Tattoo Reactions Research Articles

Surgical Treatment of Tattoo Complications.

With a continuing increase in the number of tattoos performed worldwide, the need to treat tattoo complications is growing. Earlier treatments of chronic inflammatory tattoo reactions were dominated by a medical approach, or with no active intervention. In this chapter, we will address modern surgical approaches applied to situations when medical treatment is inefficient and lasers are not applicable. Dermatome shaving is positioned as first-line treatment of allergic tattoo reactions and also indicated in a number of other tattoo reactions, supplemented with excision in selected cases. The methods allow fundamental treatment with removal of the culprit pigment from the dermis. The different instruments, surgical methods, and treatment schedules are reviewed, and a guide to surgeons is presented. Postoperative treatments and the long-term outcomes are described in detail. An algorithm on specialist treatment and follow-up of tattoo reactions, which can be practiced in other countries, is presented.

Guide to Treatment of Tattoo Complications and Tattoo Removal.

Clinicians in the fields of general medicine, dermatology, and plastic surgery are in their work now and then confronted with tattoo complications. Recognizing the rather few important diagnostic groups and urgencies, the medical 'decision tree' of treatment becomes quite simple. Acute conditions are dominated by bacterial infections needing antibiotic treatment. Systemic infection is a matter of urgency and requires intravenous treatment in a hospital without delay to prevent septic shock. Inflammatory reactions are a real challenge. Chronic allergic reactions in red tattoos are mostly nonresponsive to topical corticoid and best treated with dermatome shaving with complete removal of the hapten concentrated in the outer dermis. Laser treatment of allergic reactions can boost the allergy with worsening and a potential risk of anaphylaxis and is thus not recommended in tattoo allergy. Chronic papulonodular reactions in black tattoos with pigment agglomeration can respond to local corticoid or be treated with dermatome shaving or lasers depending on availability. It is important to recognize sarcoidosis, which is strongly associated with reactions in black tattoos. Tattoo complications also include many rare but specific entities, which require individual treatment depending on the case and the disease mechanism. Removal of tattoos in individuals regretting their tattoo is performed using Q-switched nanosecond lasers and the recently introduced picosecond lasers. In view of the various tattoo pigments with different absorption spectra and the limited number of laser wavelengths, it is difficult to predict treatment outcome, and it is recommended to pretreat small test spots. Black and red colors are removed best, while other colors are difficult. Removal of large tattoos, especially when multicolored, is hardly achievable and not recommended. Clients often have unrealistic expectations, and informed consent and dialogue between the client and the laser surgeon before and during a treatment course is important since the client shall know the risk that removal can be unsuccessful, with complications and even disfiguring leading to regret at the end.

Diagnostic Tools for Doctors' Evaluation of Tattoo Complications.

Diagnosis of tattoo complications is a multi-facetted field since many clinical entities and disease mechanisms are represented. Infections, allergies, and pigment foreign body reactions with granuloma are the major groups. The clinician needs a structured approach to diagnosis and an armamentarium of standard tests. Diagnosis primarily builds on patient history, objective clinical examination, and punch biopsy, supplemented with microbiology testing, ultrasound scanning, and clinical photography. Evaluation of allergic tattoo reactions and allergy to pigments by patch testing is not applicable and has a falsely negative outcome except for the diagnosis of allergy to metals and preservatives. Simple inspection of raw punch biopsies from chronic tattoo reactions, preferably evaluated with stereo microscopy, provides important information about the density and the local distribution of tattoo pigment in the dermis and changes of micro- anatomical skin structures. Histology may show subtle structural changes, but traditional patterns (lichenoid reaction, pseudolymphoma, granuloma, and pseudoepitheliomatous epidermal hyperplasia) are of little or no help in the diagnosis since the patterns overlap and have no distinct clinical correlates. Histology cannot separate allergic and nonallergic reactions. However, granulomatous reaction and sarcoid granuloma are significant findings since papulonodular reaction of black tattoos and sarcoidosis are strongly associated with each other. 20-MHz ultrasound scanning is important for noninvasive imaging and characterization of inflammatory tattoo reactions and can be used preoperatively as guide to treatment. Electron microscopy can visualize pigment particles in tissues, cells, and tattoo inks. Chemicals of pigment in tissues and in tattoo inks can be analyzed by high-performance liquid chromatography, mass spectroscopy, and Raman spectroscopy.

