Tattoo Medical Issues - Breast Cancer Tattoos

A variety of medical issues can result from tattooing. Because it requires breaking the skin barrier, tattooing may carry health risks, including infection and allergic reactions. Modern tattooists reduce such risks by following universal precautions, working with single-use items, and sterilising their equipment after each use. Many jurisdictions require that tattooists have bloodborne pathogen training, such as is provided through the Red Cross and the U.S. Occupational Safety and Health Administration.

Dermatologists have observed rare but severe medical complications from tattoo pigments in the body, and have noted that people acquiring tattoos rarely assess health risks prior to receiving their tattoos. Some medical practitioners have recommended greater regulation of pigments used in tattoo ink. The wide range of pigments currently used in tattoo inks may create unforeseen health problems.

Infection

Since tattoo instruments come in contact with blood and bodily fluids, diseases may be transmitted if the instruments are used on more than one person without being sterilised. However, infection from tattooing in clean and modern tattoo studios employing single-use needles is rare. With amateur tattoos, such as those applied in prisons, however, there is an elevated risk of infection. To address this problem, a programme was introduced in Canada as of the summer of 2005 that provides legal tattooing in prisons, both to reduce health risks and to provide inmates with a marketable skill. Inmates were to be trained to staff and operate the tattoo parlours once six of them opened successfully.

In the United States, the Red Cross prohibits a person who has received a tattoo from donating blood for 12 months (FDA 2000), unless the procedure was done in a state-regulated and licensed studio, using sterile technique. Not all states have a licensing program, meaning that people who receive tattoos in those states are subject to the 12-month deferral regardless of the hygienic standards of the studio. Similarly, the UK does not provide certification for tattooists, and blood donations are prohibited without exception for four months following a tattoo.

Infections that can theoretically be transmitted by the use of unsterilised tattoo equipment or contaminated ink include surface infections of the skin, hepatitis B, hepatitis C, tuberculosis, and HIV. However, no person in the United States is reported to have contracted HIV via a commercially applied tattooing process. Washington state's OSHA studies have suggested that since the needles used in tattooing are not hollow, in the case of a needle stick injury the amount of fluids transmitted may be small enough that HIV would be difficult to transmit. Tetanus risk is reduced by having an up-to-date tetanus booster prior to being tattooed. According to the Centers for Disease Control and Prevention, of 13,387 hepatitis cases in the USA in 1995, 12 cases (0.09%) were associated with tattoo parlours; by comparison, 43 cases (0.32%) were associated with dentists' offices.

In 2006, the CDC reported 3 clusters with 44 cases of methicillin-resistant staph infection traced to unlicensed tattooists.

Reactions to inks

Perhaps due to the mechanism whereby the skin's immune system encapsulates pigment particles in fibrous tissue, tattoo inks have been described as "remarkably nonreactive histologically". However, some allergic reactions have been medically documented. No estimate of the overall incidence of allergic reactions to tattoo pigments exists. Allergies to latex are apparently more common than to inks; many artists will use non-latex gloves when requested.

Allergic reactions to tattoo pigments, while uncommon, are most often seen with red, yellow, and occasionally white. Reactions can be triggered by exposure to sunlight. People who are sensitive or allergic to certain metals may react to pigments in the skin with swelling and/or itching, and/or oozing of clear fluid called serum. Such reactions are quite rare, however, and some artists will recommend performing a test patch. Because the mercury and Azo-chemicals in red dyes are more commonly allergenic than other pigments, allergic reactions are most often seen in red tattoos. Less frequent allergic reactions to black, purple, and green pigments have also been noted.

Traditional metallic salts are prevalent in tattoo inks. A 3-by-5-inch (76 by 127 mm) tattoo may contain from 1 to 23 micrograms (1.5×10^âˆ'5 to 0.000355 gr) of lead, but there is insufficient evidence to assess whether the metallic salts are harmful at this dosage and via this method. However, in 2005, there were no reports of metal toxicity from tattoo ink. Organic pigments (i.e., non-heavy metal pigments) may also pose health concerns. A European Commission noted that close to 40% of organic tattoo colorants used in Europe had not been approved for cosmetic use, and that under 20% of colorants contained a carcinogenic aromatic amine.

