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Kassirer S, Marini L, Zachary CB, Sarnoff DS, Landau M. Esthetic and medical tattooing: Part I: Tattooing techniques, implications, and adverse effects in healthy populations and special groups. J Am Acad Dermatol 2024:S0190-9622(24)00964-2. [PMID: 38980248 DOI: 10.1016/j.jaad.2024.05.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 05/02/2024] [Accepted: 05/06/2024] [Indexed: 07/10/2024]
Abstract
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.
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Affiliation(s)
- Samuel Kassirer
- American Medical Program, Tel Aviv University Faculty of Medicine, Tel Aviv, Israel
| | - Leonardo Marini
- Diplomate General Surgery and Dermatology, Medical and Scientific Director, SDC The Skin Doctors Center, Trieste, Italy
| | | | - Deborah S Sarnoff
- Clinical Professor, Ronald O. Perelman Department of Dermatology at NYU Grossman School of Medicine, New York, New York
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Chamani S, Mobasheri L, Rostami Z, Zare I, Naghizadeh A, Mostafavi E. Heavy metals in contact dermatitis: A review. J Trace Elem Med Biol 2023; 79:127240. [PMID: 37331278 DOI: 10.1016/j.jtemb.2023.127240] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 06/20/2023]
Abstract
Contact dermatitis is an inflammatory skin reaction caused by direct contact with chemical substances in the environment and can either be irritant or allergic in nature. The clinical symptoms of contact dermatitis, include local skin rash, itching, redness, swelling, and lesions. Nowadays, 15-20% of people have some degree of contact dermatitis, which can be more or less severe. Immune responses in allergic contact dermatitis (ACD) are due to the effects of cytokines and allergen-specific CD4+ and CD8+ T cells on the skin. Acids and alkalis such as drain cleaners, plants such as poinsettias, hair colors, and nail polish remover, are all prominent causes of irritant contact dermatitis (ICDs). Heavy metals are metallic elements with a high atomic weight that are hazardous in low quantities and are known to cause dermatitis after systemic or local exposure. Nickel (Ni), chromium (Cr), lead (Pb), and copper (Cu) are among the most common heavy metals used in various industries. Metal allergies may cause ACD and also systemic contact dermatitis (SCD). Contact dermatitis is detected by laboratory tests such as patch testing, lymphocyte stimulation test (LST), and evaluation of cytokine production by primary cultures of peripheral blood mononuclear cells. This article presents an update on the epidemiological and clinical characteristics of ACD and SCD caused by three heavy metals (Cr, Cu, and Pb). Ni is not discussed due to recent coverage. Furthermore, the effects of contact sensitivity to some other heavy metals, such as gold (Au), cobalt (Co), palladium (Pd), and mercury (Hg) are discussed.
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Affiliation(s)
- Sajad Chamani
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Iran
| | - Leila Mobasheri
- Department of Pharmacology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zeinab Rostami
- Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Iman Zare
- Research and Development Department, Sina Medical Biochemistry Technologies Co. Ltd., Shiraz 7178795844, Iran
| | - Ali Naghizadeh
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Iran.
| | - Ebrahim Mostafavi
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA 94305, USA; Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA.
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Schubert S, Kluger N, Schreiver I. Hypersensitivity to permanent tattoos: Literature summary and comprehensive review of patch tested tattoo patients 1997-2022. Contact Dermatitis 2023; 88:331-350. [PMID: 36772861 DOI: 10.1111/cod.14291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 02/01/2023] [Accepted: 02/08/2023] [Indexed: 02/12/2023]
Abstract
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.
