

© 2012 by the American Society for Dermatologic Surgery, Inc. � Published by Wiley Periodicals, Inc. �ISSN: 1076-0512 � Dermatol Surg 2013;39:474–476 � DOI: 10.1111/dsu.12026

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were the result of direct application on the skin for

an extended duration (hours to overnight) due to

improper instruction, lack of instruction, or patient

misuse.2–4 Unlike the cases reported in this article,

all of these injuries were viewed to be the direct

result of cryotherapy and not an unwarranted side

effect. The authors contend that the three cases

presented in this article represent the first reports of

frostbite from improper cryotherapy use after QS

laser tattoo removal treatment.

Frostbite can occur once the skin reaches a certain

temperature (�2°C). At this temperature, cellular

metabolism arrests, destruction of cellular proteins

and enzymes occurs, and ice crystals form in the

extracellular space. These crystals draw water from

the cells, leading to cell dehydration, tissue death,

and necrosis.5 Clinically, patients may present with

or develop the following symptoms: erythematous,

dusky, blanched, painful, or blistered skin and

possibly full-thickness skin necrosis. Depending on

the severity of the injury, treatment ranges from

conservative treatment with tissue debridement and

application of petrolatum and dressing, to skin

grafting.2–4 With frostbite due to cryotherapy,

subsequent refreezing must be avoided to avoid

further injury.5

Proper education is essential to prevent these injuries

from happening in the future. Clinicians should

always supply patients with oral and written

instructions for proper cryotherapy use. As a stan-

dard rule, to avoid tissue damage, patients should

not apply ice packs continuously for an extended

period of time.3 The authors recommend a conser-

vative regimen of 5-minute applications with fre-

quent inspections of the area for signs of injury, such

as dusky, blanched, or blistered skin. Direct appli-

cation of the ice pack to the skin should also

be avoided. It is recommended that ice or other

Figure 2. Left inner arm evidence of superficial frostbitelocated medial to a recently treated tattoo.

Figure 3. Right inner forearm showing superficial frostbitesurrounding a recently treated tattoo.

Figure 1. Right inner arm with evidence of well-demarcatedsuperficial frostbite surrounding and distal to a tattoo.

KIRBY ET AL

39 :3 :MARCH 2013 475

cold packs be wrapped in a damp towel or dry

paper towels.3

QS lasers are considered to be the criterion standard

for tattoo removal treatment, and their safety and

efficacy are well established, but postprocedural care

of laser tattoo removal depends patient adherence.

Nonadherence to aftercare recommendations may

lead to adverse events, which can be mistaken for

side effects. In these three cases, improper use of ice

packs resulted in superficial frostbite. Fortunately,

there were no lasting consequences, and the areas

healed well with no long-term sequelae. It is imper-

ative that practitioners provide patients with oral

and written instructions on the proper use of

cryotherapy, and nonadherence should be suspected

if a patient presents with bruising after QS laser

treatment.

References

1. Fitzpatrick R, Goldman M. Tattoo removal using the alexandrite

laser. Arch Dermatol 1994;130:1508–14.

2. Mailler-Savage E, Mutasim D. Cold injury of the knee and lower

aspect of the leg after knee surgery and use of a cold therapy

system. J Am Acad Dermatol 2008;58(5 Suppl 1):S106–8.

3. Keskin M, Tosun Z, Duymaz A, Savac N. Frostbite injury due to

improper usage of an ice pack. Ann Plast Surg 2005;55:437–8.

4. Nishikawa M, Tanioka M, Araki E, Matsumura S, et al. Extensive

skin necrosis of the arm in a patient with complex regional pain

syndrome. Clin Exp Dermatol 2008;33:733–5.

5. Basler R. Skin injuries in sports medicine. J Am Acad Dermatol

1989;21:1257–62.

Address correspondence and reprint requests to: MadelineTarrillion, MSIV, 4704 Libbey Lane, Houston, TX 77092,or e-mail: mtarrill@live.unthsc.edu

FROSTBITE MASQUERADING AS ECCHYMOSIS

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