Photosensitivity and photodynamic events in black, red and blue tattoos are common: A ‘Beach Study’

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.

Tattoos: risks and complications, clinical and histopathological approach

BACKGROUND

Skin modification through tattoos is as old as humanity itself. However, this trend is on the rise, and with the use of different types of pigments and application practices, both cutaneous and systemic complications can arise. Adverse reactions can be grouped into five classes: inflammatory, infectious, neoplastic, aesthetic, and miscellaneous. On histopathology, inflammatory reactions can exhibit a lichenoid pattern or present as spongiotic dermatitis, granulomatous reactions, pseudolymphoma, pseudoepitheliomatous hyperplasia, or scleroderma/morphea-like changes. This article reviews tattoo complications, including their clinical and histopathological characteristics.

METHODS

An open search was conducted on PubMed using the terms "tattoo", "complications", and "skin". No limits were set for period, language, or publication type of the articles.

RESULTS

Reactions to tattoos are reported in up to 67% of people who get tattooed, with papulonodular and granulomatous reactions being the most common. Some neoplastic complications have been described, but their causality is still debated. Any pigment can cause adverse reactions, although red ink is more frequently associated with them. Patients with pre-existing dermatoses may experience exacerbation or complications of their diseases when getting tattoos; therefore, this procedure is not recommended for this patient group.

CONCLUSIONS

Dermatological consultation is recommended before getting a tattoo, as well as a histopathological examination in case of complications. In patients who develop cutaneous inflammatory reactions following tattooing, additional studies are recommended to investigate systemic diseases such as sarcoidosis, pyoderma gangrenosum, atopic dermatitis, and neoplasms. It is important for physicians to be trained in providing appropriate care in case of complications.

Lessons learned in a decade: Medical-toxicological view of tattooing

Tattooing has been part of the human culture for thousands of years, yet only in the past decades has it entered the mainstream of the society. With the rise in popularity, tattoos also gained attention among researchers, with the aim to better understand the health risks posed by their application. 'A medical-toxicological view of tattooing'-a work published in The Lancet almost a decade ago, resulted from the international collaboration of various experts in the field. Since then, much understanding has been achieved regarding adverse effects, treatment of complications, as well as their regulation for improving public health. Yet major knowledge gaps remain. This review article results from the Second International Conference on Tattoo Safety hosted by the German Federal Institute for Risk Assessment (BfR) and provides a glimpse from the medical-toxicological perspective, regulatory strategies and advances in the analysis of tattoo inks.

Cutaneous Adverse Reactions Associated with Tattoos and Permanent Makeup Pigments

Tattooing is the procedure of implanting permanent pigment granules and additives into the dermal layer of the skin, serving various purposes such as decoration, medical identification, or accidental markings. There has been a significant rise in the popularity of decorative tattooing as a form of body art among both teenagers and young adults. Thus, the incidence of tattoos is increasing, with expanding applications such as permanent makeup, scar camouflage, nipple-areola, lips, and eyebrows tattooing, and utilization in oncological radiotherapy such as colon marking. However, there have been reported a broad range of adverse reactions linked to tattooing, encompassing allergic reactions, superficial and deep cutaneous infections, autoimmune disorders induced by the Koebner phenomenon, cutaneous tumors, and others. These reactions exhibit different onset times for symptoms, ranging from immediate manifestations after tattoo application to symptoms emerging several years later. Given the limited information on a tattoo's side effects, this review aims to elucidate the clinical spectrum of cutaneous complications of tattoos in different patients. The analysis will investigate both allergic and nonallergic clinical presentations of tattoo-related side effects, microscopic findings from skin biopsies, and therapeutic outcomes. This exploration is essential to improve our understanding of tattoo-related cutaneous complications and associated differential diagnoses and highlight the significance of patient awareness regarding potential risks before getting a tattoo.

[Useful knowledge regarding tattoos]

The number of people with tattoos has continued to increase in recent years. In the USA about 23% and in Europe 9-12% of the population have tattoos. In the German media (2019) and by the infoportal Statista (2017), it is assumed that 21-25% of citizens have tattoos and that the trend is increasing (Statista 2018: 36%). Men and women wear tattoos equally. The age group 20-29 years dominates with almost 50% having tattoos. The following article describes the new regulations especially the REACH (Registration, Evaluation, Authorisation and Restriction of Chemicals) regulation, legal basis, and governmental controls on the subject of "tattoos". The composition of tattooing agents and testing options relevant for the user before and for the performance of tattooing are presented. Dermatologically associated diseases and testing procedures are listed. Since 70% of the population denies knowledge of this information even when they have tattoos themselves, this update is written as an overview for treating physicians and users.

