Tattoo-related Complications Research Articles

The role of reflectance confocal microscopy in the diagnosis and management of pigmentary disorders: A review.

Reflectance confocal microscopy (RCM) has quickly transitioned from a research tool to an adjunct diagnostic bedside tool, providing the opportunity for noninvasive evaluation of skin lesions with histologic resolution. RCM is an optical imaging technique that uses near-infrared excitation wavelengths and safe low-power lasers. En-face images of different skin layers (up to the superficial dermis) are acquired in grayscale based on the reflective indices of tissue components. Melanin has the highest reflective index (contrast) and appears bright on RCM. We present a review of the current literature on the use of RCM in the diagnosis and management of pigmentary disorders. We reviewed PubMed and Ovid Medline databases from January 2000 to June 2021, using MeSH key terms: "reflectance confocal microscopy, confocal laser scanning microscopy, pigmentary disorders, treatment, melasma, vitiligo, freckles, solar lentigo, lentigo, tattoo, complications, melanoma, skin cancers, pigmented lesions, post inflammatory, melanin, photoaging" to identify studies and review articles discussing the use of RCM in the diagnosis and management of pigmentary disorders. RCM findings of pigmentary disorders were divided into the following categories: (1) disorders of increased pigmentation (post-inflammatory hyperpigmentation, melasma, Riehl's melanosis, solar lentigines, ephelides, hori nevus, naevus of Ota, café-au-lait macules, melanocytic nevus, melanoma, nevus spilus, labial mucosal melanosis, and mucosal melanoma), (2) disorders of decreased pigmentation or depigmentation (post-inflammatory hypopigmentation, vitiligo, nevus depigmentosus, halo nevus), and (3) exogenous pigmentation (tattoo, ochronosis). RCM has been explored and proven valuable for the evaluation and management of pigmentary disorders including melasma, vitiligo, solar lentigines, tattoo, and tattoo-related complications.

An 11-year Institutional Review of Nipple-Areolar Complex Tattooing for Breast Reconstruction: Identifying Risk Factors for Development of Tattoo-related Infectious Complications.

Nipple-areolar complex (NAC) tattooing remains a simple and safe procedure, which complements breast reconstruction. This study reviews 11 years of NAC tattooing to identify risk factors for tattoo-related complications. Patients undergoing NAC tattooing from January 2009 to March 2020 were reviewed. Patient information, reconstructive, and tattoo procedural details were analyzed. Tattoo-related breast infections, defined as breast redness requiring antibiotic therapy within 30 days after tattoo, were captured. Patients with reactive breast redness during the first 2 postprocedural days were excluded. Overall, 539 patients (949 breasts) were included. Implant-based reconstruction (IBR) was performed in 73.6% of breasts (n = 698), whereas 26.4% (n = 251) underwent autologous-based reconstruction (ABR). Acellular-dermal matrix was used in 547 breasts (57.6%). There as a 13.7% (n = 130) of breasts that underwent pretattoo radiation. There was a 65.3% (n = 456) of breasts that underwent subpectoral IBR, whereas 34.7% (n = 242) breasts underwent prepectoral IBR. Tattoo-related infection rate was 2.2% (n = 21 breasts). Mean time to infection was 6.5 ± 5.3 days. There was a 85.7% (n = 18) of infections that occurred in IBR patients, one third occurring in radiated patients. There was a 95.2% (n = 20) of infections that were treated with oral antibiotics only. One explantation was performed after failed intravenous antibiotics. On multivariable analysis, radiation history (odds ratio, 4.1, P = 0.007) and prepectoral IBR (odds ratio, 2.8, P = 0.036) were independent predictors of tattoo-related infection. Among irradiated breasts, breasts with IBR had greater odds of developing tattoo-related infection versus breasts with ABR (P = 0.025). Although tattoo-related infections were uncommon, previous radiation and prepectoral IBR were both found to be independent predictors of tattoo-related breast infection. There is a role for preprocedural prophylactic antibiotics in these patients to mitigate infectious risk.