MRI complications

A few cases of burns on tattoos caused by MRI scans have been documented. Problems tend to occur with designs containing large areas of black ink, since black commonly contains iron oxide; the MRI scanner causes the iron to heat up either by inducing an electric current or hysteresis. Burning can occur on smaller tattoos such as "permanent makeup", but this is rare. Non-ferrous pigments have also been known to cause burns during an MRI. It should be stressed that tattoo burns are rare, so merely having a tattoo does not contraindicate the use of MRI scanning.

Dermal conditions

The most common dermal reactions to tattoo pigments are granulomas and various lichenoid diseases. Other conditions noted have been cement dermatitis, collagen deposits, discoid lupus erythematosus, eczematous eruptions, hyperkeratosis and parakeratosis, and keloids.

Delayed reactions

Hypersensitive reactions to tattoos are known to lay latent for significant periods of time before exhibiting symptoms. Delayed abrupt chronic reactions, such as eczematous dermatitis, are known to manifest themselves from months to as many as twenty years after the patient received his or her most recent tattoo.

Azo-type pigments used in tattoos tend to cleave through enzymatic catalysis of redox reactions, resulting in highly electrophilic aromatic amine by-products capable of covalently binding with DNA. Naphthol and Azos break down in sunlight exposure into toxic and/or carcinogenic aromatic amines. As with heavy metals, these by-products of the pigments’ decomposition accumulate in the lymphatic system. Plastic-based inks (e.g., glow-in-the-dark ink) are known to lead to polymerisation under the skin, where the tattoo pigment particles converge into one solid plastic piece under the skin.

Other adverse effects

Other documented conditions caused by tattoo pigments have been carcinoma, hyperplasia, tumours, and vasculitis. Keratoacanthoma may also occur, which makes excision of the affected area mandatory.

Hematoma

Occasionally, when a blood vessel is punctured during the tattooing procedure a hematoma (bruise) may appear. Bruises generally heal within one week. Bruises can appear as halos around a tattoo, or, if blood pools, as one larger bruise. This bluish or dark blurry halo that surrounds a tattoo can also be attributed to ink diffusion or 'blow-out'. Commonly mistaken for a hematoma, this discolouration occurs when tattoo pigments spread out into the subcutaneous tissue beneath the dermal skin layer, and may be caused by ink being deposited too deep in the skin.

Burden on lymphatic system

Some pigment migrates from a tattoo site to lymph nodes, where large particles may accumulate. When larger particles accumulate in the lymph nodes, inflammation may occur. Smaller particles, such as those created by laser tattoo treatments, are small enough to be carried away by the lymphatic system and not accumulate.

Interference with melanoma diagnosis

Lymph nodes may become discolored and inflamed with the presence of tattoo pigments, but discoloration and inflammation are also visual indicators of melanoma; consequently, diagnosing melanoma in a patient with tattoos is made difficult, and special precautions must be taken to avoid misdiagnoses.

Effects of blood thinners

A regimen of blood thinners may affect the tattooing process, causing excess bleeding. This increased bleeding can slow the process of getting enough ink into the skin. The aftercare healing may also take longer.