Atlas of Illustrative Cases of Tattoo Complications.

Tattoos, and tattoo complications as well, are colorful and visually flashy. A clinical outlook provides important clues to diagnosis by pattern recognition. This atlas,which is a report of 79 case illustrations, is made as a practical tool and vade mecum for the clinician. The atlas can be used in the office and as a bedside tool. It includes characteristic photos, and each case is accompanied with a brief medical history, a comment with learning points, the final diagnosis, and a review of therapeutic options. This spectrum of cases illustrates the different diagnostic entities according to the newly proposed Bispebjerg University Hospital ('Tattoo Clinic') diagnostic system of tattoo complications, a system reported to the 11th revision of the WHO disease classification system. Cases include allergies predominantly seen in red tattoos manifesting the characteristic patterns of plaque elevation, excessive hyperkeratosis, ulcerating reactions, urticaria, and generalized skin rash. Each type of reaction has typical clues to diagnosis and a typical disease course. 'Cross-sensitivity' allergic reactions in old tattoos of the same color as the trigger tattoo are also illustrated. Reactions in black tattoos are dominated by a pattern with papulonodular reactions, which are nonallergic anddue to pigment agglomeration in the skin. Reactions may be granulomatous and a marker of systemic sarcoidosis, sometimes associated with a general outbreak in the skin in black tattoos, e.g. 'rush phenomenon'. Bacterial infections are also illustrated. The technical hazards of tattooing and sequels as well as unwanted effects of tattoo removal by lasers are shown along with severe scarring following tattoo removal by caustics. This atlas is a tutorial in modern medical and surgical treatments of tattoo complications.

From Technique of Tattooing to Biokinetics and Toxicology of Injected Tattoo Ink Particles and Chemicals.

Tattoo colourants are colourful nano- and microparticles, which are practically insoluble and thus permanent once installed in the dermis by the tattooist. Tattoo ink also has soluble ingredients and contaminants. Pigments can distribute via the lymph and possibly also directly to the blood, and a minute fraction may over time undergo metabolic breakdown and as hapten(s) induce allergic reactions of red tattoos. Carbon black of black tattoos has a tendency to agglomerate and form larger bodies that can elicit foreign body reactions in black tattoos and even granuloma formation with overlap to sarcoidosis in the clinic. Very little is known about the biokinetics and safety profile of the many tattoo pigments in use, and no specific pigment-related chemical of tattoo ink causing identified adverse reactions in humans has been depicted. Inks have many ingredients and contaminants. Insoluble and soluble ingredients of inks supposedly have very different characteristics of absorption, distribution, metabolism, and excretion, with pigments being extremely slowly excreted, contrasting soluble ingredients with fast elimination. Tattoos are a single-dose exposure. Controlling the safety of tattoo inks by banning potentially critical chemicals hitherto has been unsuccessful due to lacking documentation of clinical and epidemiological relevance and because the tattoo industry is already internationally established, free, and in the ownership of the people. Doctors treating patients with tattoo complications consequently have a key role in identifying risk situations and local outbreaks, which needs clarification, therapy, and the intervention of authorities. In the treatment of complications, as seen in general practice and in other specialties, basic insight into the fate of tattoo pigments in the body is necessary. Tattoo complications are complicated and facetted with many entities and disease mechanisms; they are a new subspecialty in medicine and dermatology.

How to Diagnose and Classify Tattoo Complications in the Clinic: A System of Distinctive Patterns.

