The prevalence of tattooing and motivations in five major countries over the world

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.

New tatt? We're ok with that! Relaxing the tattoo deferral for plasmapheresis donors maintains safety and increases donations

BACKGROUND AND OBJECTIVES

Tattooing is one of the leading donor deferral reasons in Australia. Until September 2020, donors were deferred from all donation types for 4 months after a tattoo. At this time, our guideline changed such that donations of plasma for further manufacture were accepted immediately, provided the tattoo was administered in a licensed or regulated Australian establishment. We examined the effects of this change.

MATERIALS AND METHODS

Donors with a tattoo deferral in the 2 years before or after the guideline change were identified and followed up until 3 November 2022. Between the two periods, we compared blood-borne virus (BBV) incidence, donor return, and the number of donors and donations regained after deferral.

RESULTS

The incidence of BBV infection in donors after a tattoo deferral was zero in both periods. To exceed a residual risk of 1 in 1 million for hepatitis C virus, 190 donors would need to be infected yearly from a tattoo. Donors returned to donate significantly faster after the change (median return 85 days compared with 278 days). An extra 187 donations per 10,000 person-years of observation were gained, yielding a total of 44,674 additional plasma donations nationally 0-4 months after getting a tattoo.

CONCLUSION

Allowing plasma donations immediately post-tattoo resulted in a substantial donation gain with no adverse safety effect. Lifeblood subsequently reduced the deferral for transfusible component donations to 7 days for tattoos in Australian licensed/regulated establishments.

Associations of demographic, health, and risk-taking behaviors with tattooing in a population-based cross-sectional study of ~18,000 US adults

Background

Little is known about current characteristics of individuals with tattoos. We quantified the prevalence of tattooing and associations of demographic, health, and risk-behavior factors with tattooing.

Methods

We computed adjusted prevalence ratios (PR) of tattooing in a population-based analysis of > 18,000 Utah adults from the 2020-2021 Behavioral Risk Factor Surveillance System survey.

Results

The prevalence of tattooing was 26% among women and 22% among men, with the highest prevalence among women ages 25-29 (45%). Tattoo prevalence was higher among younger individuals, individuals with a lower education level, and those without religious affiliation. Tattoo prevalence was higher among indviduals with current tobacco (women: PR = 2.89 [95% confidence interval (CI): 2.60, 3.20]; men: 3.39 [2.98, 3.86]), e-cigarette (women: 2.44 [2.21, 2.69]; men: 2.64 [2.37, 2.94]), and heavy alcohol use (women: 2.16 [1.93, 2.43]; men: 1.89 [1.63, 2.19]). Tattoo prevalence was lower among individuals receiving a flu (women: 0.84 [0.76, 0.92]; men: 0.75 [0.67, 0.84]) or COVID-19 vaccine (women: 0.65 [0.54, 0.79]; men: 0.75 [0.61, 0.92]).

Conclusions

Several risk-taking behaviors were associated with tattooing. Tattoo studios/conventions may present opportunities for partnership with tobacco cessation, alcohol reduction, and vaccination public health initiatives.

Detection of anaerobic and aerobic bacteria from commercial tattoo and permanent makeup inks

Tattooing and use of permanent makeup (PMU) have dramatically increased over the last decade, with a concomitant increase in ink-related infections. Studies have shown evidence that commercial tattoo and PMU inks are frequently contaminated with pathogenic microorganisms. Considering that tattoo inks are placed into the dermal layer of the skin where anaerobic bacteria can thrive and cause infections in low-oxygen environments, the prevalence of anaerobic and aerobic bacteria should be assessed in tattoo and PMU inks. In this study, we tested 75 tattoo and PMU inks using the analytical methods described in the FDA Bacteriological Analytical Manual Chapter 23 for the detection of both aerobic and anaerobic bacterial contamination, followed by 16S rRNA gene sequencing for microbial identification. Of 75 ink samples, we found 26 contaminated samples with 34 bacterial isolates taxonomically classified into 14 genera and 22 species. Among the 34 bacterial isolates, 19 were identified as possibly pathogenic bacterial strains. Two species, namely Cutibacterium acnes (four strains) and Staphylococcus epidermidis (two strains) were isolated under anaerobic conditions. Two possibly pathogenic bacterial strains, Staphylococcus saprophyticus and C. acnes, were isolated together from the same ink samples (n = 2), indicating that tattoo and PMU inks can contain both aerobic (S. saprophyticus) and anaerobic bacteria (C. acnes). No significant association was found between sterility claims on the ink label and the absence of bacterial contamination. The results indicate that tattoo and PMU inks can also contain anaerobic bacteria.

IMPORTANCE

The rising popularity of tattooing and permanent makeup (PMU) has led to increased reports of ink-related infections. This study is the first to investigate the presence of both aerobic and anaerobic bacteria in commercial tattoo and PMU inks under aerobic and anaerobic conditions. Our findings reveal that unopened and sealed tattoo inks can harbor anaerobic bacteria, known to thrive in low-oxygen environments, such as the dermal layer of the skin, alongside aerobic bacteria. This suggests that contaminated tattoo inks could be a source of infection from both types of bacteria. The results emphasize the importance of monitoring these products for both aerobic and anaerobic bacteria, including possibly pathogenic microorganisms.

