To Tattoo or Not: That is the Question

Abstract

Tattoos or body art has become acceptable forms of body decoration in the popular culture. The social stigma associated with tattoos has diminished in younger generations. The current popular culture has glamorized the use of tattoos as exemplified by them being worn by high profile entertainment and sports figures. Yet despite the growing popularity of tattoos, the health risks associated with them are not widely known. More recently, prominent health experts, such as the former Director of the National Institutes of Health, Dr. Healy, 2008, Aug. 4–11Healy B. The dangerous art of tattoo.U.S. News & World Report. 2008, Aug. 4–11; 145: 69Google Scholar, are speaking out about the risks of body art. In addition, evidence is beginning to accumulate demonstrating the untoward consequences of tattoos. Several recent surveys to determine the prevalence of tattoos in the United States indicate the popular trends and their growing acceptance. A survey of 500 individuals between the ages of 18 and 58 years reported 24% had tattoos. Of this group, 19% had acquired their first tattoo before 18 years of age (Laumann and Derick, 2006Laumann A. Derick A. Tattoos and body piercings in the United States: A national data set.Journal of American Academy of Dermatology. 2006; 55: 413-421Abstract Full Text Full Text PDF PubMed Scopus (442) Google Scholar). Another survey of 579 of adolescents and young adults, ages 18 to 25 years, found that 36% had tattoos (The Pew Research Center for the People and the Press, 2006The Pew Research Center for the People and the Press A potrait of “generation next”.http://people-press.org/reports/pdf/300.pdfDate: 2006Google Scholar). In a Harris poll of 2,302 adults, 14% reported having tattoos. The percentage of tattoo wearers was highest among 25- to 29-year-olds amounting to 32%, whereas 9% in the 18 to 24 years age range reported having tattoos (Harris Interactive, 2008Harris Interactive Three in ten Americans with a tattoo say having one makes them feel sexier.http://www.harrisinteractive.com/harris_poll/index.asp?PID=868Date: 2008Google Scholar). These percentages are higher than of other countries. It is estimated that approximately 9% of the populations of European countries have tattoos; this number is approximately 12% in England. (Roberts and Ryan, 2002Roberts T.A. Ryan S.A. Tattooing and high risk behavior in adolescents.Pediatrics. 2002; 110: 1058-1062Crossref PubMed Scopus (133) Google Scholar). Infections, allergic reactions, and scarring represent the range of complications associated with tattoos. HIV, hepatitis B, and hepatitis C infections can result due to contaminated needles and improper technique performed by both licensed and unlicensed tattooists (Centers for Disease Control and Prevention, 2008Centers for Disease Control and Prevention Health and safety of tattoo artists, body piercers, and their clients.http://www.cdc.gov/Features/BodyArt/Date: 2008Google Scholar, Helmenstine, 2009Helmenstine A.M. Tattoo ink chemistry. About.com: Chemistry.http://chemistry.about.com/library/weekly/aa121602a.htm?p=1Date: 2009Google Scholar, Sweeney, 2006Sweeney S.M. Tattoos: A review of tattoo practices and potential treatment options for removal.Current Opinion in Pediatrics. 2006; 18: 391-395Crossref PubMed Scopus (45) Google Scholar, United States Food and Drug Administration [FDA], 2008aUnited States Food and Drug Administration [FDA] Think before you ink: Are tattoos safe?.http://www.fda.gov/consumer/features/tattoos120607.htmlDate: 2008Google Scholar, United States Food and Drug Administration [FDA], 2008bUnited States Food and Drug Administration [FDA] Tattoos and permanent makeup.http://www.cfsan.fda.gov/~dms/cos-204.htmlDate: 2008Google Scholar, Slonim et al., 2005Slonim A.B. Roberto A.J. Downing C.R. Adolescents' knowledge, beliefs, and behaviors regarding hepatitis B: Insights and implication for programs targeting vaccine-preventable diseases.Journal of Adolescent Health. 