Tattoo complications represent a broad spectrum of clinical entities and disease mechanisms. Infections are known, but chronic inflammatory reactions have hitherto been inconsistently reported and given many interpretations and terms. A clinical classification system of distinct patterns with emphasis on inflammatory tattoo reactions is introduced. Allergic reactions prevalent in red tattoos and often associated with azo pigments are manifested as the 'plaque elevation', 'excessive hyperkeratosis', and 'ulceronecrotic' patterns. The allergen is a hapten. Nonallergic reactions prevalent in black tattoos and associated with carbon black are manifested as the 'papulonodular' pattern. Carbon black nanoparticles agglomerate in the dermis over time forming foreign bodies that elicit reactions. Many black tattoos even develop sarcoid granuloma, and the 'papulonodular' pattern is strongly associated with sarcoidosis affecting other organs. Tattoo complications include a large group of less frequent but nevertheless specific entities, i.e. irritant and toxic local events, photosensitivity, urticaria, eczematous rash due to soluble allergen, neurosensitivity and pain syndrome, lymphopathies, pigment diffusion or fan, scars, and other sequels of tattooing or tattoo removal. Keratoacanthoma occurs in tattoos. Carcinoma and melanoma are rare and occur by coincidence only. Different tattoo complications require different therapeutic approaches, and precise diagnosis is thus important as a key to therapy. The proposed new classification with characteristic patterns relies on simple tools, namely patient history, objective findings, and supplementary punch biopsy. By virtue of simplicity and broad access, these methods make the proposed classification widely applicable in clinics and hospitals. The system is reported to the 11th revision of the WHO diagnosis classification used as international standard.

Systemic Allergic Reaction to Red Tattoo Ink Requiring Excision.

Sir:We present a case of a systemic allergic red tattoo reaction that required excision and skin grafting after failure of other therapies.Tattoos are associated with an increased risk of infection, eczema, psoriasis, hyperplasia, granulomatous reactions, and neoplasm, with red ink as the most commo

Patterns of Reactions to Red Pigment Tattoo and Treatment Methods.

Tattoos are common and used extensively as either body art or cosmetic make-up; more rarely, they can be traumatic in nature. We have systemically analysed the literature for the patterns of red pigment tattoo reactions and their treatment options. Our search identified 18 articles; there was 1 non-randomised controlled trial, and the rest were small case studies. In total 139 patients were included within the studies. This review systematically analyses the different subsets of red tattoo reactions including lichenoid, dermatitis, granulomatous, pseudolymphomatous and miscellaneous reactions. The current evidence for the treatment for the above is presented. Dermatitis and lichenoid reactions appear to be the most common subtype of red pigment reactions with various treatment methods applied showing laser intervention to have some degree of success.

Self-reported tattoo reactions in a cohort of 448 French tattooists.

Self-reported complaints in people having tattoos, including swelling, itch, and photosensitivity, are frequent. Tattooists are usually heavily tattooed with multiple extended colored tattoos and constitute a specific population of interest. To assess the prevalence of cutaneous complications on tattoos among a cohort of French tattooists. An observational self-reported internet survey was performed among the tattooists of the French Tattoo Union in November 2013 to report on complaints about their tattoos. Of the 448 respondents, 42.6% reported a "tattoo reaction" on a least one of their previous tattoos: transient itch (45.7%), wax-and-waning swelling (57%), and swelling after sun exposure (23%). A tattoo "allergy" on one color of the tattoo was found in 8%. Permanent itch, swelling, and cutaneous infection were rare. No skin cancer on tattoos was reported. The binary regression analysis revealed that the area of the tattooed body surface was the main driver of the risk of developing a tattoo reaction, mainly transient or permanent swelling triggered by sun exposure or not. The tattoo reaction, transient itch, and swelling on tattoos seemed to be associated with the sun protection habits of the tattooed individuals. Professional tattooists have a high prevalence of minor complaints (transient itch and swelling) and photosensitivity on their tattoos such as in the general tattooed population.