Tattoos as a risk factor for malignant lymphoma: a population-based case-control study

Background

The popularity of tattoos has increased dramatically over the last few decades. Tattoo ink often contains carcinogenic chemicals, e.g., primary aromatic amines, polycyclic aromatic hydrocarbons, and metals. The tattooing process invokes an immunologic response that causes translocation of tattoo ink from the injection site. Deposition of tattoo pigment in lymph nodes has been confirmed but the long-term health effects remain unexplored. We used Swedish National Authority Registers with full population coverage to investigate the association between tattoo exposure and overall malignant lymphoma as well as lymphoma subtypes.

Methods

We performed a case-control study where we identified all incident cases of malignant lymphoma diagnosed between 2007 and 2017 in individuals aged 20-60 years in the Swedish National Cancer Register. Three random age- and sex-matched controls per case were sampled from the Total Population Register using incidence density sampling. We assessed exposure through a questionnaire in 2021, and data on potential confounders were retrieved from registers. We used multivariable logistic regression to estimate the incidence rate ratio (IRR) of malignant lymphoma in tattooed individuals.

Findings

The study population consisted of 11,905 individuals, and the response rate was 54% among cases (n = 1398) and 47% among controls (n = 4193). The tattoo prevalence was 21% among cases and 18% among controls. Tattooed individuals had a higher adjusted risk of overall lymphoma (IRR = 1.21; 95% CI 0.99-1.48). The risk of lymphoma was highest in individuals with less than two years between their first tattoo and the index year (IRR = 1.81; 95% CI 1.03-3.20). The risk decreased with intermediate exposure duration (three to ten years) but increased again in individuals who received their first tattoo ≥11 years before the index year (IRR = 1.19; 95% CI 0.94-1.50). We found no evidence of increasing risk with a larger area of total tattooed body surface. The risk associated with tattoo exposure seemed to be highest for diffuse large B-cell lymphoma (IRR 1.30; 95% CI 0.99-1.71) and follicular lymphoma (IRR 1.29; 95% CI 0.92-1.82).

Interpretation

Our findings suggested that tattoo exposure was associated with an increased risk of malignant lymphoma. More epidemiologic research is urgently needed to establish causality.

Funding

The Swedish Research Council for Health, Working Life and Welfare.

Tattoo-Induced Exacerbations of Systemic Disease and Uveitis

Purpose: To examine an underreported and underdiagnosed phenomenon with implications for the pathophysiological mechanisms of tattoo-induced uveitis. Methods: Two cases highlighting the clinical presentation of tattoo-related uveitis were evaluated. Results: A 28-year-old man with biopsy-proven sarcoidosis and ocular manifestations presented with worsening retinal vasculitis after acquiring a red-ink tattoo. Each subsequent flare followed acquisition of a new tattoo. A 31-year-old woman without systemic sarcoidosis presented with multiple episodes of bilateral intermediate uveitis and macular edema concurrent with inflammatory granulomas to recently acquired black-ink tattoos. A skin biopsy in both patients showed cutaneous noncaseating granulomas. Conclusions: These cases add to those reported in the literature and emphasize the importance of understanding the modifiable factors of inflammatory ocular disease. Future study is necessary to understand the mechanisms of tattoo-related uveitis.

Incarcerated Ink: A Case of Mycobacterium chelonae

A 30-year-old African American male presented with pain and swelling of the right foot one month after receiving a tattoo on this foot in prison. During his admission for presumed cellulitis, he developed a rash on his contralateral (left) leg, which had been tattooed 10 months prior. A biopsy of the contralateral (left) leg showed acute, chronic, and granulomatous inflammation with a differential diagnosis including infection. His overall condition and both legs worsened, prompting biopsy and tissue culture of the right ankle and foot. Pathology of the right foot showed a granulomatous reaction. Culture grew Mycobacterium chelonae. This case highlights the importance of considering infectious etiologies for rashes appearing within tattoos and represents the importance of a full investigation to obtain the correct diagnosis.

Tattoo-induced allergic contact dermatitis presents diagnostic challenge as a cellulitis mimic

Allergic contact dermatitis (ACD) is a prevalent condition associated with numerous potential allergen exposures. Tattoo ink is variable and may contain allergens that can be overlooked in patient education and diagnosis. We present a 27-year-old female with ACD following a new tattoo. The patient was repeatedly misdiagnosed with cellulitis by three different clinicians and treated with multiple antibiotics without improvement. The correct diagnosis was eventually made in the emergency department (ED). Although the patient was aware of her allergies to nickel and cobalt from patch testing, she was not aware of the potential for tattoo ink to contain these allergens because prior tattoos had not provoked an allergic reaction. Consequently, the appropriate care was delayed by a month, resulting in significant morbidity. This case demonstrates the potential for ACD to present similarly to cellulitis in an ED setting and the need for clinical vigilance in diagnosis of ACD. It also highlights the importance of detailed patient education on potential allergen sources particularly in the context of tattooing, which is performed with unregulated and variable ink products.

