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Contact Dermatitis •Original Article COD
Contact Dermatitis
Self-reported adverse tattoo reactions: a New York City Central Park
study
Bobbi G. Brady1,HeidiGold
2, Elizabeth A. Leger3and Marie C. Leger4
1Department of Medicine, Norwalk Hospital, Norwalk, CT 06850, 2Department of Medicine, Maimonides Medical Center, Brooklyn, NY 11219, 3Department
of Natural Resources and Environmental Science, University of Nevada, Reno, NV, 89557, USA, and 4Ronald O. Perelman Department of Dermatology, New
York University, New York, NY, 10016, USA
doi:10.1111/cod.12425
Summary Background. 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.
Objectives. To provide insights into the prevalence and nature of adverse tattoo reac-
tions.
Patients/materials/methods. We administered a survey about adverse tattoo reac-
tions to 300 randomly selected tattooed people in Central Park, New York City.
Results. Of 300 participants, 31 (10.3%) reported experiencing an adverse tattoo reac-
tion, 13 (4.3%) reported acute reactions, and 18 (6.0%) suffered from a chronic reaction
involving a specic colour lasting for >4months. Forty-four per cent of colour-specic
reactions were to red ink, which was only slightly higher than the frequency of red ink
in the sampled population (36%). Twenty-ve per cent of chronic reactions were to black
ink, which was less than expected based on the number of respondents with black tat-
toos (90.3%). Study participants with chronic, colour-specic reactions had more tattoo
colours than those without reactions.
Conclusions. This study shows that tattoo reactions are relatively common, and that
further investigation into the underlying causes is merited.
Key words: allergic contact dermatitis; tattoo allergy; tattoo epidemiology; tattoo
reactions; tattoo survey; tattoos.
Tattoos have become commonplace in the United States;
it is estimated that one-quarter of the population has at
least one permanent tattoo (1). The increasing popularity
Correspondence: Marie C. Leger, 240 E 38th Street, 12th Floor, New York,
NY 10016, USA. Tel: +1 217 721 0527. E-mail: marie.leger@nyumc.org
Present addresses: Bobbi G. Brady, Division of Dermatology, Department
of Medicine, Vanderbilt University, Nashville, TN, 37204, USA; Heidi Gold,
Division of Dermatology at Montefiore Medical Center, Bronx, NY, 10463,
USA.
Conflicts of interest: The authors have no conflicts of interest to declare.
Funding sources: This study was investigator-initiated with approval and
support from the Ronald O. Perelman New York University Department of
Dermatology. No funding was necessary for the completion of the study.
Accepted for publication 27 April 2015
of cosmetic tattoos in the form of permanent makeup
since the 1970s has added further to the proportion of
the population exposed to tattooing (2). There is limited
statistical information on adverse tattoo reactions, but
the available data suggest that they are becoming more
common. Whereas only 5 cases of adverse reactions were
reported to the United States Food and Drug Adminis-
tration (FDA) between 1988 and 2003, from 2003 to
2004, there were reports of >150 adverse reactions to
permanent makeup procedures alone (2). Understanding
the nature and prevalence of tattoo reactions is impor-
tant, as they can be quite distressing: a Danish study in
a dedicated ‘tattoo clinic’ surveyed patients with tattoo
reactions lasting for >3 months, and found that patients
reported troublesome persistent symptoms, such as
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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TATTOO REACTIONS: A CENTRAL PARK STUDY •BRADY ET AL.
itching, pain, soreness, and stinging, that had a signif-
icant impact on their quality of life, affecting daily and
leisure activities (3).
There is a growing body of literature on the prevalence
of tattoo complications in Europe, although researchers
have used a variety of methods and denitions of reaction
types, which makes it somewhat difcult to make com-
parisons among studies. A recent internet survey of 3411
tattooed respondents from German-speaking countries
recruited from a variety of advertisements, including a
press agency report placed in almost all of Germany’s
local newspapers, showed that 67.5% of respondents had
experienced an immediate adverse tattoo reaction, 8%
reported still having a reaction 4 weeks after obtaining
the tattoo, and 6% reported a persistent ongoing reaction
consisting of oedema, permanent elevation of skin, and
pruritus (4). A study of consecutive patients at a sexually
transmitted disease clinic in Copenhagen found that,
of 154 patients with 342 tattoos, 15% reported early
complaints (up to 3 months) such as itching, ulceration,
redness and swelling, prolonged healing, and infection,
and 27% reported a variety of complaints with a tattoo
3 months or more after they obtained it (5). Another Dan-
ish survey conducted on several beaches found that, of
144 sunbathers with 301 tattoos, 42% had complaints,
which were most commonly swelling, itching, stinging,
pain, and redness, 52% of which were light-induced (6).