Complications of decorative tattoo

Decorative tattoo is a popular practice that is generally safe when performed in the professional setting but can be associated with a variety of inflammatory, infectious, and neoplastic complications, risks that may be increased with current trends in home tattooing. Modern tattoo inks contain azo dyes and are often of unknown composition and not currently regulated for content or purity. Biopsy of most (if not all) tattoo reactions presenting to the dermatologist is recommended, given recent clusters of nontuberculous mycobacterial infections occurring within tattoo, as well as associations between tattoo reactions and systemic diseases such as sarcoidosis.

Histopathology and immune histochemistry of red tattoo reactions. Interface dermatitis is the lead pathology, with increase in T-lymphocytes and Langerhans cells suggesting an allergic pathomechanism.

The majority of tattoo reactions are affiliated to red pigmented areas and often suspected to be allergic in nature. A sizeable series of biopsies of such reactions has not previously been performed. The aim of this study was to type and grade epidermal and dermal changes in tattoo reactions to red/red nuances by microscopy and immunochemistry relevant for the assessment of a possible allergic pathomechanism. Skin biopsies were taken from red tattoo reactions, graded by conventional microscopy and stained for T and B-lymphocytes, Langerhans cells, macrophages and tumour necrosis factor (TNF)-α. The study included 19 biopsies from 19 patients. The culprit colours were red/pink (n = 15) and purple/bordeaux (n = 4). Interface dermatitis was clearly the lead pathology found in 78% of samples, overlapped with granulomatous (in 32%) and pseudolymphomatous reaction patterns (in 32%). Epidermal hyperkeratosis (in 89%) was common as was leakage of red pigment across the dermo-epidermal junction, with transepidermal elimination (in 28%). The dermal cellular infiltration was dominated by T-lymphocytes (in 100%), Langerhans cells (in 95%) and macrophages (in 100%). TNF-α was common. The predominant histological pattern of chronic tattoo reactions in red/red nuances is interface dermatitis. T-lymphocytes and Langerhans cells are increased suggesting an allergic pathomechanism. TNF-α may contribute to reactions. In many cases, overlapping reactive patterns were identified.

Self-reported adverse tattoo reactions: a New York City Central Park study.

Although permanent tattoos are becoming increasingly commonplace, there is a paucity of epidemiological data on adverse tattoo reactions. Several European studies have indicated that tattoo reactions may be relatively common, although the extent of this phenomenon in the United States is largely unknown. To provide insights into the prevalence and nature of adverse tattoo reactions. We administered a survey about adverse tattoo reactions to 300 randomly selected tattooed people in Central Park, New York City. Of 300 participants, 31 (10.3%) reported experiencing an adverse tattoo reaction, 13 (4.3%) reported acute reactions, and 18 (6.0%) suffered from a chronic reaction involving a specific colour lasting for >4 months. Forty-four per cent of colour-specific reactions were to red ink, which was only slightly higher than the frequency of red ink in the sampled population (36%). Twenty-five per cent of chronic reactions were to black ink, which was less than expected based on the number of respondents with black tattoos (90.3%). Study participants with chronic, colour-specific reactions had more tattoo colours than those without reactions. This study shows that tattoo reactions are relatively common, and that further investigation into the underlying causes is merited.

Introduction of dermatome shaving as first line treatment of chronic tattoo reactions

Background/aims: Chronic tattoo reactions requiring treatment have increased. Laser removal is not ideal for removal of allergic reactions. Surgical removal of culprit pigment situated in the outer dermis by dermatome shaving is rational and need to be revisited. Materials/methods: Fifty four tattoos with chronic reactions in 50 patients were treated with dermatome shaving. Tattoos with red/red nuances dominated the material. In total, 52 operations were performed in infiltration and 2 in general anaesthesia. Shaving was performed to the level in the dermis free of tattoo pigment as assessed visually by the surgeon. Results: Operative complications were few. Healing occurred over weeks as normal for this procedure. On a rating scale from 0 to 4, 4 as most severe, the patient’s severity rating of symptoms in their tattoo declined from 3.2 pre-operatively to 1.0, 0.8 and 0.7 after 3, 6 and 12 months, respectively. Burden of operation was rated low. Patient satisfaction was high. Discussion/conclusion: Dermatome shaving is efficient and with few complications, and is proposed as first line treatment of chronic tattoo reactions. Shaving of such reactions apparently has been neglected during enthusiastic introduction of laser approaches, which in the treatment of allergic tattoo reactions may be relatively contra indicated and of special risk.