Epidural analgesia and tattoos: a modified technique to minimise risks and improve safety

A healthy young woman with a sizeable lumbar tattoo was admitted to the delivery room in active labour at full-term gestation. She was experiencing strong, painful contractions and anxiety, concerned about the possible risks of receiving an epidural through a tattoo. Although there is little published evidence to suggest complications of performing an epidural through a tattoo, some studies report 'tissue coring phenomenon'. The anaesthesiology team informed the patient of the risks inherent in a traditional epidural and the potential long-term risks of receiving an epidural through the tattoo. Upon signing the informed consent form, the modified epidural technique was performed, and its administration proceeded without complications. A healthy boy was born 3.5 hours later in a vacuum-assisted delivery. This article describes the modified epidural technique designed to minimise tissue coring, and the results of 18 months of uneventful patient follow-up.

Knowledge and Attitude Towards Cutaneous Complications of Tattoos and Piercings Among the General Population in Saudi Arabia

Introduction  Tattooing and piercing, which were uncommon in affluent countries, have recently spread throughout societies. Over the past two decades, young people have shown considerable excitement for the practice. This reported growth creates more difficulties because of the numerous operations performed without awareness of health and hygiene requirements. This study aims to assess the knowledge and attitudes of the general population toward the cutaneous complications of tattoos and piercings in Saudi Arabia. Methods This was a web-based descriptive cross-sectional study. An online questionnaire was developed by the study researchers, which included participants' demographic data, their knowledge of tattoos and piercings with associated health effects and possible infections, their attitude towards tattoos and piercings, and their practice and experienced complications regarding tattooing and body piercing. The final validated questionnaire was made publicly available via social media until no more new responses were obtained. Results Eight hundred and forty-eight individuals completed the study questionnaire. The ages of the participants varied from 18 to more than 55 years old, with a mean age of 25.2 ± 13.9 years, and (589 [69.5%]) were female. The most reported health effects and infections were bacterial infections in place of body modification (479 [56.5%]), purpura (380 [44.9%]), cutaneous abscesses (380 [44%]), melanoma (338 [39.9%]), hepatitis B virus (321 [37.9%]), HIV (311 [36.7%]), sepsis (306 [36.2%]), allergic contact dermatitis (296 [35%]), and hepatitis C virus (279 [33.1%]). In total, 336 (39.6%) had an overall good knowledge of tattooing and body piercing hazards, with higher knowledge among females with high education (p< 0.05). Conclusion This study revealed that one in three individuals knew about the health risks and infections associated with tattooing and body piercing. Higher awareness was found among females with high education levels. Of all the associated complications, procedure-related infections were the most common among participants.

Recalls of tattoo and permanent makeup inks in the United States and a follow-up microbiological survey of inks with a previous recall history

In this study, we collected voluntary recall records of tattoo and permanent makeup ink from the U.S. Food and Drug Administration (US FDA) Enforcement Report Database. The recall records contain information, such as recall date, manufacturer, ink color, reason for recall, and the microorganisms detected from the ink samples. Between 2003 and 2021, a total of 15 voluntary tattoo ink recalls occurred in the U.S. market, involving over 200 tattoo inks marketed by 13 manufacturers and one distributor. Fourteen recalls were due to microbial contamination, and one recall was due to allergic reaction. As follow-up, a microbiological survey of 28 tattoo inks of new batches from seven manufacturers having products that were previously recalled was conducted. Aerobic plate count (APC) and enrichment culture methods based on the FDA's Bacteriological Analytical Manual (BAM) were used to detect microbial contamination. The results revealed that six out of 28 tattoo inks were contaminated with bacteria and were produced by two manufacturers. The level of microbial contamination was less than 250 CFU/g in three of the tattoo inks and between 1 × 103 and 1 × 105 CFU/g in the other three inks. Eleven bacterial isolates were identified, including spore-forming Bacillus-related species and potentially pathogenic species. Overall, this study shows that some tattoo ink products produced by manufacturers with a recall history continue to be contaminated with microorganisms. This highlights the need for ongoing monitoring and quality control of such products.

Prostitutes, sailors and professionals - lived experiences of medical school students and staff with tattoos

Background: The aim of this study was to explore the lived experiences of medical school students and staff to uncover gaps in policy and its effects on those with tattoos. Methods: Adopting a phenomenological design, semi-structured interviews were conducted with ten medical teaching staff and students who had tattoos, within one university medical school. Five key themes emerged: tattoo motives, tattoo content, positive and negative views on tattoos and challenges for establishing policy. Results: Findings suggested that no existing stigma towards staff or students exists, however, there is an absence in existing policy regarding tattoos. Participants' motivations for obtaining tattoos mirrored those of the public, most commonly being artistic expression. Images of tattoos related to nature were common. Views on tattoos suggested the need for a full reform of 'dress code' policy for the profession. Several ethically laden scenarios were espoused, highlighting the need for an official stance on tattoos. Policy discussions flagged challenges for those who construct such documents; cultural and generational differences being commonly identified by participants. Conclusions: Universally there was uncertainty on current policy, with no individual able to recount specific guidance. The existence of a hidden curriculum surrounding tattoos within medical school further increases the need for guidance reform.

