Analytical survey of tattoo inks-A chemical and legal perspective with focus on sensitizing substances

Analysis of blue and green REACH compliant tattoo inks

The Registration, Evaluation, Authorization, and Restriction of Chemicals (REACH) legislation in Europe has limited the use of certain materials in the manufacturing of tattoo inks; in particular, Pigment Blue 15:3 and Pigment Green 7 have been banned for the use in tattoo inks and permanent makeups and all labels must include an accurate list of ingredients. This study analyzed green and blue inks from five different manufacturers distributed to the European market, all of which claim to be REACH compliant. Nine out of ten inks analyzed were found to not be compliant and four contained banned material. The polymorph of Pigment Blue 15 found in four inks was unable to be determined. The majority of inks showed labeling inaccuracies, including the addition of unlisted poly(ethylene glycol) and propylene glycol. This study highlights issues around REACH compliance of tattoo inks on the European market and the need for manufacturing protocols to ensure accurate labeling.

Identification of the pigments used in permanent makeup and their ability to elicit allergic contact dermatitis

BACKGROUND

Decorative tattoos are known to contain ingredients that may elicit allergic contact dermatitis; it is less well-known if permanent makeup pigments carry the same risk.

OBJECTIVE

Identify pigments used in permanent makeup inks sold in the United States and review cases of allergic contact dermatitis to these pigments.

METHODS

Using internet searches, permanent makeup inks sold in the United States were identified. Safety data sheets were used to catalog pigments used in permanent makeup. A subsequent literature search was performed to identify cases of allergic contact dermatitis to these pigments.

RESULTS

A total of 974 permanent makeup inks were reviewed, and 79 unique pigments were identified. The average product contained 4 pigments. Twenty of the pigments were inorganic metals, including carbon, iron, chromium, manganese, and molybdenum. Fifty-nine pigments were organic, of which most were azo, quinacridone, or anthraquinone dyes. A literature search revealed that 10 of the 79 pigments were associated with allergic contact dermatitis.

CONCLUSION

Permanent makeup primarily uses organic pigments, although some metallic pigments are still used. Physicians should also be aware that some of these pigments-both organic and inorganic-are known causes of allergic contact dermatitis. Of note, patch testing to these ingredients can be negative.

Epidemiology of patch tested patients with permanent tattoos-A comparative analysis of 9693 IVDK patients (2020-2022)

BACKGROUND

Permanent tattooing is the invasive introduction of tattoo ink (pigments) into the dermis. The ink and aftercare cosmetics applied on pre-damaged skin may contain skin sensitisers.

OBJECTIVES

To identify patient characteristics and the pattern of sensitisation in tattooed patients patch tested within the Information Network of Departments of Dermatology (IVDK).

PATIENTS AND METHODS

Comparative analysis of patient characteristics and reaction frequencies to baseline series allergens in 1648 consecutive patients with and 8045 consecutive patients without permanent tattoos. Non-overlapping 95%-confidence intervals were considered as significant.

RESULTS

Having permanent tattoos was related with female sex, age <40 years, tobacco smoking, atopic dermatitis, (occupational) hand dermatitis and being employed in particular occupational groups (e.g., healthcare workers, mechanics, hairdressers). Sensitisation to nickel was increased in tattooed patients and associated with female sex (OR 4.23 [95%-CI, 3.48-5.18]), age ≥40 years (OR 1.26 [95%-CI, 1.08-1.49]), tobacco smoking (OR 1.19 [95%-CI, 1.01-1.40]) and having permanent tattoos (OR 1.27 [95%-CI, 1.05-1.53]).

CONCLUSIONS

The association between nickel sensitisation and permanent tattoos is probably confounded by past reactions to pierced costume jewellery. Socio-economic factors most probably contribute to the connection between tattoos, tobacco smoking, occupational or hand dermatitis, and being employed in particular occupational groups.