Authors afliated with a Bulgarian dermatology clinic
reported the overall prevalence of tattoo complications
in a series of patients to be 2.1% (5 of 234 patients),
including infectious, allergic and/or granulomatous
responses (7).
There is no corresponding literature on populations in
the United States, and there is currently no centralized
database tracking this information; therefore, the extent
of adverse events is unknown. Furthermore, tattoo ink
components are not regulated by the US federal govern-
ment. The Food, Drug, and Cosmetic Act of 1938 lists
tattoo pigments as colour additives that are intended for
topical use only, none of which are approved for injec-
tion into the skin, and the agency has never implemented
inspection of tattoo pigments (8). In contrast to the Euro-
pean studies cited above, published accounts in the United
States are primarily case studies, and do not provide infor-
mation on the prevalence rates of different types of tat-
too reaction among the general population, although our
clinical experience suggests that tattoo reactions are not
uncommon.
Chronic, colour-specic tattoo reactions have been
reported in the literature for almost every ink colour (9),
with reactions ranging from acute processes, such as
delayed healing and infection, to more chronic events,
such as keloids, allergy, autoimmune responses, and
malignancy (7, 10–12). Red ink, in particular, has been
commonly reported in association with tattoo reactions
(7, 13–15). The composition of modern tattoo ink, how-
ever, is poorly understood. Black ink is composed of soot
derivatives and carbons, including polycyclic aromatic
hydrocarbons, and this has not changed radically over
the last several decades. The composition of colour inks,
however, has changed since the 1970s. Whereas heavy
metals – such as mercury, cadmium, and lead – were
previously key ingredients in tattoos, the US FDA banned
the use of these substances for cosmetic purposes in the
1970s. They are no longer common components of tat-
too inks (16, 17), and synthetic organic pigments, such
as azo dyes and polycyclic compounds, are now more
frequently used (18, 19). Whereas there is a growing
body of literature on the safety of tattoo inks, and many
steps havebeen taken towards stricter regulation of tattoo
inks in Europe over the last decade, the regulation and
investigation of tattoo safety in the United States is not as
developed (11, 18, 19).
Given the limited epidemiological data on tattoos, we
sought to gather information on the prevalence of adverse
tattoo reactions in a tattooed population. In this study,
we report the results from a survey of 300 randomly
selected tattooed people in Central Park in New York City.
Our objectives were to estimate the prevalence rates of
self-reported acute and chronic tattoo reactions, includ-
ing colour-specic reactions, determine whether people
sought medical attention for these events, and describe
the characteristics of acute and chronic tattoo reactions.
We gathered information about colours associated with
chronic tattoo reactions, asked whether reactions were
more common when people had more tattoo colours, and
determined whether chronic allergic reactions were more
likely in people with other self-reported allergies.
Methods
Study design and mechanics
After conducting a literature review of the clinical char-
acteristics of adverse tattoo reactions, we designed an
anonymous, 17-question survey using branched logic
(Table 1). The survey was approved by the NYU Institu-
tional Review Board (Protocol no. S13-00796). Survey
data were collected in New York City’s Central Park, an
area popular with tourists and residents from a broad
socioeconomic range, on 8 weekend days and 4 week-
days in June 2013, with the aim of collecting surveys
from the rst 300 tattooed individuals who met the eligi-
bility criteria (discussed below) and consented to partici-
pate in the study. The park was divided into two sections,
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
92 Contact Dermatitis,73,91–99
TATTOO REACTIONS: A CENTRAL PARK STUDY •BRADY ET AL.
Tabl e 1 . Adverse tattoo reaction survey questions
1. What is your age?
2. Are you a male or female?
3. What is your citizenship status?
4. Do you consider your natural skin tone to be very fair, fair, medium, dark, or very dark?
5. What is your ethnicity?
6. How many tattoos do you have?
7. Where are these tattoos located on your body?
8. What total percentage of your body’s surface area is covered by tattoos? (Estimated by surveyor using ‘rule of 9s’)
9. What is the age your tattoos? If you have many tattoos, what is the age of the newest and oldest tattoos?
10. What ink colours were used in your tattoos?
11. In what geographical location was each tattoo performed?
a. Do you remember the name of the tattoo parlour?
12. Do you have any known food, drug, or other allergies? If yes, to what?
13. Do you have any history of experiencing an adverse tattoo reaction? (A tattoo reaction can be considered any skin sign or symptom that
differs from what you would consider a normal part of tattooing or tattoo healing. This can include, but is not limited to, persistent
redness, itching, rash, irritation, swelling, scarring, infection, disfigurement, raising, and photosensitivity which you consider beyond the
normal expectations for tattooing and tattoo healing.)
a. If no, you may end the survey here.
b. If yes, please describe the adverse reaction in your own words, then continue to question 14.