2005; 36: 178-186Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar). A Staphylococcus aureus skin infection may occur (United States Food and Drug Administration [FDA], 2008bUnited States Food and Drug Administration [FDA] Tattoos and permanent makeup.http://www.cfsan.fda.gov/~dms/cos-204.htmlDate: 2008Google Scholar). The CDC recently reported the outbreaks of community-associated methicillin-resistant S aureus in the states of Kentucky, Ohio, and Vermont (Centers for Disease Control, 2006Centers for Disease Control Methicillin-resistant Staphylococcus aureus skin infections among tattoo recipients—Ohio, Kentucky, and Vermont, 2004–2005.Morbidity and Mortality Weekly Report. 2006; 55: 677-678PubMed Google Scholar). These outbreaks affected 44 individuals, 34 with tattoos and 10 secondary contacts, with whom the tattooed individual had close contact. Outbreaks were traced back to unlicensed tattooists who worked in unsanitary facilities that were not properly regulated by local agencies. Many of the affected individuals in the Ohio community were high school students (Centers for Disease Control, 2006Centers for Disease Control Methicillin-resistant Staphylococcus aureus skin infections among tattoo recipients—Ohio, Kentucky, and Vermont, 2004–2005.Morbidity and Mortality Weekly Report. 2006; 55: 677-678PubMed Google Scholar). Allergic reactions occur and some happening years after the tattoo has been applied (Engel et al., 2008Engel E. Santarelli F. Vasold R. Maisch T. Ulrich H. Prantl L. et al.Modern tattoos cause high concentrations of hazardous pigments in skin.Contact Dermatitis. 2008; 58: 228-233Crossref PubMed Scopus (84) Google Scholar, United States Food and Drug Administration [FDA], 2008aUnited States Food and Drug Administration [FDA] Think before you ink: Are tattoos safe?.http://www.fda.gov/consumer/features/tattoos120607.htmlDate: 2008Google Scholar, United States Food and Drug Administration [FDA], 2008bUnited States Food and Drug Administration [FDA] Tattoos and permanent makeup.http://www.cfsan.fda.gov/~dms/cos-204.htmlDate: 2008Google Scholar). The allergic reactions include granulomas and the rarer cases of pseudolymphoma and pseudoepitheliomatous epidermal hyperplasia (Engel et al., 2008Engel E. Santarelli F. Vasold R. Maisch T. Ulrich H. Prantl L. et al.Modern tattoos cause high concentrations of hazardous pigments in skin.Contact Dermatitis. 2008; 58: 228-233Crossref PubMed Scopus (84) Google Scholar, Sweeney, 2006Sweeney S.M. Tattoos: A review of tattoo practices and potential treatment options for removal.Current Opinion in Pediatrics. 2006; 18: 391-395Crossref PubMed Scopus (45) Google Scholar, United States Food and Drug Administration [FDA], 2008aUnited States Food and Drug Administration [FDA] Think before you ink: Are tattoos safe?.http://www.fda.gov/consumer/features/tattoos120607.htmlDate: 2008Google Scholar, United States Food and Drug Administration [FDA], 2008bUnited States Food and Drug Administration [FDA] Tattoos and permanent makeup.http://www.cfsan.fda.gov/~dms/cos-204.htmlDate: 2008Google Scholar). Tattoo granulomas (small bumps forming around the injected pigment materials) are primarily associated with the use of selected color pigments: red (mercuric sulfide), yellow (cadmium sulfide), blue (cobalt), and green (chromium oxide; Sweeney, 2006Sweeney S.M. Tattoos: A review of tattoo practices and potential treatment options for removal.Current Opinion in Pediatrics. 2006; 18: 391-395Crossref PubMed Scopus (45) Google Scholar, United States Food and Drug Administration [FDA], 2008aUnited States Food and Drug Administration [FDA] Think before you ink: Are tattoos safe?.http://www.fda.gov/consumer/features/tattoos120607.htmlDate: 2008Google Scholar). Impurities of the pigment product can precipitate allergic reactions as well. For example, it is estimated that pigments have a purity level of less than 80% (Engel et al., 2008Engel E. Santarelli F. Vasold R. Maisch T. Ulrich H. Prantl L. et al.Modern tattoos cause high concentrations of hazardous pigments in skin.Contact Dermatitis. 