Esthetic and medical tattooing: Part I: Tattooing techniques, implications, and adverse effects in healthy populations and special groups

Tattooing, the introduction of exogenous pigments into the skin, has a rich history spanning thousands of years, with cultural, cosmetic, and medical significance. With the increasing prevalence of tattoos, understanding their potential complications and contraindications is of growing importance. The most common complications are hypersensitivity reactions, which may vary in morphology and timing. Infectious complications are often due to inadequate aseptic and hygienic practices during the tattooing process or healing period. Tattoo pigment can present diagnostic challenges, affecting cancer diagnosis and imaging. This CME article explores the history, cultural significance, epidemiology, chemistry, technique, contraindications, and complications of tattoos. Appreciating these factors can help individuals considering tattoos understand the safety and potential risks of their body art, and provide physicians with a thorough understanding of tattooing if consulted.

What's in My Ink: An Analysis of Commercial Tattoo Ink on the US Market

As tattoos continue to rise in popularity, the demand for tattoo ink has surged. Historically, tattoo inks have been underregulated in the US market. This study analyzes inks from nine different brands that are common in the United States, ranging from major to small manufacturers. Out of 54 inks, 45 contained unlisted additives and/or pigments. Major, unlisted adulterants include poly(ethylene glycol), propylene glycol, and higher alkanes. Many of the adulterants pose possible allergic or other health risks. Taken together, the results from this study highlight the potential for a significant issue around inaccurate tattoo ink labeling in the United States.

Tattoo Pigment Biokinetics in vivo in a 28-Day Porcine Model: Elements Undergo Fast Distribution to Lymph Nodes and Reach Steady State after 7 Days

INTRODUCTION

Pigments of tattoo inks may over time migrate to other parts of the body. Inks kinetics are still poorly understood and little studied. The aim of this first study was to investigate the kinetics of tattoo inks pigment in tattooed porcine skin, which is closer to human skin than mouse skin studied in the past.

METHODS

Three animals were tattooed on the inner thigh and one animal served as untreated control. Skin biopsies were taken on days 7, 14, and 28 after tattooing. Animals were sacrificed on day 28 and homogenate samples of the liver, spleen, kidney, and brain, as well the local lymph nodes were prepared. All samples were analyzed for ink components using inductively coupled plasma-mass spectrometry. The ink itself was characterized by dynamic light scattering and matrix-assisted laser desorption-ionization mass analysis.

RESULTS

Titanium (212 g/kg), copper (6 mg/kg), aluminum (1 mg/kg), zirconium (1 mg/kg), and chromium (3 mg/kg) were found in the ink. Significant deposits of ink elements were detected in the tattooed skin when compared to non-tattooed skin from the same animal (mean ± standard deviation: titanium 240 ± 81 mg/kg, copper 95 ± 39 mg/kg, aluminum 115 ± 63 mg/kg, zirconium 23 ± 12 mg/kg, and chromium 1.0 ± 0.2 mg/kg; p < 0.05). Lymph node concentrations of titanium, copper, aluminum, zirconium, and chromium were 42 ± 2 mg/kg, 69 ± 25 mg/kg, 49 ± 18 mg/kg, 0.3 ± 0.2 mg/kg, 0.5 ± 0.2 mg/kg, respectively.

CONCLUSION

Deposits in skin were unchanged from days 7-28 indicating no redistribution or elimination. No significant deposits of ink elements were found in the liver, spleen, kidney, and brain. In conclusion, our findings confirmed distribution of elements from tattoos to regional lymph nodes, but neither to excretory organs, e.g., liver and kidney, nor to spleen and brain. Thus systemic internal organ exposure was not found.

Are Allergy-Induced Implant Failures Actually Hypersensitivity Reactions to Titanium? A Literature Review

PURPOSE

This literature review was performed to assess whether implant failures are associated with titanium allergy.

MATERIALS AND METHODS

An electronic search of the MEDLINE/PubMed, Cochrane Library, and Scopus databases up to April 2021 was conducted, and the obtained articles were independently assessed by two reviewers. Articles describing cases of implant failure in which the cause of implant failure was only identified as allergy were included.