Potential chemical risks from tattoos and their relevance to military health policy in the United States

We summarize and consolidate disparate sources of information about the practice of tattooing and its potential implications for military population health and policy. Each branch of the United States military has policies about tattoos for service members, but these have varied over time and do not cover health protection. The number of veterans receiving disability payments and the cost of those payments has been rising over time; the broad category of skin conditions accounts for 11% of disability claims. Any additional factor, such as tattoos that may increase the occurrence of adverse skin reactions, can substantially impact veteran benefit expenses and budgets. This may be a consideration for the military as it evaluates its policies related to tattoos among service members.

Benzo(ghi)perylene (BgP) a black tattoo ingredient induced skin toxicity via direct and indirect mode of DNA damage under UVA irradiation

Tattooing is a very common fashion trend across all the ages and gender of the society worldwide. Although skin inflammatory diseases are very frequent among tattoo users because of the active chemical ingredients used in tattoo ink, yet no ingredient-specific toxicity study has been performed. Benzo(ghi)perylene (BgP) is one of the PAHs and an important ingredient of black tattoo ink that shows strong absorption in UVA and UVB radiation of sunlight. Therefore, understanding the hazardous potential of BgP especially under UVA exposure is important for the safety of skin of tattoo users by considering the fact that penetration of UVA is in the dermis region where tattoo ingredients reside. To evaluate the hazardous potential of BgP on human skin under UVA exposure, different experimental tools i.e., in-chemico, in-silico and in-vitro were utilized. Our results illustrated that BgP photosensitized under UVA (1.5 mW/cm²) irradiation shows a degradation pattern till 4 h exposure. Photosensitized BgP reduced significant cell viability (%) at 1 μg/ml concentration. However, the pretreatment of singlet and hydroxyl radical quenchers, restoration of cell viability observed, confirmed the role of type-I and type-II photodynamic reactions in phototoxicity of BgP. Further, intracellular uptake of BgP in HaCaT cells was estimated and confirmed by UHPLC analysis. Molecular docking of BgP with DNA and formation of γ-H2AX foci demonstrated the DNA intercalation and double-stranded DNA damaging potential of BgP. Furthermore, acridine orange and ethidium bromide (AO/EB) dual staining showed apoptotic cell death via photosensitized BgP under UVA irradiation. The above findings suggest that BgP reached the human skin cell and induced dermal toxicity via direct and indirect mode of DNA damage under UVA exposure finally promoting the skin cell death. Thus, BgP-containing tattoo ink may be hazardous and may induce skin damage and diseases, especially in presence of UVA radiation of sunlight. To minimize the risk of skin diseases from synthetic ingredients in tattoo ink, the study highlights the importance of developing eco-friendly and skin-friendly tattoo ingredients by companies.

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.

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.

Permanent Make-Up (PMU) Inks Decolorization Using Plant Origin Materials

Permanent make-up (PMU) has become a very popular application over the last few years. The ingredients of PMU inks, used over the face area, are organic and inorganic substances very close to the chemical composition of tattoo inks. As the application rates increase, the demand for PMU removal rises. The aim of this study is to assess the decolorization of PMU inks using preparations originating from different plant sources. The leaves of Pelargonium zonale (PE) were extracted with water for 48 h. The Total Phenolic Content (TPC) of the extract was determined using the Folin–Ciocalteu technique reaching 201.34 ± 4.57 μg Gallic Acid Equivalents (GAE)/mL of extract. The antioxidant activity of the extract was 20.87 ± 0.36 μg of Trolox equivalents (TE)/mL and 3.56 ± 0.43 mg FeSO4×7H2O mL of extract when assessed by 2,2-diphenyl-1-picrylhydrazyl (DPPH) or ferric reducing antioxidant power (FRAP) assay respectively. The decolorization potential of PE leaf extract on five commercially available PMU inks of different hues was assessed by UV-Vis spectrophotometry in comparison to polyphenol oxidases enzyme (PPO). The results demonstrated higher absorption reduction that indicates decolorization potential for the inks that have mainly ferrous oxides as colorants.

Histopathology of Dermatologic Complications of Tattoos

ABSTRACT

Tattoos are characterized by the introduction of exogenous pigments into the dermis. Tattoos usually serve cosmetic purposes, although they may have other causes, such as traumatic pigment implants in accidents or medical-related tattoos in the context of radiotherapy. Dermatologic adverse reactions are relatively uncommon, and they include infections, immune-mediated reactions, cutaneous lesions secondary to the Koebner phenomenon, exacerbation of preexisting dermatosis, benign and malignant neoplasms, and a miscellaneous group of dermatologic conditions that may appear in a preexisting tattoo. The aim of this study is to review the types of histopathologic reactions that may appear in a preexisting permanent tattoo.