Investigation of Adverse Reactions in Tattooed Skin through Histological and Chemical Analysis

BACKGROUND

Just as the number of tattooed people has increased in recent years, so has the number of adverse reactions in tattooed skin. Tattoo colourants contain numerous, partly unidentified substances, which have the potential to provoke adverse skin reactions like allergies or granulomatous reactions. Identification of the triggering substances is often difficult or even impossible.

METHODS

Ten patients with typical adverse reactions in tattooed skin were enrolled in the study. Skin punch biopsies were taken and the paraffin-embedded specimens were analysed by standard haematoxylin and eosin and anti-CD3 stainings. Tattoo colourants provided by patients and punch biopsies of patients were analysed with different chromatography and mass spectrometry methods and X-ray fluorescence. Blood samples of 2 patients were screened for angiotensin-converting enzyme (ACE) and soluble interleukin-2 receptor (sIL-2R).

RESULTS

Histology showed variable skin reactions such as eosinophilic infiltrate, granulomatous reactions, or pseudolymphoma. CD3+ T lymphocytes dominated the dermal cellular infiltrate. Most patients had adverse skin reactions in red tattoos (n = 7), followed by white tattoos (n = 2). The red tattooed skin areas predominantly contained Pigment Red (P.R.) 170, but also P.R. 266, Pigment Orange (P.O.) 13, P.O. 16, and Pigment Blue (P.B.) 15. The white colourant of 1 patient contained rutile titanium dioxide but also other metals like nickel and chromium and methyl dehydroabietate - known as the main ingredient of colophonium. None of the 2 patients showed increased levels of ACE and sIL-2R related to sarcoidosis. Seven of the study participants showed partial or complete remission after treatment with topical steroids, intralesional steroids, or topical tacrolimus.

CONCLUSIONS

The combination of the methods presented might be a rational approach to identify the substances that trigger adverse reactions in tattoos. Such an approach might help make tattoo colourants safer in the future if such trigger substances could be omitted.

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.

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.

Exploratory evaluation of tolerability, performance, and cosmetic acceptance of dexpanthenol-containing dermo-cosmetic wash and sun-care products for tattoo aftercare

Background and Aims

Tattoo prevalence has significantly increased over the last decades. Proper tattoo aftercare, such as cleansing, moisturizing, and protection against sunlight, is essential to prevent complications and to keep the beauty of the tattoo. The tolerability, performance, and cosmetic acceptability of two dexpanthenol-containing dermo-cosmetic products, a wash and a sun-care, were investigated on tattooed skin in two separate trials.

Methods

Two single-center, exploratory, open-label cosmetic studies were conducted between August and November 2020 to evaluate the dexpanthenol-containing dermo-cosmetic products. In the first study, healthy adults applied the 2.5% dexpanthenol-containing wash right after their tattoo session daily for 14 consecutive days. In the second study, healthy adults applied the 2.5% dexpanthenol-containing sun-care sun protection factor 50+ cream on existing tattoos that were daily exposed to sunlight for 28 consecutive days. Clinical examination by a dermatologist and self-assessment through subject questionnaires were used to assess the tolerability, acceptance, ease of use, and cosmetic outcomes of both products. Additionally, transepidermal water loss and moisturization assessments were performed to evaluate skin hydration after use of the sun-care product.

Results

Both study products were well tolerated, and no product related adverse events were reported during the studies. At least 90% of the study participants appreciated the performance of the dexpanthenol-containing wash and sun-care product, including moisturizing properties, relief of unpleasant sensations, and preservation of the cosmetic appearance of the tattoo. For the sun-care, it was shown that its application supported maintaining the skin barrier of tattooed skin, while keeping it hydrated.

Conclusion

The 2.5% dexpanthenol-containing wash and sun-care products are well tolerated and appreciated by tattooed subjects. Hence, they represent valid options for tattoo aftercare in line with current recommendations and practice.

“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.

Comparative study of 1064 nm nanosecond, 1064 nm picosecond, 755 nm, and 595 nm lasers for tattoo removal: An essential role by macrophage

OBJECTIVES

Tattoo removal is in high demand, and many types of lasers can be used for tattoo removal. Macrophages play an important role in the persistence of tattoos. However, comparative studies of the efficacy of tattoo removal with different lasers versus the relationship between the destruction of pigment particles or recruitment of macrophages after laser treatment are lacking.