RESULTS

Twelve studies were included. Eight studies identified Ti allergy by clinical examinations, of which four used patch tests, three used the lymphocyte transformation test (LTT)/memory lymphocyte immunostimulation assay (MELISA), and one used both tests. Nine studies reported cases of titanium hypersensitivity in combination with other systemic allergy-related disorders, with eight cases also showing positive results for Ni, Hg, Cr, and Co hypersensitivity. Ten papers reported the improvement of symptoms after the removal of the Ti implants and their replacement with zirconia implants, and two of these papers showed good results.

CONCLUSION

Cases of probable titanium allergy included those with true titanium allergies and those with a potentially different cause. However, the differentiation of these cases is difficult. Since no definitive method has been established for diagnosing titanium allergy, a comprehensive diagnosis based on the clinical course and clinical examination using a patch test/LTT/MELISA is necessary. Implant treatment should be performed with caution in patients with any preoperative allergies.

Cohort profile: The Swedish Tattoo and Body Modifications Cohort (TABOO)

PURPOSE

The Swedish Tattoo and Body Modifications Cohort (TABOO) cohort was established to provide an infrastructure for epidemiological studies researching the role of tattoos and other body modifications as risk factors for adverse health outcomes. It is the first population-based cohort with detailed exposure assessment of decorative, cosmetic, and medical tattoos, piercing, scarification, henna tattoos, cosmetic laser treatments, hair dyeing, and sun habits. The level of detail in the exposure assessment of tattoos allows for investigation of crude dose-response relationships.

PARTICIPANTS

The TABOO cohort includes 13 049 individuals that participated in a questionnaire survey conducted in 2021 (response rate 49%). Outcome data are retrieved from the National Patient Register, the National Prescribed Drug Register and the National Cause of Death Register. Participation in the registers is regulated by Swedish law, which eliminates the risk of loss to follow-up and associated selection bias.

FINDINGS TO DATE

The tattoo prevalence in TABOO is 21%. The cohort is currently used to clarify the incidence of acute and long-lasting health complaints after tattooing based on self-reported data. Using register-based outcome data, we are investigating the role of tattoos as a risk factor for immune-mediated disease, including hypersensitisation, foreign body reactions and autoimmune conditions.

FUTURE PLANS

The register linkage will be renewed every third year to update the outcome data, and we have ethical approval to reapproach the responders with additional questionnaires.

Hypersensitivity to permanent tattoos: Literature summary and comprehensive review of patch tested tattoo patients 1997-2022

We outline constituents of tattoo and permanent make-up ink with regard to inflammatory tattoo reactions and population-based confounders. The comprehensive review of patch-tested tattoo patients between 1997 and 2022 shows that tattoo allergy cannot be reliably diagnosed via patch testing with today's knowledge. Weak penetration and slow haptenization of pigments, unavailability of pigments as test allergens and a lack of knowledge concerning relevant epitopes hamper the diagnosis of tattoo allergy. Patch testing p-phenylenediamine and disperse (textile) dyes is not able to close this gap. Sensitization to metals was associated with all types of tattoo complications, although often not clinically relevant for the tattoo reaction. Binders and industrial biocides are frequently missing on ink declarations and should be patch tested. The pigment carbon black (C.I. 77266) is no skin sensitizer. Patch tests with culprit inks were usually positive with cheap ink products for non-professional use or with professionally used inks in patients with eczematous reactions characterized by papules and infiltration. Tape stripping before patch testing and patch test readings on Day 8 or 10 may improve the diagnostic quality. The meaningfulness of the categorical EU-wide ban of Pigment Green 7 and Pigment Blue 15:3 is not substantiated by the presented data.

