Talking about tattoos

ConsumerReports.org reported in 2008 that tattoos had become mainstream. More than one-third of US adults aged younger than 35 years have at least 1 tattoo, according to the article.¹

The part of that statistic that most concerns pediatricians is that tattooing can result in complications, ranging from localized inflammatory skin eruptions to sometimes life-threatening infections and hepatitis. Some teenagers are at higher risk for complications than others.

Pediatricians who recognize and diagnose tattoo complications early on can help to prevent morbidity-even mortality. Pediatricians also can help by counseling their teenaged patients about potential dangers before children go under the needle.²

Physician awareness, surveillance, and action are needed, especially when one considers: “There is no standard regulation for training or licensing, no requirements for inspection, record-keeping, informed consent, or oversight for compliance and complications,” according to ConsumerReports.org.¹

A problematic process

It’s no wonder that tattooing can result in skin and other health problems. Permanent tattooing involves making ink-filled injections into the dermis.³

The inks injected often consist of products that shouldn’t be put into the body. Among those: azo pigments, which contain impurities and are manufactured for use as printing inks and automobile paint.¹ “Alarmingly, in tattooing, hundreds of milligrams are injected directly into the skin,” according to ConsumerReports.org.

Even the water used in the tattoo ink or to dilute it is a potential health concern. Tattoo artists have been known to use distilled or reverse osmosis water to create or dilute tattoo ink products, which could expose adolescents and others to germs and infection.⁴

Cases in point

Researchers published a study in 2013 on increasing reports of cutaneous inoculation of nontuberculous (atypical) mycobacteria (NTM) during the tattooing process.⁵ The 3 NTM skin infections reported in the study prompted the government to conduct an epidemiologic investigation.

Researchers in the study interviewed tattoo artists involved in the NTM cases about their practices, ink procurement, use, and other symptomatic clients. They uncovered 31 cases of suspected or confirmed NTM inoculation from tattooing and concluded the problem stemmed from a bottle of gray-wash ink used on the tattoos.⁵

Cutaneous complications

In a review for emergency physicians about problems associated with tattoos and piercings, investigators reported in 2011 that the prevalence of tattoo complication rates is about 2% to 3%.⁶ 

Tattoo complications are on the rise, according to a study published in 2014 by Bassi et al.⁷ “The most common skin reactions to tattoos include a transient acute inflammatory reaction due to trauma of the skin with needles and medical complications, such as superficial and deep local infections, systemic infections, allergic contact dermatitis, photodermatitis, granulomatous and lichenoid reactions, and skin diseases localized on tattooed area (eczema, psoriasis, lichen, and morphea),” the researchers write. “Next to these inflammatory skin reactions we have to consider also the possibility of the development of cutaneous conditions such as pseudolymphomatous reactions and pseudoepitheliomatous hyperplasia.” 

Most of the complications are infections resulting from tattoo artists’ nonsterile techniques.⁶

The clinical manifestations of inflammatory conditions that result from tattooing include focal edema, pruritus, and papules or nodules at the site of the tattoo.² Most cutaneous eruptions are localized to the tattoo, but more widespread urticarial lesions have been reported.

Whereas skin reactions from tattooing can occur in otherwise healthy people, teenagers and others with preexisting conditions might have a heightened risk.² Patients with psoriasis, systemic lupus, and sarcoidosis, for example, are among those who might be more likely to develop lesions at the site of a tattoo.

Tattoos are associated not only with skin eruptions but also with potentially hiding skin cancer transformation. Tattoos on melanocytic nevi can delay skin cancer diagnoses or lead to false diagnoses.²

This list of potential complications from tattooing goes on to include localized community-acquired methicillin-resistant Staphylococcus aureus (MRSA) as well as human papillomavirus, which have been reported in immunocompetent patients.² In addition, although tattoos are said to be a risk factor for hepatitis A and hepatitis C infection, data looking at the association are incomplete because of other possible causes, such as intravenous drug use, cocaine use, sexual partners, and more.