MATERIALS AND METHODS

Tattoo models were established on the rat dorsal surface and randomly treated with 1064 nm nanosecond, 1064 nm picosecond, 755 nm, and 595 nm lasers for one session. Clinical photographic evaluation, melanin index, hematoxylin and eosin staining, identification of macrophages by CD68 staining, and transmission electron microscopy were conducted at different time points.

RESULTS

Regardless of the pulse duration, all lasers included were effective for the removal of black tattoos, with 1064 nm lasers having the best efficacy, followed by 755 and 595 nm lasers. The diameter of the pigment particles and recruitment of dermal macrophages correlated with the efficacy of tattoo removal.

CONCLUSIONS

In this study, the 1064 nm lasers were found to be the most effective for black tattoo removal. However, there was no significant difference between the 1064 nm picosecond and the nanosecond lasers. Macrophage recruitment plays an essential role in pigment metabolism during laser-tattoo removal.

Increased prevalence of transfusion-transmitted diseases among people with tattoos: A systematic review and meta-analysis

Whether having a tattoo increases the risk of transfusion-transmitted diseases (TTDs) is controversial. Although a few studies have suggested a strong association between having tattoos and TTDs, other studies have not shown the significance of the association. In addition, previous studies mainly focused only on hepatitis C viral infections. The objective of our study was to identify the prevalence and risk of TTDs in people with tattoos as compared with the non-tattooed population. A systematic review of the studies published before January 22, 2021, was performed using the Pubmed, Embase, and Web of Science databases. Observational studies on hepatitis C virus (HCV), hepatitis B virus (HBV), human immunodeficiency virus (HIV), and syphilis infections in people with and without tattoos were included. Studies that reported disease status without serological confirmation were excluded. A total of 121 studies were quantitatively analyzed. HCV (odds ratio [OR], 2.37; 95% confidence interval [CI], 2.04–2.76), HBV (OR, 1.55; 95% CI, 1.31–1.83), and HIV infections (OR, 3.55; 95% CI, 2.34–5.39) were more prevalent in the tattooed population. In subgroup analyses, the prevalence of HCV infection was significantly elevated in the general population, hospital patient, blood donor, intravenous (IV) drug user, and prisoner groups. IV drug users and prisoners showed high prevalence rates of HBV infection. The prevalence of HIV infection was significantly increased in the general population and prisoner groups. Having a tattoo is associated with an increased prevalence of TTDs. Our approach clarifies in-depth and supports a guideline for TTD screening in the tattooed population.

Tattoos Dermatological Complications: Analysis of 53 Cases from Northern Poland

BACKGROUND

The frequency of tattoos varies from 10% to 30% across the population worldwide. The growing popularity of tattooing increases the number of cutaneous reactions connected with this procedure. As we have not found any previous studies in the literature concerning tattoo complications in Poland and other Eastern European countries, we believe this to be the first study of this kind.

OBJECTIVE

The primary objective of this study was to evaluate the clinical spectrum of complications associated with the procedure of permanent tattooing among patients from Northern Poland.

METHODS

Medical data of 53 patients who developed tattoo-related cutaneous conditions were analyzed. All of the patients were consulted in the Dermatology, Venereology and Allergology Clinic in Gdańsk in the years 2018-2021. Medical history, dermatological assessment, and photographic documentation of skin lesions were performed in each case. Dermoscopic examination was carried out in 16 cases and 20 skin biopsies of the tattoo reactions were performed.

RESULTS

Twenty-one patients (40%) presented tattoo ink hypersensitivity reactions, out of which 18 were triggered by the red ink. In 11 cases (21%), contact dermatitis has developed after tattooing, while 9 of the patients (17%) presented tattoo infectious complications, including local bacterial infections, common warts, molluscum contagiosum, and demodicosis. We collected 8 cases (15%) of papulonodular reactions in black tattoos, and in 6 of them, histology showed granuloma formation. In 2 cases (4%), symptoms of anaphylaxis were observed after the tattooing procedure, and in another 2 cases (4%), Koebner phenomenon in the tattoo was diagnosed. Dermoscopy was the clue to the diagnosis in 4 cases.

CONCLUSIONS

This is the first report presenting multiple cases of tattoo complications from Eastern Europe. The results of the study are consistent with other researches, showing a similar distribution of tattoo complications and that across the different pigments used, the red ink is most frequently responsible for tattoo reactions. We emphasize the usefulness of dermoscopic examination in the diagnosis of tattoo-related infections and draw the reader's attention to the rare, yet hazardous complications connected with peri-tattooing anaphylaxis.

The efficacy and the adverse reactions of laser-assisted tattoo removal - a prospective split study using nanosecond and picosecond lasers

BACKGROUND

Laser pulses with nanosecond duration (NSL) have been the golden standard to destroy the pigment particles in skin. It is still controversially discussed whether picosecond pulses (PSL) are superior for tattoo removal.

OBJECTIVES

To compare the efficacy and the adverse reactions of nanosecond and picosecond laser pulses in a comparative study.