References

Case studies

Reactions to inks

• Mortimer NJ, Chave TA, Johnston GA (2003). "Red tattoo reactions". Clin Exp Dermatol. 28 (5): 508â€"10. doi:10.1046/j.1365-2230.2003.01358.x. PMID 12950341. 
• Lubeck G, Epstein E (1952). "Complications of tattooing". Calif Med. 76 (2): 83â€"5. PMC 1521348. PMID 14905289. 
• Engel E, Santarelli F, Vasold R, et al. (2008). "Modern tattoos cause high concentrations of hazardous pigments in skin". Contact Dermatitis. 58 (4): 228â€"33. doi:10.1111/j.1600-0536.2007.01301.x. PMID 18353031. 
• Steinbrecher I, Hemmer W, Jarisch R (2004). "Adverse reaction to the azo dye Pigment Red 170 in a tattoo". J Dtsch Dermatol Ges. 2 (12): 1007â€"8. PMID 16285314. 
• Kleinerman R, Greenspan A, Hale EK (2007). "Mohs micrographic surgery for an unusual case of keratoacanthoma arising from a longstanding tattoo". J Drugs Dermatol. 6 (9): 931â€"2. PMID 17941365. 
• Pauluzzi P, Giordani M, Guarneri GF, et al. (1998). "Chronic eczematous reaction to red tattoo". J Eur Acad Dermatol Venereol. 11 (2): 187â€"8. doi:10.1111/j.1468-3083.1998.tb00780.x. PMID 9784053. 
• Kluger N, Minier-Thoumin C, Plantier F (2008). "Keratoacanthoma occurring within the red dye of a tattoo". J Cutan Pathol. 35 (5): 504â€"7. doi:10.1111/j.1600-0560.2007.00833.x. PMID 17976209. 
• Winkelmann RK, Harris RB (1979). "Lichenoid delayed hypersensitivity reactions in tattoos". J Cutan Pathol. 6 (1): 59â€"65. doi:10.1111/j.1600-0560.1979.tb00306.x. PMID 438395. 
• Verdich J (1981). "Granulomatous reaction in a red tattoo". Acta Derm Venereol. 61 (2): 176â€"7. PMID 6165203. 
• Cairns RJ, Calnan CD (1962). "Green tattoo reactions associated with cement dermatitis". Br J Dermatol. 74 (74): 288â€"94. doi:10.1111/j.1365-2133.1962.tb13513.x. PMID 13875622. 
• Balfour E, Olhoffer I, Leffell D, et al. (2003). "Massive pseudoepitheliomatous hyperplasia: an unusual reaction to a tattoo". Am J Dermatopathol. 25 (4): 338â€"40. doi:10.1097/00000372-200308000-00010. PMID 12876493. 
• Schwartz RA, Mathias CG, Miller CH, et al. (1987). "Granulomatous reaction to purple tattoo pigment". Contact Dermatitis. 16 (4): 198â€"202. doi:10.1111/j.1600-0536.1987.tb01424.x. PMID 3595119. 
• Morales-Callaghan AM Jr; Aguilar-Bernier M Jr; Martínez-García G; et al. (2006). "Sarcoid granuloma on black tattoo". J Am Acad Dermatol. 55 (5 Suppl): S71â€"3. doi:10.1016/j.jaad.2005.12.022. PMID 17052538. 
• Cui W, McGregor DH, Stark SP, et al. (2007). "Pseudoepitheliomatous hyperplasia - an unusual reaction following tattoo: report of a case and review of the literature". Int J Dermatol. 46 (7): 743â€"5. doi:10.1111/j.1365-4632.2007.03150.x. PMID 17614808. 
• Biro L, Klein WP (1967). "Unusual complications of mercurial (cinnabar) tattoo. Generalized eczematous eruption following laceration of a tattoo". Arch Dermatol. 96 (2): 165â€"7. doi:10.1001/archderm.1967.01610020057017. PMID 6039153. 
• Antal AS, Hanneken S, Neumann NJ, et al. (2008). "Erhebliche zeitliche Variationsbreite von Komplikationen nach Tätowierungen". Der Hautarzt. 59 (10): 769â€"71. doi:10.1007/s00105-008-1631-y. PMID 18773181. 

Toxins in inks

• Civatte J, Bazex J (2007). "Piercing and tattooing: regulation is needed to reduce complications". Bull Acad Natl Med. 191 (9): 1819â€"38. PMID 18663977. 
• Hannuksela M (2005). "Tattoo pigments contains toxic compounds, but legislators do not pay attention". Duodecim. 121 (17): 1802â€"2. PMID 16262117. 
• Möhrenschlager M, Worret WI, Köhn FM (2006). "Tattoos and permanent make-up: background and complications". MMW Fortschr Med. 148 (41): 34â€"6. PMID 17190258. 
• Poon, Kelvin Weng Chun (2008), In situ chemical analysis of tattooing inks and pigments: modern organic and traditional pigments in ancient mummified remains, University of Western Australia 
• Wollina U, Gruner M, Schönlebe J (2008). "Granulomatous tattoo reaction and erythema nodosum in a young woman: common cause or coincidence?". J Cosmet Dermatol. 7 (2): 84â€"8. doi:10.1111/j.1473-2165.2008.00368.x. PMID 18482009. 

