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
474
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: [email protected]
FROSTBITE MASQUERADING AS ECCHYMOSIS
DERMATOLOGIC SURGERY476