Tattooing in Psoriasis: A Questionnaire-Based Analysis of 150 Patients

Purpose

Among populations of Western countries, tattoos have become an accepted form of skin ornamenting. With tattoos growing in popularity, also patients suffering from chronic dermatoses may more often be willing to get tattooed. Psoriasis is not considered as a strict contraindication for tattooing; however, it is not advised to get a tattoo while undergoing immunosuppressive treatment and during an active stage of the disease. We attempted to assess the knowledge level of tattooed psoriatic patients about the potential risks connected with tattooing, as well as to explore their attitudes and tendencies towards this procedure. Moreover, we analyzed the frequency and type of tattoo complications in this study group.

Patients and Methods

An anonymous, online questionnaire was performed among online communities dedicated to psoriasis. Data from 150 tattooed psoriatic patients have been scrutinized.

Results

Eight percent of the surveyed psoriatic patients sought medical advice before getting a tattoo. While undergoing the tattooing procedure, 23 (15.3%) of the respondents received systemic psoriasis treatment: 8 (5.3%) being treated with methotrexate, 5 (3.3%) with cyclosporine A, one (0.7%) acitretin, and 9 (6%) patients were under biological treatment. Thirteen (8.7%) of the participants experienced complications associated with their tattoos, among which, the insurgence of the Koebner phenomenon on the tattoo, was the most frequent one (8 cases- 5.3%). Getting tattooed improved patients' self-esteem in 76 (50.7%) of the cases.

Conclusion

An increased level of education among patients, medical practitioners, and tattooists concerning general precautions of tattooing in psoriasis is advisable.

Complications of tattoos and permanent makeup: overview and analysis of 308 cases

BACKGROUND

Worldwide 10-20% of the population is tattooed. However, tattoo complications can occur, such as allergic tattoo reactions, infections, and manifestations of autoimmune dermatoses. Despite the growing popularity of tattoos and changes in tattoo ink composition over the last decades, little is known about these complications, its clinical aspects, pathomechanism, and relative occurrence.

OBJECTIVE

The aim of this article is to describe the types and clinical aspects of dermatological tattoo complications, its relative occurrence and underlying conditions.

METHODS

We performed a retrospective cohort study enrolling all patients with tattoo complications from the Tattoo Clinic. Tattoo complications were categorized into infections, inflammatory tattoo reactions, neoplasms, or miscellaneous reactions and correlated to clinical data.

RESULTS

Of the total of 326 patients, 301 patients were included with 308 complications. The majority of the complications were chronic: 91.9%. Allergic red tattoo reactions and chronic inflammatory black tattoo reactions (CIBTR) accounted for 50.2% and 18.2%, respectively, of all tattoo complications. Of these CIBTR reactions, extracutaneous involvement was found in 21.4%, including tattoo-associated uveitis (7.1%) and systemic sarcoidosis (14.2%). Of all black tattoo reactions, systemic sarcoidosis was found in 7.8%.

CONCLUSION

Tattoos can cause a wide range in complications that may start years after getting the tattoo. The most frequent tattoo reactions are allergic red tattoo reactions and chronic inflammatory black tattoo reactions, making these the most relevant for the dermatologist. CIBTR have a high percentage of multi-organ involvement, and therefore, screening for sarcoidosis, including ocular involvement, is advised.

Phototoxic versus photoprotective effects of tattoo pigments in reconstructed human skin models: In vitro phototoxicity testing of tattoo pigments: 3D versus 2D

The increasing number of tattooed persons urges the development of reliable test systems to assess tattoo associated risks. The alarming prevalence of 60 % phototoxic reactions in tattoos ask for a more comprehensive investigation of phototoxic reactions in tattooed skin. Here, we aimed to compare the cellular responses of human skin cells to ultraviolet (UV)A and UVB irradiation in doses of short to intermitted sun exposure (3-48 J/cm² and 0.05-5 J/cm², respectively) in the presence of tattoo pigments. Therefore, we used fibroblast monolayer culture (2D), our recently developed three dimensional full-thickness skin model with dermal-located tattoo pigments (TatS_FT) and its dermal equivalents (TatS_DE) that lack keratinocytes. We tested the most frequently used tattoo pigments carbon black, titanium dioxide (TiO₂) anatase and rutile as well as Pigment Orange (P.O.)13 in ranges from 0.067 to 2.7 ng/cell in 2D. For TatS_DE and TatS_FT, concentrations were 1.3 ng/cell for TiO₂, 0.67 ng/cell for P.O.13 and 0.067 ng/cell for carbon black. We assessed cell viability and cytokine release in all systems, and cyclobutane pyrimidine dimer (CPD) formation in TatS_FT. Phototoxicity of tattoo pigments was exclusively observed in 2D, where especially TiO₂ anatase induced phototoxic effects in all concentrations (0.067-2.7 ng/cell). In contrast, fibroblasts were protected from UV irradiation in TatS_DE by TiO₂ and carbon black. Neither toxic nor protective effects were recorded in TatS_FT. P.O.13 showed altered cytokine secretion in 2D (0.067-1.3 ng/cell) and TatS_DE, despite the absence of significant effects on viability in all systems. All pigments reduced the number of CPDs in TatS_FT compared to the pigment-free controls. In conclusion, our study shows that within a 3D arrangement, intradermal tattoo pigments may act photoprotective despite intrinsic phototoxic properties in 2D. Thus, dermal 3D equivalents should be considered to evaluate acute tattoo pigment toxicology.