METHODS

The prospective study included 23 subjects with 30 black or coloured tattoos, which were split into two halves treated with either a new PSL (532, 1064 nm) or standard NSL (694 nm). The lasers were applied at regular time intervals of 4 weeks for up to eight treatments. Tattoo clearance (primary endpoint), pain and adverse reactions (secondary endpoints) were appraised by physicians, blinded observers, and by subjects. The extent and duration of adverse reactions were additionally assessed by using a questionnaire and photo-documentation after each treatment session.

RESULTS

The tattoo clearance appeared to be more effective for PSL compared to NSL but without statistical significance (P > 0.05). Pretreated tattoos responded better to laser treatments than previously untreated tattoos. Subjects felt significantly less pain with PSL than with NSL (P < 0.001). Transient adverse reactions were statistically less pronounced lasting shorter for PSL as for NSL, especially blistering, pruritus, and burning sensation. Hypopigmentation appeared after NSL treatments only, whereas hyperpigmentation was caused by both lasers. No scarring was detected with either laser.

CONCLUSIONS

Both laser systems enable acceptable clearance of most tattoos in the present study. PSL cause less collateral skin damage as compared to NSL.

Laser vs. thermal treatments of green pigment PG36: coincidence and toxicity of processes

Comparative laser and thermal treatments were carried out on PG36, a green phthalocyanine-based pigment, permitted in European countries where legislation on tattoo composition was issued. Prior to the treatments, PG36 was characterized by SEM imaging, EDX, IR and UV-Vis spectroscopies, revealing an excess of Si and C and O as compared to the pure halogenated Cu-phthalocyanine. Laser treatments were carried out with a Nd:YAG device applied to H₂O and propan-2-ol dispersions. Pyrolysis and calcinations were carried out in air or under N₂ flow. The outcome of the different procedures was analyzed by UV-Vis spectroscopy, GC-mass spectrometry, X-ray diffraction of the solid residues, SEM microscopy and dynamic light scattering. The comparative analysis indicated the production of different fragment compounds depending on the treatment, (pyrolysis or laser), and, to some extent, to the solvent of the dispersion, with pyrolysis generating a larger number of hazardous compounds. Hydrocarbons and cyclic siloxanes present as additives in PG36 were stable or degraded depending on the treatment. The morphology of the products is also treatment-dependent with nanoparticles < 20 nm and fibers being produced upon laser treatments only. Based on the experimental findings, the equivalence of laser and thermal treatments is evaluated.

Tattoo aftercare management with a dermo-cosmetic product: Improvement in discomfort sensation and skin repair quality

Background

A moisturizer application during the healing process after a tattoo session is a common practice to help wound healing and to reduce discomfort sensations. This practice was recently recommended by the standard European guidelines on tattoos, with the use of an adapted ointment to keep the site moist.

Aims

To assess the efficacy and the tolerability of a specific dermo‐cosmetic product (Cicabio Pommade, Laboratoire Bioderma, NAOS, France) in tattoo aftercare.

Patients/Methods

Thirty subjects included in this survey applied the product immediately after the tattoo session for 14 days. The objective symptoms (redness, edema, skin repair quality) were assessed by the tattooist and the subjects. The subjective symptoms, discomfort sensations (pain, itching, burning sensations, tingling), soothing, moisturizing, and undesirable effects were assessed by the tattooed individuals.

Results

After 14 days of application, redness was absent for 100% and 96% of subjects according to the tattoo artist and the subjects, respectively, and edema had completely disappeared for both assessors. Most of the subjects rated the skin quality repair and the aesthetic outcomes as very good to excellent. Soothing and moisturizing effects were observed as early as the first day. The effects were maintained over 14 days. Discomfort sensations were judged absent to slight in 96%–100% of cases after 7 days. They were assessed as absent to slight in all cases for pain, itching, and tingling, and in 96% for burning sensations after 14 days. The product was very well tolerated by 87% of the subjects.

Conclusions

Our survey demonstrates that this dermo‐cosmetic product is suitable for tattooed skin aftercare as it reduced skin discomfort as soon as the first day and led to a good skin quality repair while being well tolerated.

Nickel and tattoos: Where are we?

Tattoos are not mentioned as a source of exposure to nickel. Traces of nickel are, however, almost inevitably found in tattoo inks as impurities and sometimes in tattooed skin. Whether nickel in tattoos has any health consequence is debated. We performed a narrative review of what is currently known about this topic. Today, nickel is frequently detected in inks, but at highly variable levels. It appears to be at higher concentrations in green, blue, and sometimes brown and violet inks. Only nickel allergy in tattooed individuals and nickel-associated tattoo ink allergy are addressed in the literature. Reports of tattoo ink allergy related to nickel are rare and heterogenous. Authors often neglect possible implications of other metals or dyes. A positive patch test is not enough to confirm the role of nickel in a reaction observed after tattooing. We found no report of any systemic complication attributed to nickel from tattoos. The Council of Europe ResAP(2008)1 bans the presence of nickel at high levels in tattoo inks, which is a safety net for individuals with nickel allergy. Large epidemiologic case-control studies with systematic biopsies on normal and inflamed tattoos and patch testing would help to understand the role of nickel in tattoo ink allergies.