Permanent tattoos are not the only culprits. Temporary henna tattoos also are associated with inflammatory skin reactions, including local and generalized allergic contact dermatitis, with potential for severe bullous reactions, erythema multiforme, and postinflammatory dyspigmentation.²

When, how to treat

Most tattoos results in localized swelling and redness lasting several days, depending on the tattoo’s location.² Inflammatory reactions might present as edema, erythema, and pruritus, which go beyond the tattoo’s borders.

Pediatricians and other physicians can treat inflammatory skin conditions resulting from tattoos locally, with topical or intralesional corticosteroids.² Systemic corticosteroids and antihistamines are likely needed to treat widespread urticaria.

Treating localized bacterial impetigo with topical antibiotics might suffice, but pediatric patients with bacterial cellulitis or endocarditis need to be hospitalized.²

Pediatricians should drain and culture suspected MRSA infections, and treat with systemic antibiotics based on culture results and the prevalence of bacterial strains in the community.²

Counseling pediatric patients

There is the need to make adolescents and others more aware of potential health consequences of tattooing because the literature suggests that these groups might not comprehend them.⁸

Ideally, pediatricians should talk with patients before they get tattoos about the potential dangers and how to best avoid them. In particular, physicians should counsel teenagers with systemic or cutaneous conditions known to demonstrate the Koebner phenomenon, as well as those who have risk factors for melanoma or other skin cancers.²

REFERENCES

1. Avitzur O. Teen tattoos: Easy to get, easier to regret. Consumer Reports. Available at: www.consumerreports.org/cro/news/2008/11/teen-tattoos-easy-to-get-easier-to-regret/index.htm. Published November 24, 2008. Accessed September 26, 2014.

2. Juhas E, English JC 3rd. Tattoo-associated complications. J Pediatr Adolesc Gynecol. 2013;26(2):125-129.

3. Tattoos. KidsHealth Nemours website. Available at:. http://kidshealth.org/teen/your_body/skin_stuff/safe_tattooing.html#. Reviewed March 2013. Accessed September 26, 2014.

4. Centers for Disease Control and Prevention. The hidden dangers of getting inked. Available at: http://blogs.cdc.gov/publichealthmatters/2012/08/the-hidden-dangers-of-getting-inked/. Published August 22, 2012. Updated September 17, 2012. Accessed September 26, 2014.

5. Falsey RR, Kinzer MH, Hurst S, et al. Cutaneous inoculation of nontuberculous mycobacteria during professional tattooing: a case series and epidemiologic study. Clin Infect Dis. 2013;57(6):e143-e147.

6. Urdang M, Mallek JT, Mallon WK. Tattoos and piercings: a review for the emergency physician. West J Emerg Med. 2011;12(4):393-398.

7. Bassi A, Campolmi P, Cannarozzo G, et al. Tattoo-associated skin reaction: the importance of an early diagnosis and proper treatment. Biomed Res Int. 2014;2014:354608.

8. Sweeney SM. Tattoos: a review of tattoo practices and potential treatment options for removal. Curr Opin Pediatr. 2006;18(4):391-395. 

Ms Hilton is a medical writer who has covered health and medicine for 25 years. She resides in Boca Raton, Florida. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.

TATTOO TIPS FOR PATIENTS

To reduce infection, those seeking tattoos should:

• Use tattoo parlors approved/registered by their local jurisdictions.

• Request inks that are manufactured specifically for tattoos.

• Ensure that tattoo artists follow appropriate hygienic practices.

• Be aware of the potential for infection after tattooing and promptly seek medical care if skin problems occur.

For more information, visit the Centers for Disease Control and Prevention:

http://1.usa.gov/1ncZxtk

Persons who experience a problem should notify the tattoo artist and the US Food and Drug Administration’s MedWatch program:

www.fda.gov/Safety/MedWatch/default.htm

For more safety tips, see the Nemours KidsHealth web page on tattoos:

http://kidshealth.org/teen/your_body/skin_stuff/safe_tattooing.html