14. Which tattoo was involved?
a. How old was the tattoo when the reaction began?
b. Were there any particular colors of ink involved?
c. Where is the involved tattoo located on your body?
15. Did you report this reaction to the tattoo parlor where you received the tattoo?
16. Did you seek medical attention for the tattoo reaction? If yes:
a. What type of health care provider did you see?
b. Were you given any specific diagnosis?
c. Were you administered, prescribed, or told to use any topical, oral, or injectable medications for treatment of the reaction? If yes:
i. Did the reaction resolve with treatment?
17. If you are currently experiencing a tattoo reaction (with or without prior treatment), how long have you been experiencing this reaction?
a. What symptoms still persist?
north and south of 79th street, and individual persons or
groups of people encountered at leisure in Central Park
were approached.
The surveyors, 2 medical students, introduced them-
selves and the purpose of the study, and asked poten-
tial participants whether they had any tattoos that they
would be willing to discuss for the purposes of the inves-
tigation. If a person did have a tattoo and verbally con-
sented to participate in the study, the person was given
an information sheet that contained the background, pur-
pose and contact information for the study. If a group
was approached with more than 1 eligible participant,
only 1 individual’s information was collected, in order to
reduce the possibility that people in the group may have
received tattoos from a similar geographical area or tat-
too parlour. Participants were told that they could end
the survey at any time or choose to omit answering ques-
tions that they felt to be intrusive or irrelevant. The only
question omitted by choice by any of the participants was
age, and these participants were labelled as ‘unknown’
in any data regarding age. A verbal survey was then
administered to individuals, with answers being recorded
by the surveyors. All eligible participants completed the
branched survey to the appropriate point according to
their personal history of exposure to an adverse tattoo
reaction. The surveyors did not interrupt, interfere with
or correct responses. The investigators estimated the body
surface area of the tattoos by using the Wallace rule of
nines. When possible, the surveyors evaluated the tattoos
themselves to determine size. When this was not possible,
respondents were asked to use their palms (representing
1% body surface area) to indicate the size of their tattoos.
Study participants and data analysis
Eligibility criteria included age of at least 18 years, one
tattoo having been performed in the United States, and
the ability to read and understand English. Surveys
were administered to the rst 308 encountered per-
sons with tattoos who consented to participation and
met the eligibility criteria. In 8 cases, participants were
deemed ineligible when it was found that all of their
tattoos were received outside of the United States, and
the data from these participants were not used in the
analysis. Approximately 5–10% declined to join after the
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Contact Dermatitis,73,91–99 93
TATTOO REACTIONS: A CENTRAL PARK STUDY •BRADY ET AL.
surveyors introduced themselves and described the study,
most citing time concerns.
For the purposes of this study, we dened adverse tat-
too reactions as ‘any skin sign or symptom that differs
from what you would consider a normal part of tattoo-
ing or tattoo healing’ (Table 1). We dened acute reactions
as lasting for <4 months, including descriptions of occur-
rences such as infection or delayed healing, and chronic
reactions as lasting for >4 months, including one or more
of the following associated symptoms: itching, scaling,
swelling, persistent elevation, or scarring. Self-reported
food, drug or other allergies were analysed as a unit,
owing to uncertainty about underlying causes.
We compiled response data of all participants, and
ANOVA was used to determine whether participants with
no reaction, acute reactions or chronic, colour-specic
reactions differed in the number of tattoos, area covered
with tattoos (presented as an estimate of the percentage
of skin surface area with tattoos), and number of tattoo
colours. Because of the likelihood of positive correlations
between the number of tattoos, tattooed area, and the
number of tattoo colours, we conducted a second analy-
sis to determine whether participants with chronic reac-
tions had more tattoo colours than other participants,
after controlling for the number and size of their tattoos.
This was performed with ANCOVA, with the type of reac-
tion, the number of tattoos and tattooed area included in
the model, with the last two factors being included as con-
tinuous covariates. Finally, a chi-square test was used to
determine whether participants with other types of aller-
gies were more likely to have tattoo reactions than other
participants. Analyses were conducted in JMP v. 11.0.0
(SAS Institute, Cary, NC, USA), with signicance mea-
sured at p<0.05. Values in the text and gures are either
raw data or means ±standard errors.