Health knowledge and motives on tattooing: A community-based cross-sectional study in Greece

BACKGROUND

Tattooing is becoming an increasingly common trend mainly but not merely among the youth. However, the choice of ink body art is associated with an increase of dermatological complications.

AIM

To assess young persons' health knowledge and motives toward tattooing.

METHODS

The main instrument used was an online structured questionnaire with scaling and dichotomous questions, consisting of three components: (a) the participants' sociodemographic profile, (b) health knowledge assessment, (c) motives toward or against tattooing. Simple univariate techniques and multiple logistic regression were used to data analysis. Two logistic models were developed having as dependent variable whether the respondents have or would like to have a tattoo. The independent variables in the models were sociodemographic characteristics of participants and three variables concerning respondents' health knowledge and motives on tattooing.

RESULTS

The study sample amounted to 629 young adults living in Athens, the capital city of Greece. The prevailing age group among tattooed persons was 19-25 years old (69.5%), with females being more likely to be tattooed than males. Among tattooed participants, knowledge in specific health complications appeared high, while in other potential complications was particularly low. The main motives identified were ideology/message and aesthetics/fashion (77% in total). Quite interesting, participants with medium and high health knowledge level showed, respectively 50%, and three times higher probability of having tattoos compared to low level. Only 16.2% of the tattooed participants regarded tattoo as dangerous to health (p < 0.0005).

CONCLUSIONS

The likelihood of acquiring ink body art is increasing critically among young adults. Even though this tendency is accompanied with adequate levels of knowledge concerning health hazards, systematic health education programs for more informed and safe choices are needed to be implemented, with particular emphasis on young people.

Epidermal Barrier Function and Skin Homeostasis in Skin with Permanent and Adhesive Tattoos: A Cross-Sectional Study

Tattoos are a current trend, but their impact on skin homeostasis and epidermal barrier function is not well known. So, the aims of this study are (1) to investigate epidermal barrier function and skin homeostasis in skin with permanent tattoos, adhesive temporary tattoos and non-tattooed skin, and (2) to analyze the effect of petrolatum on skin with permanent and adhesive tattoos. In total, 67 tattoos were enrolled (34 permanent tattoos and 33 adhesive tattoos). Temperature, transepidermal water loss (TEWL), stratum corneum hydration (SCH), erythema and total antioxidant capacity (TAC) were measured in skin with permanent tattoos, adhesive tattoos and non-tattooed skin before and after petrolatum application. The temperature was lower (30.47 °C vs. 31.01 °C; p = 0.001) on skin with permanent tattoos than non-tattooed skin, while SCH (48.24 Arbitrary Units (AU) vs. 44.15 AU; p = 0.008) was higher. Skin with adhesive tattoos showed lower temperature, SCH (21.19 AU vs. 41.31 AU; p < 0.001) and TAC (1.27 microcoulombs (uC) vs. 3.48 uC; p < 0.001), and higher TEWL (8.65 g/h/m² vs. 6.99 g/h/m²; p = 0.003), than non-tattooed skin. After petrolatum application, the temperature decreased on skin with permanent tattoos, and TEWL and SCH decreased on skin with adhesive tattoos. Adhesive tattoos may affect skin barrier function, while permanent tattoos may have a lower impact. Tattooed and non-tattooed skin responds in different ways to moisturizers.

[Reluctance determinants of dermatologists about tattooing in patients with psoriasis. An international study]

BACKGROUND

Tattoos are an increasingly common phenomenon, with a prevalence of around 10-30 % of the population in Western countries. The "Tatou" project assessed the risks of tattooing for patients with psoriasis. The first part revealed strong opposition to tattoos in these patients on the part of dermatologists, despite fewer than a quarter of them having any personal experience of complications. The second part showed a very low rate (6.6 %) of local complications on tattoos in these patients as well as absence of severe complications. These observations led us to assess the reasons for reluctance about tattoos in the 468 dermatologists involved in the first part of the "Tatou" project.

PATIENTS AND METHODS

We conducted a cross-sectional international study in France, Finland and Italy to evaluate the experience and opinions of dermatologists regarding tattoos in psoriasis patients via an anonymous questionnaire. We then examined the stated reasons for opposition to tattoos in order to establish the profiles of "tattoo-sceptical" dermatologists with regard to 4 different situations: active psoriasis, quiescent psoriasis, treatment with topical steroids and biotherapies.

RESULTS

The opinion of dermatologists regarding tattoos was generally unfavourable (3.5±2.8/10), in particular, via multivariate analysis, among older dermatologists (P=0.01), dermatologists in private practice (P=0.04), and non-tattooed dermatologists (P<0.0001). In multivariate analysis, the main parameter affecting the position of practitioner with regard to tattoos was their personal opinion of tattoos (P<0.0001), regardless of disease activity or type of treatment. Italian, Finnish and female dermatologists exhibited greater reluctance but in a less consistent fashion.