Inflammatory Complications Related to Tattooing

: Although tattooing is an ancient practice, its increasing popularity and social acceptance, variability of tattoo ink composition, sporadic reports of novel tattoo reactions and advances in the field of tattoo removal techniques make it a topic of immense interest among dermatologists and pathologists alike. Since effective legislation governing the tattoo industry is largely lacking in most regions of the world, it is important to recognize the range of tattoo-related complications from a dermatopathological perspective. Using a pattern-based approach, this review details the broad spectrum of inflammatory reactions, which may be encountered in adverse reactions associated with tattooing. Awareness of the range of inflammatory tattoo reactions is crucial as some of these patterns of inflammation can be associated with systemic disorders and others may serve as important clues for an underlying infective condition.

Tattoo complaints and complications: diagnosis and clinical spectrum.

Tattoos cause a broad range of clinical problems. Mild complaints, especially sensitivity to sun, are very common and seen in 1/5 of cases. Medical complications are dominated by allergy to tattoo pigment haptens or haptens generated in the skin, especially in red tattoos but also in blue and green tattoos. Symptoms are major and can be compared to cumbersome pruritic skin diseases. Tattoo allergies and local reactions show distinct clinical manifestations, with plaque-like, excessive hyperkeratotic, ulcero-necrotic, lymphopathic, neuro-sensory, and scar patterns. Reactions in black tattoos are papulo-nodular and non-allergic and associated with the agglomeration of nanoparticulate carbon black. Tattoo complications include effects on general health conditions and complications in the psycho-social sphere. Tattoo infections with bacteria, especially staphylococci, which may be resistant to multiple antibiotics, may be prominent and may progress into life-threatening sepsis. Contaminated tattoo ink is an open-window risk vector that can lead to epidemic tattoo infections across national borders due to contaminated bulk production. Hepatitis B and C and human immunodeficiency virus (HIV) transferred by tattooing remain a significant risk needing active prevention. It is noteworthy that cancer arising in tattoos, in regional lymph nodes, and in other organs due to tattoo pigments and ingredients has not been detected or noted as a significant clinical problem hitherto, despite millions of people being tattooed for decennia. Clinical observation and epidemiology disagree with register data, which indicate an increased risk of cancer due to chemical carcinogens present in some inks. Registers rely on chronic dosaging of cell lines and animals. However, tattooing in humans is essentially a single-dose exposure, which might explain the observed discrepancy.

Chronic tattoo reactions cause reduced quality of life equaling cumbersome skin diseases.

Tattoos are often associated with mild complaints, but some people develop complications that may require medical treatment, and the burden of these events has hitherto been neglected. To understand the dimensions and the psychological symptomatology of adverse events both the sensory and affective impacts, including the effect on quality of life, should be studied. Itch severity and influence on quality of life can be measured objectively. The Itch Severity Scale and Dermatology Life Quality Index scoring systems have been applied to different dermatological diseases. When ISS and DLQI scores were applied to patients with chronic tattoo reactions, tattoo complaints and impact on quality of life that were comparable to patients presenting cumbersome dermatological disease such as psoriasis, eczema and pruritus, which often show widespread effects to the skin, were uncovered. In conclusion, chronic tattoo reactions should be ranked as a cumbersome dermatological disease and, accordingly, given priority attention and qualified treatment by the public health care system.

Complications of decorative tattoos: recognition and management.