Assessing Infection Risks among Clients and Staff Who Use Tattooing Services in Poland: An Observational Study.

Across cultures and generations, people have tattooed their bodies. Although blood-borne infections from tattooing have been reduced, certain service aspects remain improperly managed. We assessed the infection risks associated with tattooing by conducting a cross-sectional study (2013–2014) in Poland using an anonymous questionnaire survey. Scoring procedures for blood-borne infection risks for tattooists and their clients were used. Overall, 255 tattooists were interviewed. A quasi-random selection of tattoo parlors was based on a service register. Knowledge, attitudes, and behavior regarding blood-borne infection risks were assessed using a questionnaire. Simultaneously, tattoo centers were audited. Tattooing had a higher infection risk for tattooists than for clients. Approximately 50% of respondents underwent training on postexposure procedures, which constituted almost one in five of the reported needlestick/cut injuries sustained while working. Furthermore, 25.8% had no knowledge regarding risk from reliable sources, and 2.1% had not broadened their knowledge. Tattooists and their clients are at a risk of infection, and knowledge concerning infection risks remains an underestimated preventative factor. Service quality surveillance and creation of a register for tattoo-related complications may help assess the scale of this public health issue. However, a lack of these records implies the challenges in developing effective organizational and legal protections.

Evaluation of phototoxicity of tattoo pigments using the 3 T3 neutral red uptake phototoxicity test and a 3D human reconstructed skin model

Phototoxicity due to dermally impregnated compounds exposed to ultraviolet radiation is associated with skin inflammation. The phototoxicity potential of active substances applied to the skin should be evaluated. Pigments are widely used for tattoos, and hypersensitivity reactions, such as photoallergic dermatitis, are possible tattoo-related complications. However, the phototoxicity of these chemicals is not well known. In this study, we evaluated the phototoxicity potential of six tattoo pigments, cadmium sulfide, carbazole, cadmium selenide, mercury (II) sulfide, chromium oxide, and cobalt aluminate, using in vitro methods—3 T3 neutral red uptake (NRU) phototoxicity test (PT) and a 3D human reconstructed skin model (EpiDerm). The validated 3 T3 NRU PT indicated the phototoxicity potential of carbazole and cadmium sulfide. The 3D human skin model confirmed that only carbazole was phototoxic. The 3 T3 NRU PT data corresponded well with those from the 3D skin model and suggested the need to employ several test systems for final phototoxicity assessment. In addition to the results obtained using 3 T3 NRU PT, further testing on 3D skin models may better reflect the bioavailability of a given chemical in the skin.

Assessing Infection Risks Among Clients and Staff Using Tattooing Services in Poland

Background: Across cultures and through the ages, people have tattooed their bodies. However, clients attending tattooing services may be at risk due to the use of dyes that compromise the immune system, and unintentional pathogenic infection may further increase client risk. To reduce these risks, aseptic techniques should be used and maintained throughout the period of tattooing, until completion of wound healing. Client education concerning tattoo-related health risks and risk prevention is needed to ensure appropriate understanding before informed consent is given prior to tattooing. This study aimed to assess the risks of transmitting infections due to tattooing. Methods: From 2013 to 2014, an anonymous questionnaire survey and simultaneous audits were conducted in all of Poland's voivodships (the highest-level administrative subdivisions of Poland), and 255 individuals who performed tattoos and permanent makeup were interviewed. A quasi-random selection of tattoo parlors was based on a register of services. Scoring procedures concerning blood-borne infection risks for individuals performing tattoos and for their clients were applied in the analyses. Findings: Of the respondents, approximately 50% had participated in training on post-exposure procedures, almost one in five reported needlestick/cut injuries sustained while working, 25·8% had not obtained their knowledge in relation to risk from reliable sources, and 2·1% had not sought to broaden their knowledge. Interpretation: Tattooists and their clients are at risk of infection, and knowledge concerning the risk of infection is still an underestimated preventative factor. Service quality surveillance and the establishment of a register for tattoo-related complications may provide an opportunity to assess the scale of this public health issue. However, the lack of a register that records tattoo-related adverse reactions and complications means that it has not yet been possible to develop effective organizational and legal protections. Funding Statement: Swiss Contribution and the Polish Ministry of Health (No: KIK35) as well as voluntary inputs. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: Participation in the study was voluntary and anonymous, and informed consent was obtained from all participants prior to commencing the interviews. The study proposal and design was accepted by the “Project HCV” Steering Committee and was undertaken at tattoo centers by State Sanitary Inspection staff during their routine duties.