Tattoos - more than just colored skin? Searching for tattoo allergens

During tattooing, a high amount of ink is injected into the skin. Tattoo inks contain numerous substances such as the coloring pigments, impurities, solvents, emulsifiers, and preservatives. Black amorphous carbon particles (carbon black), white titanium dioxide, azo or polycyclic pigments create all varieties of color shades in the visible spectrum. Some ingredients of tattoo inks might be hazardous and allergenic chemicals of unknown potential. In Germany, about 20 % of the general population is tattooed and related adverse reactions are increasingly reported. Since tattoo needles inevitably harm the skin, microorganisms can enter the wound and may cause infections. Non-allergic inflammatory reactions (for example cutaneous granuloma and pseudolymphoma) as well as allergic reactions may emerge during or after wound healing. Especially with allergies occurring after weeks, months or years, it remains difficult to identify the specific ingredient(s) that trigger the reaction. This review summarizes possible adverse effects related to tattooing with a focus on the development of tattoo-mediated allergies. To date, relevant allergens were only identified in rare cases. Here we present established methods and discuss current experimental approaches to identify culprit allergens in tattoo inks - via testing of the patient and in vitro approaches.

The effect of a color tattoo on the local skin redox regulatory network: an N-of-1 study

Biomedical aspects of tattooing have been extensively discussed in literature, however pathophysiological effects of tattoo inks in the human body are still unexplored. Oxidative stress is considered responsible for the adverse effects of tattooing, however no experimental evidence for tattoo ink-related oxidative stress in the human body currently exists. The aim was to examine the effect of a blue tattoo on skin redox regulatory network (RRN) parameters in a single human subject. Skin surface oxidation-reduction potential (ORP) was analyzed with a PH60F flat probe. Interstitial and intracellular fluid enriched capillary blood from the tattoo and the control area was extracted and analyzed with I2/KI-stabilized microORP, nitrocellulose redox permanganometry (NRP), carbonato-cobaltate (III) formation-derived H2O2 dissociation rate assay, 1,2,3-trihydroxybenzene autoxidation assay, thiobarbituric reactive substances (TBARS) assay and 5,5,'-dithio-bis-(2-nitrobenzoic acid) (DTNB)-based determination of free thiol content in low molecular weight and protein precipitate fractions. Surface ORP analysis revealed a greater antioxidant capacity of tattooed skin in comparison with the control (CTR). Capillary blood analysis confirmed greater reductive capacity in the tattoo sample both by microORP (-4.33 mV vs CTR) and NRP (+10.8%). Hydrogen peroxide dissociation rate (+11.8%), and protein sulfhydryl content (+8.5%) were increased, and lipid peroxidation (-15%) was reduced in the tattoo sample in comparison with the CTR. In this N-of-1 study, RRN of tattooed skin was shifted toward a more reductive state with all parameters indicating reduced levels of oxidative stress in comparison with nontattooed skin. The local antioxidant effect of copper(II) phthalocyanine provides one possible explanation of the observed effects.

Histopathological evaluation of cutaneous reactions to tattoos: Study at a tertiary care center

BACKGROUND

Tattooing has been around for many years and is becoming an increasingly common fashion trend. As there are often few regulatory laws regarding the practice, an increase in the incidence of cutaneous reactions to tattoo inks is noted. These include allergic reactions, granulomatous dermatitis, infections, lichenoid dermatoses, and sometimes malignancy. The present study examines the histopathological changes seen in patients with cutaneous reactions to tattoo ink.

METHOD

A prospective observational study was conducted over 18 months in the dermatology clinic of a tertiary care center in western India. The study population included 22 patients with cutaneous reactions over the tattoos. Punch biopsy specimens were sent to study the pattern of histopathological response.