Quantitative analysis of restricted metals and metalloids in tattoo inks: A systematic review and meta-analysis

The various ingredients and impurities that can be detected within tattoo inks have been associated with a myriad of dermatologic complications. Legislation regarding these antigenic substances varies widely around the world, with Europe serving as both the research and regulatory center on these intradermal formulations. Although industry is said to be moving away from metallic and metalloid pigments in exchange for organic or organometallic dyes, surveys of commercially available inks continue to detect these elements at concentrations considered unsafe for application into the dermis. In order to better assess the formulation and safety of tattoo ink, we present a systematic review and meta-analysis of studies quantifying restricted metals and metalloids in commercially available tattoo ink products. Among the papers selected, inconsistencies were noted in the degree of specificity by which ink products were identified and the elements sampled for. In addition, the analytical targets' valency and/or solubility were not always considered in accordance with regulation criteria. Of note, chromium, by total content and that of its regulated +6 valency, exceeded its maximum allowed concentration in nearly every sample tested. Total copper content exceeded the limit for soluble copper in half of inks sampled. In descending order, concentrations of cadmium, barium, mercury, soluble copper, arsenic, zinc, antimony, and lead violated regulations in one-sixth or fewer of samples tested. Cobalt and tin levels never violated regulation. Overall, our findings indicate that unsafe levels of restricted elements continue to be detected across studies, warranting further investigation under a regulatory lens.

Development and Validation of the Epidemiological Tattoo Assessment Tool to Assess Ink Exposure and Related Factors in Tattooed Populations for Medical Research: Cross-sectional Validation Study

BACKGROUND

Tattooing, whose popularity is growing worldwide, is an invasive body art that involves the injection of chemical mixtures, the tattoo ink, into the upper layer of the dermis. Although these inks may contain environmental toxins, including known human carcinogens, their long-term health effects are poorly studied. To conduct the urgently required epidemiological studies on tattoos and their long-term health effects, a validated method for assessing the complex tattoo exposure is needed.

OBJECTIVE

We aimed to develop and validate the Epidemiological Tattoo Assessment Tool (EpiTAT), a questionnaire to self-assess tattoo ink exposure in tattooed populations suitable for application in large epidemiological cohort studies.

METHODS

One of 3 preliminary versions of the EpiTAT using one of the alternative tattoo measurement units hand surface, credit card, or body schemes was randomly filled in by tattooed volunteers in Lyon, France. To identify the most suitable unit of tattoo self-assessment, a validation study was conducted with the selected respondents (N=97) to compare the self-assessments of tattoo surface, color, and coverage with validation measurements made by trained study personnel. Intraclass correlation, the Kendall rank correlation, and 2-tailed t tests were used to statistically compare tattoo size, color area, and tattoo coverage separately for each questionnaire version. Participants' opinions on the alternative measurement units were also considered in the overall evaluation. For quality control of the validation measures, digital surface analysis of 62 photographs of selected tattoos was performed using Fiji/ImageJ.

RESULTS

In general, the results revealed overestimation of self-assessed measures compared with validation measures (eg, mean tattooed body surface 1768, SD 1547, cm2 vs 930, SD 1047, cm2, respectively, for hand surface; P<.001) and validation measures compared with digital image analysis (mean individual tattoo surface 147, SD 303.9, cm2 vs 101, SD 154.7, cm2, respectively; P=.05). Although the measurement unit credit card yielded the most accurate measures for all variables of interest, it had a much lower completion rate (78/129, 60.5%) than hand surface (89/104, 85.6%) and body schemes (90/106, 84.9%). Hand surface measured total tattoo size more accurately than body schemes (absolute agreement intraclass correlation coefficient: 0.71 vs 0.64, respectively).

CONCLUSIONS

The final version of the EpiTAT contains 21 items and uses hand surface as a visual unit of measurement. Likert scales are used to assess color and coverage as a proportion of the total tattoo area. The overestimation of tattoo size by self-reporting merits further research to identify potential influential factors or predictive patterns that could be considered when calculating exposure.