Tattoo-associated complications and related topics: A comprehensive review

As tattoos become more common, it is likely that practitioners will encounter adverse tattoo reactions with increasing frequency. While some tattoo-related complications (TRCs) may be nonspecific and challenging to diagnose, others present overtly and can be identified quickly by a well-informed practitioner. TRCs occur at both of these extremes, highlighting the need for better awareness and knowledge sharing regarding this heterogeneous group of morbidities. This review is a result of a compilation of the best available clinical evidence across various groupings of TRCs. The authors' intent was to provide the reader with a comprehensive overview of the topic while creating a rich repository of referenced knowledge for future investigations. From the standpoint of frontline health-care providers, effective recognition and management of TRCs require an open-mind, high degree of clinical suspicion, and nonjudgmental approach to a mainstream phenomenon that is still considered by many to be a taboo. The following core competencies are addressed in this article: Medical knowledge, Patient care, and Systems-based practice.

Tattoo side effects worldwide: a Google Trends–based time series analysis

It is not known whether tattoo-related complications are becoming more frequent and, if so, how quickly. Data generated throughGoogle Trends (GT) worldwide, from January 1st, 2004 to December 31st, 2018, were analyzed for the search volume indexes (SVIs) of selected symptoms ("swollen tattoo," "raised tattoo," "tattoo bumps," "itchy tattoo," "tattoo fading"), diagnosis ("infected tattoo," "tattoo allergy"), and control terms ("tattoo care," "tattoo healing"). For 2004-2018, the mean SVIs for symptoms were: "itchy tattoo" (41) > "tattoo bumps" (31) > "raised tattoos" (30) > "tattoo fading" (24) > "swollen tattoo" (22). The mean SVIs by 5-year periods showed a regular and constant increase for "itchy tattoo." The search for "infected tattoo" saw a slight but progressive increase, whereas the search for "tattoo allergy" remained stable between 2004 and 2018. Analysis of GT shows an increased search for symptoms such as itching, bumps, and induration on tattoos. However, it cannot be confirmed whether this rise points to a real increase of side effects, or to the popularity of tattoos and generalization of internet use as a tool to obtain information. GT could be of interest for detecting and following trends related to tattoo complications. Use of informal terms rather than medical terms is warranted.

Diagnostic Tools to Use When We Suspect an Allergic Reaction to a Tattoo: A Proposal Based on Cases at Our Hospital

IntroductionTattooing has become a popular practice in western countries, particularly among younger populations. Tattoos, however, can cause complications, such as infections, allergic or foreign-body reactions, and even systemic inflammatory responses. Patients and methodsWe conducted a retrospective study of all patients seen for tattoo-related complications at our skin allergy unit between January 2002 and December 2016. ResultsWe studied 23 patients. Nine of these experienced early complications, all related to infection. The other 14 patients developed late reactions. Ten were diagnosed with probable allergic contact dermatitis to ink, but the suspect allergen was identified in just 3 cases and confirmed in just 1 of these. There were 2 cases of cutaneous sarcoidosis, 1 case of foreign body granuloma, and 1 case of neuropathy. ConclusionsComplications resulting from tattoos are relatively common dermatology complaints. Drawing from our experience, we propose a diagnostic algorithm designed to guide dermatologists in evaluating different reactions to tattoos and prescribing appropriate treatment.