Other dermatological reactions

• Kazandjieva J, Tsankov N (2007). "Tattoos: dermatological complications". Clin Dermatol. 25 (4): 375â€"82. doi:10.1016/j.clindermatol.2007.05.012. PMID 17697920. 
• Kluger N (2012). "Acute complications of tattooing presenting in the ED". Am J Emerg Med. 30: 2055â€"2063. doi:10.1016/j.ajem.2012.06.014. PMID 22944541. 
• Müller KM, Schmitz I, Hupe-Nörenberg L (2002). "Reaction patterns to cutaneous particulate and ornamental tattoos". Der Pathologe. 23 (1): 46â€"53. PMID 11974503. 
• Papageorgiou PP, Hongcharu W, Chu AC (1999). "Systemic sarcoidosis presenting with multiple tattoo granulomas and an extra-tattoo cutaneous granuloma". J Eur Acad Dermatol Venereol. 12 (1): 51â€"3. doi:10.1111/j.1468-3083.1999.tb00809.x. PMID 10188151. 
• Schmitz I, Müller KM (2004). "Elemental analysis of tattoo dyes: is there a potential risk from tattoo dyes?". J Dtsch Dermatol Ges. 2 (5): 350â€"3. doi:10.1046/j.1439-0353.2004.04755.x. PMID 16281523. 

MRI

• Klitscher D, Blum J, Kreitner KF, et al. (2005). "MRT-induced burns in tattooed patients: Case report of a traumatic surgery patient". Unfallchirurg. 108 (5): 410â€"4. doi:10.1007/s00113-004-0877-9. PMID 15909207. 
• Stecco A, Saponaro A, Carriero A (2007). "Patient safety issues in magnetic resonance imaging: state of the art". Radiol Med. 112 (4): 491â€"508. doi:10.1007/s11547-007-0154-4. PMID 17563855. 
• Wagle WA, Smith M (2000). "Tattoo-induced skin burn during MR imaging". AJR Am J Roentgenol. 174 (6): 1795. doi:10.2214/ajr.174.6.1741795. PMID 10845532. 
• Vahlensieck M (2000). "Tattoo-related cutaneous inflammation (burn grade I) in a mid-field MR scanner". Eur Radiol. 10 (1): 197. doi:10.1007/s003300050034. PMID 10663745. 
• Franiel T, Schmidt S, Klingebiel R (2006). "First-degree burns on MRI due to nonferrous tattoos". AJR Am J Roentgenol. 187 (5): W556. doi:10.2214/AJR.06.5082. PMID 17056894. 

Lymph nodes and melanoma

• Gutermuth J, Hein R, Fend F, et al. (2007). "Cutaneous pseudolymphoma arising after tattoo placement". J Eur Acad Dermatol Venereol. 21 (4): 566â€"7. doi:10.1111/j.1468-3083.2006.01964.x. PMID 17374006. 
• Gall N, Bröcker EB, Becker JC (2007). "Particularities in managing melanoma patients with tattoos: case report and review of the literature". J Dtsch Dermatol Ges. 5 (12): 1120â€"1. doi:10.1111/j.1610-0387.2007.06386.x. PMID 17919304. 
• Chikkamuniyappa S, Sjuve-Scott R, Lancaster-Weiss K, et al. (2005). "Tattoo pigment in sentinel lymph nodes: a mimicker of metastatic malignant melanoma". Dermatol Online J. 11 (1): 14. PMID 15748555. 
• Hannah H, Falder S, Steele PR, et al. (2000). "Tattoo pigment masquerading as secondary malignant melanoma". Br J Plast Surg. 53 (4): 359. doi:10.1054/bjps.2000.3346. PMID 10876271. 
• Kluger N, Jolly M, Guillot B (2008). "Tattoo-induced vasculitis". J Eur Acad Dermatol Venereol. 22 (5): 643â€"4. doi:10.1111/j.1468-3083.2008.02729.x. PMID 18384545. 
• Sperry K (1992). "Tattoos and tattooing. Part II: Gross pathology, histopathology, medical complications, and applications". Am J Forensic Med Pathol. 13 (1): 7â€"17. doi:10.1097/00000433-199203000-00003. PMID 1585890. 
• Zirkin HJ, Avinoach I, Edelwitz P (2001). "A tattoo and localized lymphadenopathy: a case report". Cutis. 67 (6): 471â€"2. PMID 11419018.