Are Some Metals in Tattoo Inks Harmful to Health? An Analytical Approach

Tattoo application is widely performed all over the world; however, injection of coloring substances into the skin as metals may pose a risk for allergies and other skin inflammations and systemic diseases. In this context, tattoo inks in green, black, and red colors of three brands were purchased. Before starting the analysis, the acid mixture suitable for microwave burning was determined, and according to these results, the inks were digested with nitric acid, hydrochloric acid, and hydrofluoric acid. Then, method validation was performed for tattoo inks using inductively coupled plasma-mass spectrometry. The relative contribution of metals to the tattoo ink composition was highly variable between colors and brands. Elements found in the main components of inks are as follows (in mg kg^-1): Al, 1191.1-3424.9; Co, 0.04-1.07; Cu, 1.24-2523.4; Fe, 16.98-318.42; Ni, 0.63-17.53; and Zn, 2.6-46.9. It has been determined by the Environmental Protection Agency that in some products, especially the copper element is above the determined limit. The analysis results obtained were classified by chemometric analysis, and the color and brand relationship were determined. More toxicological studies are necessary to understand the effects of tattoo inks containing heavy metals and/or organic components.

“For Asia Market Only”: A Green Tattoo Ink between Safety and Regulations

Due to the increasing tattoo practicing in Eastern countries and general concern on tattoo ink composition and safety, the green tattoo inks Green Concentrate by Eternal, for European and “for Asia Market Only” were analyzed, under the premise that only the former falls under a composition regulation. A separation of the additives from the pigment was carried out by successive extraction in solvents of different polarities, i.e., water, acetone and dichloromethane. The solid residues were analyzed by IR and Raman spectroscopies, the liquid fractions by GC/mass spectrometry. The relative pigment load and element traces were also estimated. We found that the European and the Asian inks are based on the same pigment, PG7, restricted in Europe, though at different loads. They have a similar content of harmful impurities, such as Ni, As, Cd and Sb and both contain siloxanes, including harmful D4. Furthermore, they have different physical-chemical properties, the European ink being more hydrophilic, the Asian more hydrophobic. Additionally, the Asian ink contains harmful additives for the solubilization of hydrophobic matrices and by-products of the phthalocyanine synthesis. Teratogenic phthalates are present as well as chlorinated teratogenic and carcinogenic compounds usually associated to the laser treatment for removal purposes, to a larger extent in the European ink. The composition of the inks does not seem to reflect regulatory restrictions, where issued.

Tattoo inks are toxicological risks to human health: A systematic review of its ingredients, fate inside skin, toxicity due to polycyclic aromatic hydrocarbons, primary aromatic amines, metals, and overview of regulatory frameworks

Today, tattooing has become very popular among people all over the world. Tattooists, with the help of tiny needles, place tattoo ink inside the skin surface and unintentionally introduce a large number of unknown ingredients. These ingredients include polycyclic aromatic hydrocarbons (PAHs), heavy metals, and primary aromatic amines (PAAs), which are either unintentionally introduced along with the ink or produced inside the skin by different types of processes for example cleavage, metabolism and photodecomposition. These could pose toxicological risks to human health, if present beyond permissible limits. PAH such as Benzo(a)pyrene is present in carbon black ink. PAAs could be formed inside the skin as a result of reductive cleavage of organic azo dyes. They are reported to be highly carcinogenic by environmental protection agencies. Heavy metals, namely, cadmium, lead, mercury, antimony, beryllium, and arsenic are responsible for cancer, neurodegenerative diseases, cardiovascular, gastrointestinal, lungs, kidneys, liver, endocrine, and bone diseases. Mercury, cobalt sulphate, other soluble cobalt salts, and carbon black are in Group 2B, which means they may cause cancer in humans. Cadmium and compounds of cadmium, on the other hand, are in Group 1 (carcinogenic to humans). The present article addresses the various ingredients of tattoo inks, their metabolic fate inside human skin and unintentionally added impurities that could pose toxicological risk to human health. Public awareness and regulations that are warranted to be implemented globally for improving the safety of tattooing.

Tattoo Ink Market in France: A Field Study among 598 Professional Tattooists

BACKGROUND

Tattoo ink safety is one of the main concerns surrounding tattooing practices. In order to better assess the risks and increase the safety of tattoo inks, it is important to know about the habits of tattooists in real life.