Tattooing is an ancient practice that enjoys continued popularity. Although a modern, professionally performed tattoo is generally safe, complications can occur. A skin biopsy of all tattoo reactions is recommended as some tattoo reactions have systemic implications. Tattoo-related infections are seen days to decades after tattooing, and range from acute pyogenic infections to cutaneous tuberculosis. In particular, non-tuberculous mycobacterial infections happen in tattoos with increasing frequency and are introduced at the time of tattooing through contaminated ink or water used to dilute inks. Despite a transition in tattoo pigments from metal salts to industrial azo dyes, hypersensitivity reactions also persist, and include eczematous, granulomatous, lichenoid, and pseudoepitheliomatous patterns (among others). Granulomatous tattoo reactions can be a clue to cutaneous or systemic sarcoidosis, particularly in the setting of interferon use. Pseudoepitheliomatous tattoo reactions have substantial overlap with squamous cell carcinoma and keratoacanthoma, making diagnosis and management difficult. Other malignancies and their benign mimics can occur in tattoos, raising questions about the safety of tattoo ink and its role in carcinogenesis.

Necrobiotic Granulomatous Tattoo Reaction

The application of decorative tattoos to the skin is an ancient practice, which continues to be popular in the present day. Increasingly, a number of complications of tattoo application are recognized, including a diverse variety of cutaneous hypersensitivity reactions to tattoo pigments. Herein we describe an unusual case of a necrobiotic granulomatous tattoo reaction showing combined features of necrobiosis lipoidica and early granuloma annulare. The relevant literature is reviewed, and the practical significance of such unusual histological features as a part of the tattoo reaction is discussed.

Patients with tattoo reactions have reduced quality of life and suffer from itch: Dermatology Life Quality Index and Itch Severity Score measurements.

Tattoos are a trend with increasing side-effects. The burden of local reaction with swelling, itching and discomfort may impel sufferers to consult medical assistance. To assess tattoo reactions and their influence on quality of life and itching by utilizing the Dermatology Life Quality Index (DLQI) scoring system and Itch Severity Scale (ISS). Patients attending the 'Tattoo Clinic' at Bispebjerg University Hospital, Denmark with tattoo problems spanning more than 3months were invited. Forty patients participated during September-November 2012. Patients attending their routine consultations completed the ISS and DLQI questionnaires. Patients with tattoo reactions experienced reduced quality of life, DLQI score 7.4 and were burdened by itch, ISS score 7.2. Both DLQI and ISS results attained the level of discomfort of known skin diseases such as psoriasis, pruritus and eczema albeit the typical tattooed affected areas are smaller. Sufferers of tattoo reactions have reduced quality of life and are often burdened by itching attaining the level of other cumbersome afflictions recognized as dermatological diseases associated with itch. Tattoo reactions warrant diagnosis and treatment with same professional intent shared with other skin diseases.

Patch test study of 90 patients with tattoo reactions: negative outcome of allergy patch test to baseline batteries and culprit inks suggests allergen(s) are generated in the skin through haptenization.

Tattoo reactions, especially in red tattoos, are often suggested as allergic in nature, however, systematic evaluation by patch testing has not performed in the past. To report the results of patch testing in 90 patients with non-infectious chronic tattoo reactions. From 2009 to 2013 at the 'Tattoo Clinic', Department of Dermatology, Bispebjerg University Hospital, 90 patients were patch tested with batteries of baseline allergens, disperse dyes/textile allergens, and a selection of tattoo ink stock products, which, according to case observations, were problematic, supplemented with individual culprit inks when accessible. Patients with reactions to the tattoo colour red, the most predominant colour associated with skin reactions, showed negative patch test results with common allergens. Outcomes were also negative in patients who had experienced concomitant reactions in another hitherto tolerated tattoo of the same colour as the problematic tattoo. The allergen or allergens responsible for tattoo reactions are not present directly in tattoo ink stock products. This is despite the fact that clinical histories suggest that the vast majority of clinical reactions, especially reactions to red and red nuances, are likely to be allergic events caused by the injected inks. We suggest that the responsible allergen results from a complicated and slow process of haptenization, which may even include photochemical cleavage of red azo pigment.