RESULTS

All 22 patients studied were between the ages of 17 and 35 years. The mean duration of development of reaction was 8.1 months. Most of the reactions were seen in black ink tattoos performed by amateurs. Perivascular and spongiotic dermatitis suggestive of allergic response was the most common feature on histopathology. Granulomatous response and lichenoid response were seen in five and three biopsies, respectively.

CONCLUSION

Legalization is needed for this practice to prevent tattoo reactions. Histopathological evaluation is important as tattoo reactions may be associated with skin infections and malignancies.

How to advise a patient who wants a tattoo?

Tattooing and permanent make-up have become mainstream procedures. Many factors play a role in the final outcome of a tattoo and the satisfaction of the customer. The technical and artistic skills of the tattooist will determine the esthetic result and will help to guide the customers in their decision and choice of the tattoo. Although tattooing is by many considered as safe one should be are aware of the risks of complications related to this body modification technique. Some customers have a medical problem and some doubt about the safety of the procedure. People with increased risk of adverse events often seek medical advice prior to decide to get a tattoo or PMU. Physicians should not only be informed about the medical history of their patients but also have some basic knowledge of the practice of tattooing and the effects this procedure can exert on the skin and on the health condition of the patient. Contraindications and special precautions with regard to skin diseases and specific systemic conditions will be addressed in this article.

TatS: a novel in vitro tattooed human skin model for improved pigment toxicology research

Reports of tattoo-associated risks boosted the interest in tattoo pigment toxicity over the last decades. Nonetheless, the influence of tattoo pigments on skin homeostasis remains largely unknown. In vitro systems are not available to investigate the interactions between pigments and skin. Here, we established TatS, a reconstructed human full-thickness skin model with tattoo pigments incorporated into the dermis. We mixed the most frequently used tattoo pigments carbon black (0.02 mg/ml) and titanium dioxide (TiO2, 0.4 mg/ml) as well as the organic diazo compound Pigment Orange 13 (0.2 mg/ml) into the dermis. Tissue viability, morphology as well as cytokine release were used to characterize TatS. Effects of tattoo pigments were compared to monolayer cultures of human fibroblasts. The tissue architecture of TatS was comparable to native human skin. The epidermal layer was fully differentiated and the keratinocytes expressed occludin, filaggrin and e-cadherin. Staining of collagen IV confirmed the formation of the basement membrane. Tenascin C was expressed in the dermal layer of fibroblasts. Although transmission electron microscopy revealed the uptake of the tattoo pigments into fibroblasts, neither viability nor cytokine secretion was altered in TatS. In contrast, TiO2 significantly decreased cell viability and increased interleukin-8 release in fibroblast monolayers. In conclusion, TatS emulates healed tattooed human skin and underlines the advantages of 3D systems over traditional 2D cell culture in tattoo pigment research. TatS is the first skin model that enables to test the effects of pigments in the dermis upon tattooing.

Incorporation in Lipid Microparticles of Acid Red 87, a Colorant Used in Tattoo Inks: Effect on Photodegradation Under Simulated Sunlight and Laser Radiation

Tattoo colorants decompose under solar radiation and when exposed to laser light for their removal, leading to the accumulation in the dermis of toxic products. Aim of this study was to develop lipid microparticles (LMs) loaded with the colorant, Acid Red 87 (C.I. 45380) used in tattoo inks, and to investigate the effect of this system on the photostability of the colorant under simulated sunlight or laser irradiation. LMs loaded with C.I. 45380 were prepared by melt emulsification using tristearin and phosphatidylcholine as excipients. They were characterized by optical microscopy, laser diffraction, X-ray diffraction and release studies. Free C.I. 45380 and the colorant-loaded LMs were irradiated with a solar simulator or a Q-switched laser. Irradiation with a solar simulator demonstrated that photodecomposition of C.I. 45380 was markedly reduced by incorporation of the dye in the LMs, from 20.5 ± 4.6% to 1.3 ± 1.8%. Conversely, the laser-induced degradation of the colorant (30.1 ± 6.6%) was not significantly influenced by encapsulation in the LMs (the encapsulated C.I. 45380 loss was 27.4 ± 5.5%). Incorporation of C.I. 45380 in lipid microparticles enhances the photostability under sunlight of tattoo inks containing this colorant, without affecting its laser-induced degradation and hence laser removal efficiency.

Identification of pigments related to allergic tattoo reactions in 104 human skin biopsies

Background

Red tattoos are prone to allergic reactions. The identity of the allergen(s) is mostly unknown.

Objectives

Chemical analysis of human skin biopsies from chronic allergic reactions in red tattoos to identify culprit pigment(s) and metals.