2008; 58: 228-233Crossref PubMed Scopus (84) Google Scholar). To date, there has been negligible progress in adequately regulating the pigments used for tattooing. Instead, regulatory efforts have been directed to the licensing of tattooists and monitoring tattoo establishments, although there is greater variability with regulations at the state level (Centers for Disease Control and Prevention, 2008Centers for Disease Control and Prevention Health and safety of tattoo artists, body piercers, and their clients.http://www.cdc.gov/Features/BodyArt/Date: 2008Google Scholar, United States Food and Drug Administration [FDA], 2008aUnited States Food and Drug Administration [FDA] Think before you ink: Are tattoos safe?.http://www.fda.gov/consumer/features/tattoos120607.htmlDate: 2008Google Scholar). The composition of tattoo pigments are revealing There are approximately 50 pigment colors used for body art (United States Food and Drug Administration [FDA], 2008bUnited States Food and Drug Administration [FDA] Tattoos and permanent makeup.http://www.cfsan.fda.gov/~dms/cos-204.htmlDate: 2008Google Scholar). The coloring materials used for tattoos are primarily azo pigments. These pigments are preferred for tattooing for its color intensity and longevity properties (Engel et al., 2008Engel E. Santarelli F. Vasold R. Maisch T. Ulrich H. Prantl L. et al.Modern tattoos cause high concentrations of hazardous pigments in skin.Contact Dermatitis. 2008; 58: 228-233Crossref PubMed Scopus (84) Google Scholar). The worrisome choice of this product for tattooing is that it is used for industrial purposes such as printing and in the paints of automobiles (Engel et al., 2008Engel E. Santarelli F. Vasold R. Maisch T. Ulrich H. Prantl L. et al.Modern tattoos cause high concentrations of hazardous pigments in skin.Contact Dermatitis. 2008; 58: 228-233Crossref PubMed Scopus (84) Google Scholar, United States Food and Drug Administration [FDA], 2008bUnited States Food and Drug Administration [FDA] Tattoos and permanent makeup.http://www.cfsan.fda.gov/~dms/cos-204.htmlDate: 2008Google Scholar). Surprisingly, azo pigments are not allowed to be used in the manufacturing of cosmetics due to carcinogenic risks (Kuczkowski, 2004Kuczkowski K.M. Tattoo pigments: Popular fashion accessories or health hazards?.Photochemistry and Photobiology. 2004; 80: 157Crossref PubMed Scopus (3) Google Scholar). It is known that as azo pigments degrade, carcinogenic amines are produced (Engel et al., 2008Engel E. Santarelli F. Vasold R. Maisch T. Ulrich H. Prantl L. et al.Modern tattoos cause high concentrations of hazardous pigments in skin.Contact Dermatitis. 2008; 58: 228-233Crossref PubMed Scopus (84) Google Scholar). Some pigments contain plastic materials. Black pigment is composed of two forms of iron oxide (also known as rust), carbon and logwood. Ochre is composed of iron oxides that are mixed with clay. Green colors contain lead (Helmenstine, 2009Helmenstine A.M. Tattoo ink chemistry. About.com: Chemistry.http://chemistry.about.com/library/weekly/aa121602a.htm?p=1Date: 2009Google Scholar). None of the colorants have been approved for injection into the skin (United States Food and Drug Administration [FDA], 2008bUnited States Food and Drug Administration [FDA] Tattoos and permanent makeup.http://www.cfsan.fda.gov/~dms/cos-204.htmlDate: 2008Google Scholar). In addition, the colorants have not been subjected to the level of product safety review warranted because there are currently a dearth of regulations to provide oversight and monitoring here in the United States or worldwide (Engel et al., 2008Engel E. Santarelli F. Vasold R. Maisch T. Ulrich H. Prantl L. et al.Modern tattoos cause high concentrations of hazardous pigments in skin.Contact Dermatitis. 2008; 58: 228-233Crossref PubMed Scopus (84) Google Scholar). According to FDA regulations as specified in the Federal Food, Drug, and Cosmetic Act, tattoo inks are considered to be appropriate for obtaining FDA approval prior to public use. However, the FDA has not exercised its authority due to other more compelling public health concerns and until recently, the lack of substantive empirical evidence (United States Food and Drug Administration [FDA], 2008bUnited States Food and Drug Administration [FDA] Tattoos and permanent makeup.http://www.cfsan.fda.gov/~dms/cos-204.htmlDate: 2008Google Scholar). Yet the full scope of the untoward effects of tattoos cannot be estimated because there are no public health reporting requirements for disclosing problems associated with body art (Engel et al., 2008Engel E. Santarelli F. Vasold R. Maisch T. Ulrich H. Prantl L. et al.Modern tattoos cause high concentrations of hazardous pigments in skin.Contact Dermatitis. 