¿Qué procedimientos diagnósticos deberíamos realizar ante una sospecha de reacción alérgica a un tatuaje? Propuesta basada en nuestra casuística

IntroductionTattooing has become a popular practice in western countries, particularly among younger populations. Tattoos, however, can cause complications, such as infections, allergic or foreign-body reactions, and even systemic inflammatory responses. Patients and methodsWe conducted a retrospective study of all patients seen for tattoo-related complications at our skin allergy unit between January 2002 and December 2016. ResultsWe studied 23 patients. Nine of these experienced early complications, all related to infection. The other 14 patients developed late reactions. Ten were diagnosed with probable allergic contact dermatitis to ink, but the suspect allergen was identified in just 3 cases and confirmed in just 1 of these. There were 2 cases of cutaneous sarcoidosis, 1 case of foreign body granuloma, and 1 case of neuropathy. ConclusionsComplications resulting from tattoos are relatively common dermatology complaints. Drawing from our experience, we propose a diagnostic algorithm designed to guide dermatologists in evaluating different reactions to tattoos and prescribing appropriate treatment.

Medical Complications of Tattoos: A Comprehensive Review.

Tattoos are defined as the introduction of exogenous pigments into the dermis in order to produce a permanent design. This process may occur unintentional or may be deliberately administered for cosmetic or medical reasons. Tattoos have been around for over 5000years and over time have evolved to represent a common cosmetic practice worldwide. Currently, adverse reactions are relatively rare and generally unpredictable and predominantly include immune-mediated reactions and skin infections. Along with better healthcare standards and more stringent public health mandates such as the provision of disposable needles, major infectious complications related to hepatitis and human retroviral infections have decreased significantly. When they do occur, skin infections are most frequently associated with Staphylococcus aureus or Streptococcus pyogenes. The aim of this study is to review the types and rates of medical complications of permanent tattoos. PubMed search and search dates were open ended. Acute local inflammation is the most common complication, but infections, allergic contact dermatitis, and other inflammatory or immune responses that are not well-characterized may occur. As many patients with immune reactions to tattoos do not react on skin or patch testing, it is postulated that the antigens contained in dyes or pigments are such small molecules that they need to be haptenized in order to become immunogenic. Red ink is associated more frequently with long-term reactions, including granulomatous and pseudolymphomatous phenomena or morphea-like lesions and vasculitis. Exacerbation of preexisting psoriasis, atopic dermatitis, and pyoderma gangrenosum may occur after tattooing. There is no well-defined association between cancer and tattoos. The treatment of tattoo-related complications may include local destructive measures (cryotherapy, electro-surgery, dermabrasion, chemical destruction, ablative laser destruction), surgical excision, and thermolysis of the pigment using Q-switched laser therapy.

Important to recognize and manage complications of decorative tattoos

Despite the common practice of modern aseptic technique and the increasing use of azo dye-based inks, decorative tattoos are frequently complicated by infectious, inflammatory or neoplastic conditions. Moreover, as the number of people receiving tattoos increases, the number of tattoo-related complications reported can be expected to rise.

Preoperative Localization of Colorectal Tumors with Endoscopic Tattooing for Laparoscopic Surgery

Background: Effective localization of colorectal tumors with a visible marker is necessary for adequate resection in laparoscopic surgery. Tattooing of these tumors by endoscopy is a widely utilized method for proper localization. Methods: A retrospective study of 50 patients who underwent tattooing with colonoscopy prior to colorectal surgery over a 12-year period was conducted. One patient was excluded from analysis due to incomplete data. Tattooing was performed using SPOT endoscopic marker (GI Supply, Camp Hill, PA), which is a prepackaged biocompatible agent containing highly purified, very fine carbon particles. Results: 49 patients received endoscopic tattooing with colonoscopy. Of these 49 patients, 37 patients had tattooing identified in either surgery and/or surgical pathology specimens. 12 lesions were not identified on both surgery and pathology. No tattoo related complications were noted. There were no conversions from laparoscopic to open surgical resection due to poorly visualized tattooed lesions. No patients underwent intra-operative colonoscopy to confirm accurate tattoo placement. Conclusions: All colonic lesions that appear to be malignant should be tattooed during endoscopy to improve surgical localization. Tattoo endoscopy is a safe and effective method for preoperative tumor localization.