OBJECTIVE

We investigated the most popular inks in the French market and how professional tattooists used them in their daily practice.

METHODS

We performed an observational, self-reported, online survey concerning the French tattoo artists. All active professional tattooists in France were invited to take part in a six-question Internet survey regarding their tattoo inks usage habits.

RESULTS

598 tattooists reported 36 different brands of black inks and 30 of colored inks. However, 6 brands of black inks were used by 14.2-44% of the tattooists and, for colored inks, 5 manufacturers were favored by 11.2 up to 55.7% of the tattooists. The majority of tattooists (68.9%) mixed two different colors or more to obtain a new shade while 21.7% would try to find the adequate shade within the assortment provided by a manufacturer. 54.4% had between 10 and 40 references, 31.9% had less than 10 references, 11.5% had 40-100 references, and 2.2% had >100 references.

CONCLUSIONS

The market of tattoo inks in France is dominated only by a fistful of brands. Controls by official authorities should target those popular brands, even though all brands should respect the law. Toxicological studies should always precise the provenance market and which brands are tested, so we can assess their impact in real life. Tattooists should also try to lower the number of ready-made colors they require.

Contact sensitization to iron - a potentially underestimated metal allergen and elicitor of complications in patients with metal implants

BACKGROUND

Little is known about sensitization to iron (Fe) in private, working and medical settings, particulary implantology.

OBJECTIVES

To investigate sensitization to metals, particularly to Fe, both in pre-implant individuals with presumed metal allergy and in patients with suspected metal implant allergy. To further characterize Fe-sensitized individuals.

METHODS

Analysis of patch test reactions to an Fe (II)-sulfate-containing metal series in 183 consecutive patients (41 pre-implant, 142 metal implant-bearers). Test readings on D2, D3 and D6. Evaluation of questionnaire-aided history, of metal reactivity patterns, and demographics of Fe-reactors.

RESULTS

Metal reactivity in pre-implant/implant/total group was: to nickel 39%/30%/32%; to cobalt 17%/15%/15%; to chromium 7%/13%/11%. Co-sensitizations cobalt/nickel (19/58) and cobalt/chromium (11/21) were significant at P < .001; co-sensitizations Fe/Nickel (4/10) and chromium/knee arthroplasty (11/73) at P = .03. Ten of 183 (5.5%) reacted to Fe (2 of 41 pre-implant patients, 8 of 142 implant-bearers) with 10 only reacting on D6. Fe-reactivity was highest in complicated knee arthroplasty (7/73). Further peculiarities of Fe reactors included frequent isolated Fe reactivity (6/10), occupational metal exposure (7/10), previous (par)enteral Fe-substitution (6/10).

CONCLUSIONS

The 5.5% prevalence of Fe-reactions suggests a potentially underestimated role of this metal allergen in general and in implant-bearers. The latter also show a distinct metal sensitization pattern. This article is protected by copyright. All rights reserved.

Aluminum-Allergen of the Year 2022

ABSTRACT

Exposure to elemental aluminum and its salts is unavoidable. Aluminum as a metal is present in transport, construction, packaging, and electronic equipment. Aluminum salts are present in consumer products, food items and drinking water, vaccines, drugs, and antiperspirants. Aluminum in vaccines and preparations for allergen-specific immunotherapy are the major sensitization sources. The predominent clinical manifestations of aluminum allergy are pruritic subcutaneous nodules and eczematous dermatitis. Patch testing shall be performed with aluminum chloride hexahydrate (ACH) in petrolatum. The preparation with ACH 10% detects substantially more aluminum allergy than ACH 2%. A patch test with elemental aluminum, for example, an empty Finn Chamber, is only positive when there is a strong aluminum allergy. A patch test reading should be performed 1 week after the application so as not to miss 15% to 20% of aluminum allergy. Aluminum should be included in any baseline patch test series for children and investigated for a possible inclusion in baseline series for adults. Aluminum test chambers can interfere with the testing resulting in both false-negative and false-positive patch test reactions to nonaluminum contact sensitizers.