2008; 58: 228-233Crossref PubMed Scopus (84) Google Scholar). Erroneously, a belief exists that the temporary tattoos such as henna are without risk. The FDA has not approved the use of henna for tattoos; it is approved only for use in hair dyes (Jacob et al., 2008Jacob S.E. Zapolanski T. Chayavichitsilp P. Connelly E.A. Eichenfield L.F. P-Phenylenediamine in black henna tattoos: A practice in need of policy in children.Archives in Pediatric and Adolescent Medicine. 2008; 162: 790-791Crossref PubMed Scopus (24) Google Scholar, United States Food and Drug Administration [FDA], 2008aUnited States Food and Drug Administration [FDA] Think before you ink: Are tattoos safe?.http://www.fda.gov/consumer/features/tattoos120607.htmlDate: 2008Google Scholar, United States Food and Drug Administration [FDA], 2008bUnited States Food and Drug Administration [FDA] Tattoos and permanent makeup.http://www.cfsan.fda.gov/~dms/cos-204.htmlDate: 2008Google Scholar). p-Phynylenediamine is an oxidative chemical that is added to black henna to increase its longevity and color intensity. It is an additive that can cause contact dermatitis with permanent effects. The long-lasting effects include sensitization to hair and clothing dyes. It can also cause cross-reactivity to ester anesthetics, sulfonamides, and hydrochlorothiazides (Jacob et al., 2008Jacob S.E. Zapolanski T. Chayavichitsilp P. Connelly E.A. Eichenfield L.F. P-Phenylenediamine in black henna tattoos: A practice in need of policy in children.Archives in Pediatric and Adolescent Medicine. 2008; 162: 790-791Crossref PubMed Scopus (24) Google Scholar, Sweeney, 2006Sweeney S.M. Tattoos: A review of tattoo practices and potential treatment options for removal.Current Opinion in Pediatrics. 2006; 18: 391-395Crossref PubMed Scopus (45) Google Scholar). Kohl and harquus are other types of temporary tattoos that can cause contact dermatitis as well. Harquus is a temporary black tattoo ink that is used primarily in North African and Middle East (Mataix et al., 2008Mataix J. Silvestre J.F. Blanes M. Pastor N. Lucas a. Allergic contact dermatitis to a temporary black harquus tattoo.European Academy of Dermatology and Venerology. 2008; 22: 1245-1246Crossref PubMed Scopus (5) Google Scholar). One of the major problems with temporary tattoos is the users are under the misconception that they are harmless. Based on this belief, parents may allow young children to have temporary tattoos. Having a tattoo can be especially risky for youth with special health care needs. A survey was conducted in England with 486 pediatric cardiology patients and their families as well as 62 cardiologists to assess their awareness of the risk of endocarditis associated with tattoos. Interestingly, nearly 20% (17.9%) of the youth indicated they had a tattoo; and nearly the same percentage (17.7%) reported they had undergone body piercing. Of those responding to seeking advice about the risks associated with either tattooing or body piercing, just 38% had sought advice because most were not aware of the necessity to do so. Likewise, 64% of the cardiologists had not reviewed as part of preventive care, the dangers associated with tattooing, whereas 56% had discussed the importance of sterile precautions and antibiotic prophylaxis prior to having body piercing (i.e., ears). (Shebani et al., 2007Shebani S.O. Miles H.F.J. Simmons P. Stikcley J. De Giovanni J.V. Awareness of the risk of endocarditis associated with tattooing and body piercing among patients with congenital heart disease and paediatric cardiologists in the United Kingdom.Archives of Diseases in Children. 2007; 92: 1013-1014Crossref PubMed Scopus (33) Google Scholar). Several treatment approaches can be used for tattoo removal, although not without their own set of risks. These treatments include dermabrasion, cryosurgery, excision, chemical peels, and continuous wave lasers (Saini et al., 2008Saini R. Winhoven S.M. Kaufman J. Hypertrophic scar after chemical tattoo removal.Dermatologic Surgery. 2008; 34: 1599-1602Crossref PubMed Scopus (13) Google Scholar, Sweeney, 2006Sweeney S.M. Tattoos: A review of tattoo practices and potential treatment options for removal.Current Opinion in Pediatrics. 2006; 18: 391-395Crossref PubMed Scopus (45) Google Scholar). Q-switched lasers have been cited as one of the most effective techniques for tattoo removal, although costly and painful (Saini et al., 2008Saini R. Winhoven S.M. Kaufman J. Hypertrophic scar after chemical tattoo removal.Dermatologic Surgery. 