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Affiliation(s)
- Steffen Schubert
- Information Network of Departments of Dermatology (IVDK), Institute at the University Medical Center Göttingen, Göttingen, Germany
| | - Nicolas Kluger
- Department of Dermatology, 'Tattoo' Consultation, Bichat-Claude Bernard Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,Department of Dermatology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Ines Schreiver
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
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Kiszla BM, Elmets CA, Mayo TT. Quantitative analysis of restricted metals and metalloids in tattoo inks: A systematic review and meta-analysis. CHEMOSPHERE 2023; 313:137291. [PMID: 36436582 DOI: 10.1016/j.chemosphere.2022.137291] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/15/2022] [Accepted: 11/17/2022] [Indexed: 06/16/2023]
Abstract
The various ingredients and impurities that can be detected within tattoo inks have been associated with a myriad of dermatologic complications. Legislation regarding these antigenic substances varies widely around the world, with Europe serving as both the research and regulatory center on these intradermal formulations. Although industry is said to be moving away from metallic and metalloid pigments in exchange for organic or organometallic dyes, surveys of commercially available inks continue to detect these elements at concentrations considered unsafe for application into the dermis. In order to better assess the formulation and safety of tattoo ink, we present a systematic review and meta-analysis of studies quantifying restricted metals and metalloids in commercially available tattoo ink products. Among the papers selected, inconsistencies were noted in the degree of specificity by which ink products were identified and the elements sampled for. In addition, the analytical targets' valency and/or solubility were not always considered in accordance with regulation criteria. Of note, chromium, by total content and that of its regulated +6 valency, exceeded its maximum allowed concentration in nearly every sample tested. Total copper content exceeded the limit for soluble copper in half of inks sampled. In descending order, concentrations of cadmium, barium, mercury, soluble copper, arsenic, zinc, antimony, and lead violated regulations in one-sixth or fewer of samples tested. Cobalt and tin levels never violated regulation. Overall, our findings indicate that unsafe levels of restricted elements continue to be detected across studies, warranting further investigation under a regulatory lens.
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Affiliation(s)
- B Matthew Kiszla
- UAB Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Craig A Elmets
- UAB Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA; Birmingham VA Medical Center, Birmingham, AL, USA.
| | - Tiffany T Mayo
- UAB Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA.
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Szulia A, Antoszewski B, Zawadzki T, Kasielska-Trojan A. When Body Art Goes Awry-Severe Systemic Allergic Reaction to Red Ink Tattoo Requiring Surgical Treatment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10741. [PMID: 36078458 PMCID: PMC9517851 DOI: 10.3390/ijerph191710741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 06/15/2023]
Abstract
The aim of this report is to present a case of a patient who developed unusual systemic hypersensitivity reaction to a red-pigmented tattoo and to discuss diagnostic difficulties in case of systemic reactions to tattoo ink. The patient reported erythroderma on his arms and chest accompanied by plaque elevation of red parts of his most recently performed forearm tattoo as his primary symptoms. His health condition entailed a prolonged topical and intravenous immunosuppressive therapy, which proved ineffective. Over a year after emergence of initial symptoms, he presented to the Plastic Surgery Clinic with generalized erythroderma, systemic lymphadenopathy, elevation and granuloma formation in red tattoos on his forearm and complaints of fatigue and inability to participate fully in work-related and social activities. The patient underwent six staged excisions with direct closures, flap plasties and full-thickness skin grafts. Following completion of each surgical resection, the patient's symptoms gradually subsided. We find this case illustrative of a clinical challenge that delayed hypersensitivity reactions to red tattoos may pose. Furthermore, we provide insights on management of hypersensitivity reactions. This report underlines the importance of social awareness of and public health approach to tattoo complications as key to successful prevention, identification and treatment of adverse reactions to tattoos.
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Affiliation(s)
- Agata Szulia
- The Military Medical Faculty, Medical University of Lodz, 90-419 Lodz, Poland
| | - Bogusław Antoszewski
- Plastic, Reconstructive and Aesthetic Surgery Clinic, Medical University of Lodz, Kopcinskiego 22, 90-153 Lodz, Poland
| | - Tomasz Zawadzki
- Plastic, Reconstructive and Aesthetic Surgery Clinic, Medical University of Lodz, Kopcinskiego 22, 90-153 Lodz, Poland
| | - Anna Kasielska-Trojan
- Plastic, Reconstructive and Aesthetic Surgery Clinic, Medical University of Lodz, Kopcinskiego 22, 90-153 Lodz, Poland