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.

Histopathologic Reaction Patterns in Decorative Tattoos

In recent years, the practice of decorative tattooing has seen rising popularity and increased social acceptance. As newer tattoo inks are developed and utilized, it is expected that the rate of reactions will rise. Thus, dermatologists are more likely to encounter tattoo-related complications. An understanding of the most common histopathologic reaction patterns ideally will result in increased clinical detection of situations requiring additional evaluation, whether it is for an underlying infection, systemic involvement of disease, or to rule out a cutaneous malignancy. This review will describe both the clinical and histopathologic features of pathologic reactions to decorative tattoos. The main histopathologic reactions are divided into six distinct categories: allergic hypersensitivity, granulomatous, interface, pseudolymphomatous, oncologic and infectious.

Tattoo Ink-Related Cutaneous Pseudolymphoma: A Rare but Significant Complication. Case Report and Review of the Literature

The demand for decorative tattoos is steadily growing worldwide, and in the US it is estimated that up to 24% of adults has one or more tattoos. Subsequently, the number of tattoo-related complications is increasing. Among these, lymphoproliferative disorders play a minor but important role. The aim of this article is to arouse the awareness of plastic surgeons and dermatologists about this rare but serious complication and to stimulate stricter clinical control of their tattooed patients. We report a new case of tattoo-related cutaneous pseudolymphoma (CPL) and perform a review of the last 30 years of literature on the topic in PubMed. Apart from this new case, only 18 cases of CPL have been reported in PubMed so far. In contrast to the classic knowledge, the T cell was the predominant phenotype in 68% of cases. Red is confirmed to be the most involved ink. Topical and intralesional steroids, laser therapy, and surgery were used for treatment of CPL. Even if CPL is a very rare and benign complication, we should not forget that in rare cases pseudolymphoma may evolve into a true lymphoma. Diagnosis is still difficult and is based on anamnestic, clinical, and histopathological data. From the review of the literature, the T cell predominance suggests a reclassification of tattoo-induced CPL and there is not a gold standard treatment yet. Finally, once a pseudolymphoma is diagnosed, there must be a long follow-up because of the possibility to transform into a malignancy. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Utility of Endoscopic Tattooing Prior to Colorectal Surgery in Identification and Resection of Colorectal Tumors or Other Colorectal Pathology