Material and methods

One hundred four dermatome biopsies were analyzed by matrix‐assisted laser desorption/ionization tandem mass spectrometry (MALDI‐MS/MS) for identification of commonly used organic pigments. Metal concentrations were assessed by inductively coupled plasma (ICP)‐MS and x‐ray fluorescence (XRF). Fourteen patients had cross‐reactions in other red tattoos.

Results

In total, the identified pigments were mainly azo Pigment Red (P.R.) 22 (35%), P.R. 210 (24%), P.R. 170 (12%), P.R. 5 (0.9%), P.R. 112 (0.9%), and Pigment Orange (P.O.) 13 (11%). P.R. 122 (0.9%) and Pigment Violet (P.V.) 23 (8%) were also common. P.R. 22, P.R. 170, and P.R. 210 also dominated in patients with cross‐reactions. In 22% of the biopsies, no red pigment was detected. Element analysis indicated the presence of the sensitizers nickel and chromium.

Conclusions

P.R. 22, P.R. 170, and P.R. 210 were identified as the prevailing pigments behind chronic allergic reactions in red tattoos. The epitope causing the reaction might be a pigment‐degradation product. Metal contamination may derive from different sources, and its role in red tattoo allergy cannot be ascertained.

An update on cutaneous complications of permanent tattooing

Introduction: Decorative tattooing involves the introduction of exogenous pigments and/or dyes into the dermis to produce a permanent design.Areas covered: This review provides an overview of the current aspects of cutaneous complications associated with permanent tattooing and permanent make-up based on the previous reviews of interest, case series, and case reports of interest. References for this review were found through a search of PubMed by use of the terms 'tattoo', 'tattoos', or 'tattooing'.Expert opinion: Complications include primarily infections, allergy to tattoo pigments, benign, and sometimes malignant tumors arising on tattoos and the localization of various dermatoses to tattoos. Immunocompromised patients and individuals with chronic conditions should be able to discuss with their physician and ask advice before getting tattooed. Tattoo color allergy still remains an unsolved issue. The identification of current culprit failed. It is most likely a byproduct that appears in situ in the skin during the life of the tattooed bearer. Studies involving expert centers are warranted to establish the best treatments for tattoo allergy. The risk of tattoo associated cancers appears to this author as largely overstated. However, case controls studies on large on cohorts of individuals with or without tattoos could help to evaluate whether tattoos have a possible in role in cancers.

Tattooist-Associated Tattoo Complications: "Overworked Tattoo," "Pigment Overload" and Infections Producing Early and Late Adverse Events

BACKGROUND

Tattooist-related technical failures of tattooing were hitherto unstudied and related to clinical complications. Tattooing requires talent, training and experience. Amateurism is a challenge in popular tattoo industry with no formal education and certification of the tattooists.

OBJECTIVE

To study technical tattoo failures causing disease in a consecutive hospital material of tattoo complications.

MATERIAL

574 patients with 702 tattoo complications referred to the "Tattoo Clinic" (a subspecialised dermatological clinic) were enrolled. Patients were examined clinically and classified with respect to the cause of complication.

RESULTS

147 (21%) tattooist and tattoo studio-related complications were recorded, i.e. excessive pigment installed in the dermis with "pigment overload" in 64 (9%), tattoo "needle trauma" with "overworked tattoos" in 43 (6%), contaminated ink causing infection in 20 (3%), and other sources of infections related to tattooing in 20 (3%). Pain and discomfort were particularly common as well as long-term complications including scarring induced by "needle trauma." "Pigment overload" with black pigment carried a special risk of granulomatous inflammation and sarcoid granuloma and was observed in 12/35 (34%) of punch biopsies taken from tattoos with "pigment overload." Keratoacanthoma associated with trauma was observed in 1 case. 82% of complications were related to professional tattooists working in a tattoo studio and 18% to amateurs.

CONCLUSION

Technical failures of tattooing are associated with medical tattoo complications. "Needle trauma" with major skin damage, e.g. "overworked tattoo," and installation of excessive pigment, e.g. "pigment overload," and (re)use of contaminated tattoo ink bottles are identified failures calling for preventive intervention.

Comparison of the skin sensitization potential of 3 red and 2 black tattoo inks using interleukin-18 as a biomarker in a reconstructed human skin model

BACKGROUND

During the last decade, the number of people with ≥1 tattoo has increased noticeably within the European population. Despite this, limited safety information is available for tattoo inks.

OBJECTIVES

To test the skin sensitization potential of 5 tattoo inks in vitro by using reconstructed human skin (RHS) and the contact sensitization biomarker interleukin (IL)-18.