CONCLUSION

This analysis suggests a lack of objectivity among dermatologists opposed to tattoos probably stemming more from a poor opinion of this practice than from any fear of complications in their psoriatic patients.

Tattoos among athletes: a matter of concern?

Ten to 30% of the population is currently tattooed. This trend does not spare athletes and sports medicine specialists may have to manage tattooed athletes. The purpose of this study was to review the possible issues associated with tattoos among athletes. Overall, tattooed athletes are exposed to the same complications as anyone, mainly healing issues, skin infections and allergic reactions to a tattoo color. Besides, the main pitfall in sports medicine remains invasive gestures such as puncture or infiltration, as they must be avoided at all cost if the tattoo is recent and under healing. Issues associated with imaging are rather limited (artifacts, visible calcification). Burns during magnetic resonance imagining may occur but they are rather rare. Local neuromuscular complications attributable to tattooing are exceptional. Whether tattoos may have a "systemic" impact on the prevalence of unexplained symptoms in athletes (fatigue, distant tendon or musculoskeletal wounds) remain unknown.

[Tinea corporis within recent tattoos]

INTRODUCTION

Tattoos are occasionally associated with cutaneous infections. Diagnosis can be challenging as the clinical presentation of such infections may differ from those on plain skin. Herein we report an atypical form of tinea corporis restricted to two recent tattoos during healing, caused by environmental contamination. We reviewed the literature for all cases of fungal infection after tattooing.

PATIENTS AND METHODS

A 27-year-old female patient was seen for ring-shaped, erosive, oozing, pruritic and rapidly extensive skin lesions as well as infiltrated papular lesions occurring on tattoos done 6 and 12 days earlier. Fungal analysis revealed Microsporum canis. History-taking indicated that the patient's cat had ringworm and that the patient's sister also had skin lesions consistent with tinea corporis.

DISCUSSION

Tinea on tattoos is rarely reported. We found ten additional cases in the literature, as well as five cases of less common fungal infections. These could be explained by the skin break created by the needle during tattooing resulting in an impaired skin barrier, or by accidental self-inoculation (e.g. foot-tattoos). The hypothesis of local immune deficiency induced by tattoo inks strikes us as rather improbable. Unlike usual cases of infections (pyogenic bacteria, mycobacteria, viral hepatitis), fungal infections are not related to a lack of hygiene on the part of the tattooist, but rather to contamination during the healing phase. Their clinical presentation may be atypical, resulting in diagnostic difficulties.

A tattoo granuloma with uveitis (TAGU) without sarcoidosis

Tattooing is associated with a handful of potential complications. Short-term complications such as pain, pruritus, erythema, or swelling at the tattoo-site commonly occur from local skin trauma. Long-term complications tend to involve infections or immune-mediated reactions such as sarcoidosis. The sudden development of a papulonodular skin eruption affecting a particular pigment in a tattoo is often the initial manifestation of undiagnosed sarcoidosis in these patients. However, in a small number of individuals, the granulomatous change in the tattoo and uveitis occur in the absence of any evidence of sarcoidosis. A case is presented of a tattoo granuloma with uveitis (TAGU) without sarcoidosis.

Tatouage et réaction sarcoïdosique

La pratique du tatouage se développe de plus en plus dans le monde entier. Les infections sont connues, mais les réactions inflammatoires chroniques ont souvent donné lieu à des manifestations cliniques variées. À côté des réactions allergiques, les réactions non allergiques prévalent dans les tatouages noirs et se manifestent sous la forme de lésions « papulo-nodulaires ». L’importance de la biopsie des lésions papulo-nodulaires pour confirmer le diagnostic doit être soulignée. Les nanoparticules de noir de carbone s’agglomèrent dans le derme avec le temps pour former des granulomes sarcoïdosiques. Granulome à corps étranger lié au pigment et sarcoïdose sont souvent difficiles à distinguer. La couleur noire semble la plus fréquente. D’autres étiologies que le pigment sont évoquées, tel que le rôle d’un agent infectieux, mais à ce jour aucun n’a été identifié, un terrain génétique particulier, qu’il reste à définir. Des localisations systémiques étant possible, le bilan d’extension est important à réaliser. Le traitement est le même que la sarcoïdose classique. Certains médicaments favoriseraient le développement d’une sarcoïdose sur tatouage. Ils doivent donc être recherchés systématiquement. Il est aussi important à titre préventif, que les sujets et leur médecin traitant soient informés de ce risque potentiel lié à ces médicaments indiqués dans des pathologies graves spécifiques.

Recurrent lichenoid reaction to black tattoo ink: A case report and brief review of the literature

Cutaneous reactions to tattoos are increasing as the prevalence of tattoos increases. Lichenoid reactions often occur in red tattoos and are usually localised to the tattoo. We present a case of recurrent lichenoid reaction occurring in both the black tattooed and adjacent non-tattooed skin.

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.