Purpose: The purpose of this study is to evaluate the efficacy of tattooing during colonoscopy to accurately localize colorectal lesions prior to laparoscopic surgery. Methods: We conducted a retrospective chart review of patients receiving tattoos during colonoscopy at MEDSTAR Georgetown University Hospital from January 1, 2000 to May 10, 2012. We identified 50 patients who received tattooing with colonoscopy prior to colorectal surgery. One patient was excluded from analysis due to incomplete data. Patients' records were reviewed to determine rates of accurate identification of endoscopic tattooing during colorectal surgery and surgical pathology. Data regarding indication for colonoscopy, endoscopic findings, endoscopic and surgical pathology were collected. Results: Fifty patients (mean age 64.8 yrs, range 28-89; male 23 [46%], female 27 [54%]) were identified as having tattooing with colonoscopy for identification of lesions for subsequent colorectal surgery. Of the 40 patients that had tattooing for localization of tumor, 15 (37.5%) were located in the sigmoid colon, 15 (37.5%) right colon, 3 (7.5%) rectum, 5 (12.5%) left colon, and 2 (5%) transverse colon. Ten patients had tattooing for other colonic pathology, including 6 for sigmoid diverticulosis, 3 for strictures, and 1 for sigmoid inflammation. Out of 49 patients with complete records, there were 24 (49%) patients with tattoo markings visualized during colorectal surgery and on surgical pathology, 8 (16%) during surgery but not on pathology, 5 (10%) on pathology but not during surgery, and 12 (24%) had no tattoo markings visualized during surgery or on pathology. However, in all 12 (24%) cases, surgical pathology demonstrated successful resection of colonic lesions. On surgical pathology, there were 28 (57%) adenocarcinomas, 6 (12%) benign, 5 (10%) adenomas, 1 (2%) metastatic cancer, 1 (2%) lipoma and 8 (16%) other (diverticulosis, inflammation or abscess). No tattoo related complications were noted. There were no conversions from laparoscopic to open surgical resection due to poorly visualize tattooed lesions. Conclusion: Overall, tattooing was visualized in 32 (65%) of surgeries and 29 (59%) of surgical pathology. Endoscopic tattooing was identified both during surgery and on pathology in 24 (49%) patients, therefore establishing a strong correlation between tattooing and accurate resection. Majority of tattooed lesions were adenocarcinoma (28, 57%), confirming the importance of tattooing in colorectal cancer resection. All colonic lesions that appear to be malignant should be tattooed during endoscopy to improve surgical localization. Tattoo endoscopy is a safe and effective method for preoperative tumor localization.

Leaving a mark: the frequency and accuracy of tattooing prior to laparoscopic colorectal surgery

Intra-operative localization of small cancers and polyps during laparoscopic colorectal surgery is difficult due to reduced tactile feedback. The consequences of failing to identify the lesion for resection can result in open conversion or removal of the wrong segment of bowel. Data were collected from a prospectively-kept database over a 12-month period from April 2008 to March 2009 and analysed retrospectively. Details concerning the documentation, visibility and accuracy of tattoos were recorded. Eighty-five patients (88 lesions) underwent laparoscopic resection for a benign or malignant colorectal tumour during 1 year from April 2008. Eighty-one patients underwent endoscopic visualization of the tumour as a first or second procedure. Of these 81 patients, 83 lesions were visualized endoscopically and 54 (65.1%) were tattooed in 52 patients. In the 52 patients, 36 (69%) of the tattoos were carried out on the first endoscopy. At operation the tattoo was judged to be visible and accurate in 70%, visible but inaccurate in 7% and not visible in 15%. It was significantly easier to see the tattoo in women (19/21 women vs 21/29 men; P=0.03) but there was no relationship between tattoo visibility and BMI. An accurate tattoo did not reduce the conversion rate (P=0.71). No tattoo-related complications were encountered. The practice of tattooing colorectal cancers is variable in frequency, technique and accuracy. We advocate that all colonic lesions suspicious for cancer should be tattooed during endoscopy at a defined distance below the tumour, adhering to a departmental protocol in case surgery is required.

Endoscopic Tattooing: Complications Might Be Preventable with Careful Technique

Endoscopic tattooing was performed in the past using sterilized solutions of India ink, which often contained immunologically active proteins and occasionally caused complications that included sterile abscesses and even development of inflammatory bowel disease. Now, sterile suspensions of pure carbon black (Spot; GI Supply) are typically used and assumed to be inert and safe for injection. To investigate this assumption, researchers from a large center for endoscopic mucosal resection (EMR) of colonic lesions prospectively reviewed cases involving tattoo-related complications. Four cases were identified during 5 …

Detection of Cervical Lymph Nodes in Head and Neck Cancer: A Study of the Correlation Between Ultrasonic and Histological Findings in Wales

Detection of Cervical Lymph Nodes in Head and Neck Cancer: A Study of the Correlation Between Ultrasonic and Histological Findings in Wales