METHODS

Two red and 3 black tattoo inks, 1 additive (Hamamelis virginiana extract) and 1 irritant control (lactic acid) were tested. The culture medium of RHS (reconstructed epidermis on a fibroblast-populated collagen hydrogel) was supplemented with test substances in a dose-dependent manner for 24 hours, after which cytotoxicity (histology; thiazolyl blue tetrazolium bromide assay) and skin sensitization potential (IL-18 secretion; enzyme-linked immunosorbent assay) were assessed.

RESULTS

All but 1 ink showed cytotoxicity. Notably, 1 red ink and 1 black ink were able to cause an inflammatory response, indicated by substantial release of IL-18, suggesting that these inks may be contact sensitizers.

CONCLUSIONS

The in vitro RHS model showed that 4 tattoo inks were cytotoxic and 2 were able to cause an inflammatory IL-18 response, indicating that an individual may develop allergic contact dermatitis when exposed to these tattoo inks, as they contain contact sensitizers.

A Practical Guide About Tattooing in Patients with Chronic Skin Disorders and Other Medical Conditions

With tattoos becoming increasingly mainstream, dermatologists are more and more often consulted by patients who are considering getting an ornamental, cosmetic, or even a medical tattoo, and who subsequently ask for advice. This includes not only patients with chronic skin diseases such as psoriasis or atopic dermatitis but also patients with other medical conditions. This review first explores the reasons why patients may want to get a tattoo and aims to offer some key information to dermatologists on what they should know about tattooing and the main risks associated with this procedure. Second, the risks and recommendations of tattooing in patients with specific skin diseases are described more in detail, and the relative and strict contraindications discussed, including the necessity to discontinue certain treatments that could influence the outcome of the procedure and the final result. Our aim was to provide dermatologists with the current knowledge they need to help their patients make adequate and informed choices on skin art, focusing specifically on considerations in patients with chronic skin conditions. Finally, other aspects regarding some general systemic conditions and concomitant diseases that the patient could present are also addressed. In particular, the risks of tattooing in patients with diabetes, coagulation disorders, heart conditions, immunosuppressive treatments, and pregnancy are discussed.

Diagnostic Tools to Use When We Suspect an Allergic Reaction to a Tattoo: A Proposal Based on Cases at Our Hospital

INTRODUCTION

Tattooing has become a popular practice in western countries, particularly among younger populations. Tattoos, however, can cause complications, such as infections, allergic or foreign-body reactions, and even systemic inflammatory responses.

PATIENTS AND METHODS

We conducted a retrospective study of all patients seen for tattoo-related complications at our skin allergy unit between January 2002 and December 2016.

RESULTS

We studied 23 patients. Nine of these experienced early complications, all related to infection. The other 14 patients developed late reactions. Ten were diagnosed with probable allergic contact dermatitis to ink, but the suspect allergen was identified in just 3 cases and confirmed in just 1 of these. There were 2 cases of cutaneous sarcoidosis, 1 case of foreign body granuloma, and 1 case of neuropathy.

CONCLUSIONS

Complications resulting from tattoos are relatively common dermatology complaints. Drawing from our experience, we propose a diagnostic algorithm designed to guide dermatologists in evaluating different reactions to tattoos and prescribing appropriate treatment.

Cutaneous and systemic complications associated with tattooing

Tattooing can result in a wide variety of complications, whose prevalence and incidence remain still unclear. Hypersensitivity reactions (or allergies) to tattoo pigments are currently the most common complication on a tattoo, however they are not predictable. Infections are nowadays directly related to the lack of asepsis and hygiene during the tattooing procedure or during the healing phase. Patients with a known cutaneous disease should be warned of a potential risk of localization of their disease to the tattoo. A skin eruption restricted to a tattoo may reveal sarcoidosis. Patients with chronic conditions and/or impaired immunity should discuss with their physician about the possibility and when to have a tattoo.

Patterns of Reactions to Red Pigment Tattoo and Treatment Methods

Tattoos are common and used extensively as either body art or cosmetic make-up; more rarely, they can be traumatic in nature. We have systemically analysed the literature for the patterns of red pigment tattoo reactions and their treatment options. Our search identified 18 articles; there was 1 non-randomised controlled trial, and the rest were small case studies. In total 139 patients were included within the studies. This review systematically analyses the different subsets of red tattoo reactions including lichenoid, dermatitis, granulomatous, pseudolymphomatous and miscellaneous reactions. The current evidence for the treatment for the above is presented. Dermatitis and lichenoid reactions appear to be the most common subtype of red pigment reactions with various treatment methods applied showing laser intervention to have some degree of success.