2008; 34: 1599-1602Crossref PubMed Scopus (13) Google Scholar, Sweeney, 2006Sweeney S.M. Tattoos: A review of tattoo practices and potential treatment options for removal.Current Opinion in Pediatrics. 2006; 18: 391-395Crossref PubMed Scopus (45) Google Scholar). Untoward reactions of Q-switched laser treatments include the hyper/hypopigmentation, atropic scarring, and localized granulomatous reactions. In addition, laser treatment may cause a chemical reaction with certain color pigments resulting in a permanently darkened tattoo (Sweeney, 2006Sweeney S.M. Tattoos: A review of tattoo practices and potential treatment options for removal.Current Opinion in Pediatrics. 2006; 18: 391-395Crossref PubMed Scopus (45) Google Scholar). Depending on a number of factors including the type of pigment used and tattooist's procedure, the tattoo itself may not be completely removed (Saini et al., 2008Saini R. Winhoven S.M. Kaufman J. Hypertrophic scar after chemical tattoo removal.Dermatologic Surgery. 2008; 34: 1599-1602Crossref PubMed Scopus (13) Google Scholar, Sweeney, 2006Sweeney S.M. Tattoos: A review of tattoo practices and potential treatment options for removal.Current Opinion in Pediatrics. 2006; 18: 391-395Crossref PubMed Scopus (45) Google Scholar). Removal of the tattoo may result in severe scarring requiring the use of skin grafts for treatment (Healy, 2008, Aug. 4–11Healy B. The dangerous art of tattoo.U.S. News & World Report. 2008, Aug. 4–11; 145: 69Google Scholar). Health education regarding the health risks of tattoos needs to be provided to youth and their families during routine health supervision visits. This health prevention conversation needs to occur with youth with special health care needs and their families as well. It is important that youth and families are fully informed of the possible health risks associated with both temporary and permanent tattoos. For those who choose to have a tattoo, information about obtaining a tattoo under safer conditions is needed as recommended by the Centers for Disease Control and Prevention, 2008Centers for Disease Control and Prevention Health and safety of tattoo artists, body piercers, and their clients.http://www.cdc.gov/Features/BodyArt/Date: 2008Google Scholar. The youth should know to go only to a licensed facility and query them as to their safety procedures. Major elements of safety and infection control procedures they should ask about are the following: (a) Does the facility use disposable needles and razors and dispose of them after one time use? (b) Are razors and needles discarded into disposable, biohazard-labeled containers? (c) Is the tattoo artist required to wash hands before and after putting on disposable gloves? (d) What is the procedure for sterilizing reusable equipment and supplies? and (e) Are client stations disinfected between clients? (Centers for Disease Control and Prevention, 2008Centers for Disease Control and Prevention Health and safety of tattoo artists, body piercers, and their clients.http://www.cdc.gov/Features/BodyArt/Date: 2008Google Scholar). Nurses are in an ideal position to advocate for regulations to protect the public from the harmful effects of tattooing. Tattoo consumers would be well served by being fully informed of the potential risks associated with tattooing. As Dr. Healy, 2008, Aug. 4–11Healy B. The dangerous art of tattoo.U.S. News & World Report. 2008, Aug. 4–11; 145: 69Google Scholar suggested, all potential users of tattoo services should be given an informed consent with detailed explanation of the potential risks prior to undergoing tattooing. Furthermore, consumers need to be advised that if they experience adverse reactions to tattoos, it should be reported to the FDA. Adverse reactions can be reported to the local FDA district office or contacting FDA's Center for Food Safety and Applied Nutrition Adverse Events Reporting System at 301.436.2405 and by email [email protected] (United States Food and Drug Administration [FDA], 2008bUnited States Food and Drug Administration [FDA] Tattoos and permanent makeup.http://www.cfsan.fda.gov/~dms/cos-204.htmlDate: 2008Google Scholar).