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van der Bent SAS, Berg T, Karst U, Sperling M, Rustemeyer T. Allergic reaction to a green tattoo with nickel as a possible allergen. Contact Dermatitis 2019; 81:64-66. [PMID: 30663069 PMCID: PMC6618257 DOI: 10.1111/cod.13226] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/15/2019] [Accepted: 01/16/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Sebastiaan A S van der Bent
- Academic Tattoo Clinic Amsterdam, Department of Dermatology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Tanja Berg
- Institute of Inorganic and Analytical Chemistry, University of Münster, Münster, Germany
| | - Uwe Karst
- Institute of Inorganic and Analytical Chemistry, University of Münster, Münster, Germany
| | - Michael Sperling
- Institute of Inorganic and Analytical Chemistry, University of Münster, Münster, Germany.,European Virtual Institute for Speciation Analysis (EVISA), Münster, Germany
| | - Thomas Rustemeyer
- Academic Tattoo Clinic Amsterdam, Department of Dermatology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
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Réactions dites « allergiques » aux tatouages : prise en charge et algorithme thérapeutique. Ann Dermatol Venereol 2016; 143:436-45. [DOI: 10.1016/j.annder.2016.03.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 02/02/2016] [Accepted: 03/17/2016] [Indexed: 11/19/2022]
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Islam PS, Chang C, Selmi C, Generali E, Huntley A, Teuber SS, Gershwin ME. Medical Complications of Tattoos: A Comprehensive Review. Clin Rev Allergy Immunol 2016; 50:273-86. [DOI: 10.1007/s12016-016-8532-0] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bregnbak D, Johansen JD, Jellesen MS, Zachariae C, Menné T, Thyssen JP. Chromium allergy and dermatitis: prevalence and main findings. Contact Dermatitis 2015; 73:261-80. [DOI: 10.1111/cod.12436] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 05/12/2015] [Accepted: 05/12/2015] [Indexed: 12/14/2022]
Affiliation(s)
- David Bregnbak
- Department of Dermato-Allergology; National Allergy Research Centre, Copenhagen University Hospital Gentofte; Hellerup 2900 Denmark
| | - Jeanne D. Johansen
- Department of Dermato-Allergology; National Allergy Research Centre, Copenhagen University Hospital Gentofte; Hellerup 2900 Denmark
| | - Morten S. Jellesen
- Materials and Surface Engineering, Department of Mechanical Engineering; Technical University of Denmark; DK-2800 Lyngby Denmark
| | - Claus Zachariae
- Department of Dermato-Allergology; Gentofte University Hospital; Hellerup 2900 Denmark
| | - Torkil Menné
- Department of Dermato-Allergology; National Allergy Research Centre, Copenhagen University Hospital Gentofte; Hellerup 2900 Denmark
| | - Jacob P. Thyssen
- Department of Dermato-Allergology; National Allergy Research Centre, Copenhagen University Hospital Gentofte; Hellerup 2900 Denmark
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Bernstein EF. A widespread allergic reaction to black tattoo ink caused by laser treatment. Lasers Surg Med 2015; 47:180-2. [DOI: 10.1002/lsm.22319] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2014] [Indexed: 11/09/2022]
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Forte G, Petrucci F, Cristaudo A, Bocca B. Market survey on toxic metals contained in tattoo inks. THE SCIENCE OF THE TOTAL ENVIRONMENT 2009; 407:5997-6002. [PMID: 19766292 DOI: 10.1016/j.scitotenv.2009.08.034] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Revised: 08/19/2009] [Accepted: 08/25/2009] [Indexed: 05/28/2023]
Abstract
Tattooing practice is adopted worldwide and represents an important socio-cultural phenomenon, but, the injection into the skin of coloring agents as metals might pose a risk for allergies and other skin inflammations as well as for systemic diseases. In this context, 56 inks for tattooing purchased from 4 different supply companies were analyzed for metal concentration. Aliquots of pigments were microwave digested by nitric acid, fluoridric acid and hydrogen-peroxide and Al, Ba, Cd, Co, Cr, Cu, Fe, Hg, Mn, Ni, Pb, Sb, Sr and V were quantified by sector field inductively coupled plasma mass spectrometry. Limits of quantification varied from 0.07 ng/ml (Cd) to 10 ng/ml (Al and Fe); recoveries ranged from 92% (Cd and Sb) to 109% (Sr); within- and between-day precisions were 3.2% and 4.67% on average. The relative contribution of metals to the tattoo inks composition was highly variable between brands and colors, even in pigments with the same base color. Elements found as the main components of inks were as follows (in microg/g): Al, 1.59-5893; Ba, 0.058-1226; Cu, 0.076-31,310; Fe, 0.717-88,443; Sr, 0.174-36.4. Toxic metals as Cd, Mn, Pb, Sb and V were over the 1 microg/g in a few cases, while Hg was in traces. Among the allergenic metals, Cr was the highest (0.315-147 microg/g), followed by Ni (0.037-9.59 microg/g) and Co (0.0028-6.43 microg/g) then. On 56 tattoo inks, Cr, Ni and Co exceeded the safe allergological limit of 1 microg/g in 62.5%, 16.1% and 1.8% of cases, respectively.
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Affiliation(s)
- Giovanni Forte
- Istituto Superiore di Sanità, Viale Regina Elena 299, Rome, Italy
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