A medical-toxicological view of tattooing

Long perceived as a form of exotic self-expression in some social fringe groups, tattoos have left their maverick image behind and become mainstream, particularly for young people. Historically, tattoo-related health and safety regulations have focused on rules of hygiene and prevention of infections. Meanwhile, the increasing popularity of tattooing has led to the development of many new colours, allowing tattoos to be more spectacular than ever before. However, little is known about the toxicological risks of the ingredients used. For risk assessment, safe intradermal application of these pigments needs data for toxicity and biokinetics and increased knowledge about the removal of tattoos. Other concerns are the potential for phototoxicity, substance migration, and the possible metabolic conversion of tattoo ink ingredients into toxic substances. Similar considerations apply to cleavage products that are formed during laser-assisted tattoo removal. In this Review, we summarise the issues of concern, putting them into context, and provide perspectives for the assessment of the acute and chronic health effects associated with tattooing.

Self-reported tattoo reactions in a cohort of 448 French tattooists

BACKGROUND

Self-reported complaints in people having tattoos, including swelling, itch, and photosensitivity, are frequent. Tattooists are usually heavily tattooed with multiple extended colored tattoos and constitute a specific population of interest.

OBJECTIVES

To assess the prevalence of cutaneous complications on tattoos among a cohort of French tattooists.

METHODS

An observational self-reported internet survey was performed among the tattooists of the French Tattoo Union in November 2013 to report on complaints about their tattoos.

RESULTS

Of the 448 respondents, 42.6% reported a "tattoo reaction" on a least one of their previous tattoos: transient itch (45.7%), wax-and-waning swelling (57%), and swelling after sun exposure (23%). A tattoo "allergy" on one color of the tattoo was found in 8%. Permanent itch, swelling, and cutaneous infection were rare. No skin cancer on tattoos was reported. The binary regression analysis revealed that the area of the tattooed body surface was the main driver of the risk of developing a tattoo reaction, mainly transient or permanent swelling triggered by sun exposure or not. The tattoo reaction, transient itch, and swelling on tattoos seemed to be associated with the sun protection habits of the tattooed individuals.

CONCLUSION

Professional tattooists have a high prevalence of minor complaints (transient itch and swelling) and photosensitivity on their tattoos such as in the general tattooed population.

Bioanalytical evidence that chemicals in tattoo ink can induce adaptive stress responses

Tattooing is becoming increasingly popular, particularly amongst young people. However, tattoo inks contain a complex mixture of chemical impurities that may pose a long-term risk for human health. As a first step towards the risk assessment of these complex mixtures we propose to assess the toxicological hazard potential of tattoo ink chemicals with cell-based bioassays. Targeted modes of toxic action and cellular endpoints included cytotoxicity, genotoxicity and adaptive stress response pathways. The studied tattoo inks, which were extracted with hexane as a proxy for the bioavailable fraction, caused effects in all bioassays, with the red and yellow tattoo inks having the greatest response, particularly inducing genotoxicity and oxidative stress response endpoints. Chemical analysis revealed the presence of polycyclic aromatic hydrocarbons in the tested black tattoo ink at concentrations twice the recommended level. The detected polycyclic aromatic hydrocarbons only explained 0.06% of the oxidative stress response of the black tattoo ink, thus the majority of the effect was caused by unidentified components. The study indicates that currently available tattoo inks contain components that induce adaptive stress response pathways, but to evaluate the risk to human health further work is required to understand the toxicokinetics of tattoo ink chemicals in the body.

Formation of highly toxic hydrogen cyanide upon ruby laser irradiation of the tattoo pigment phthalocyanine blue

Since laser treatment of tattoos is the favored method for the removing of no longer wanted permanent skin paintings, analytical, biokinetics and toxicological data on the fragmentation pattern of commonly used pigments are urgently required for health safety reasons. Applying dynamic headspace—gas chromatography with mass spectrometric detection (DHS—GC/MS) and comprehensive two-dimensional gas chromatography coupled to time-of-flight mass spectrometry (GCxGC—ToF-MS), we identified 1,2-benzene dicarbonitrile, benzonitrile, benzene, and the poisonous gas hydrogen cyanide (HCN) as main fragmentation products emerging dose-dependently upon ruby laser irradiation of the popular blue pigment copper phthalocyanine in suspension. Skin cell viability was found to be significantly compromised at cyanide levels of ≥1 mM liberated during ruby laser irradiation of >1.5 mg/ml phthalocyanine blue. Further, for the first time we introduce pyrolysis-GC/MS as method suitable to simulate pigment fragmentation that may occur spontaneously or during laser removal of organic pigments in the living skin of tattooed people. According to the literature such regular tattoos hold up to 9 mg pigment/cm² skin.