Results
Participant demographics (Table 2)
Approximately equal numbers of male and female partic-
ipants were surveyed, the majority (265/300; 88.3%) of
whom were US citizens. The reported age of participants
ranged from 18 to 69 years, with 2 participants not dis-
closing their age. A history of allergy was reported by 103
of 300 (34.3%) participants, most commonly to foods and
antibiotics, and seasonal allergic rhinitis, although ani-
mal and other allergies were also reported
Tattoo characteristics (Table 3)
The majority of participants surveyed had fewer than
ve tattoos, with 53 being the largest number of tattoos
Tabl e 2 . Demographics of 300 participants inter viewed in Central
Park, New York City
Category Characteristics
No. with
characteristic
%with
characteristic
Sex Male 149 49.7
Female 151 50.3
Citizenship US citizen 265 88.3
Foreign citizen 35 11.7
Age (years) 18– 19 9 3
20– 29 175 58.3
30– 39 82 27.3
40– 49 20 6.7
50– 59 9 3
60– 69 3 1
Unknown 2 0.7
Allergy status No allergies 197 65.7
Allergies 103 34.3
Type of allergy Foods 42 40.7
Animals 15 14.6
Seasonal/environmental 32 31.1
Antibiotics 29 28.2
Other 11 10.7
reported, and the average number of tattoos being 4.7.
The estimated area covered by tattoos ranged from 0.5%
to 90%, and the average area covered was 7.2%. The most
common tattoo location was the arm (67.7%), including
the hand, wrist, and shoulder, but almost all areas of the
body were reported to have tattoos. A full spectrum of
colours was reported in participants’ tattoos. The most
common colour was black, and >90% of participants
reported having black ink in at least a portion of their tat-
toos. Other common colours included red (36.0%), blue
(30.3%), and green (28.0%); many other colours were
present to lesser degrees (Table 3). Participants had aver-
age of 2.5 colours on their body, and 134 (44.7%) of par-
ticipants had only one colour; the vast majority (91%) of
single-colour tattoos were black. There was a signicantly
positive relationship between the number of tattoos and
the number of colours (p<0.0001), but there was a lot
of variation, and the overall explanatory power was low
(r2=0.11). The oldest reported tattoo was 41 years old,
and the newest was 1week old.
Prevalence and characteristics of acute and chronic
reactions
Adverse tattoo reactions were reported by 10.3%
(31/300) of survey participants. Thirteen of the 31
cases, representing 4.3% of participants, were acute
adverse reactions that ranged in duration from a few days
to 4 months. These reactions most often occurred a few
days to weeks after tattoo placement, and included pain
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
94 Contact Dermatitis,73,91–99
TATTOO REACTIONS: A CENTRAL PARK STUDY •BRADY ET AL.
Tabl e 3 . Tattoo characteristics of 300 participants interviewed in
Central Park, New York City
Category of
characteristic Characteristic
No. with
characteristic
%with
characteristic
Number of
tattoos
19230.7
24816.0
34916.3
43411.3
5134.3
6– 10 36 12.0
11– 20 18 6.0
≥21 10 3.3
Body part with
tattoo
Arm 203 67.7
Back 106 35.3
Leg 98 32.7
Flank/abdomen 66 22.0
Chest 50 16.7
Hips 33 11.0
Neck 32 10.7
Head 9 3.0
Genitals 4 1.3
Buttocks 3 1.0
Outer lip 3 1.0
Inner lip 3 1.0
Colours in
tattoos
Black 271 90.3
Red 108 36.0
Blue 91 30.3
Green 84 28.0
Yellow 63 21.0
Purple 45 15.0
Orange 36 12.0
Pink 31 10.3
White 14 4.7
Grey 10 3.3
Brown 10 3.3
Rust 2 0.7
Peach, magenta, or
fluorescent green
10.3
at the tattoo site, infections requiring antibiotics, itching,
swelling, and prolonged scabbing.
Eighteen of the 31 cases, representing 6.0% of the
survey population, were chronic, lasting for >4months.
Chronic reactions were all colour-specic (Table 4), and
were described as itchy, scaly, raised, oedematous, or
a combination of these symptoms, involving only spe-
cic colours within a tattoo. Two chronic cases were
described as ‘scarring.’ One colour-specic reaction was
described as being triggered by sun exposure. Another
participant described a red reaction developing 2 weeks
after a new tattoo, with subsequent development of a
similar response in the red ink portion of an 8-year-old
tattoo. The onset of chronic reactions as participants
described them ranged from ‘immediately’ to 4years
after tattoo acquisition. Almost two-thirds of participants
with chronic reactions reported immediate reactions
(11/18; 61.1%), and the majority of these respondents
(16/18; 88.9%) reported experiencing ongoing symp-
toms. Less than one-third of respondents with any type
of adverse reaction (9/31; 29%) had obtained medical
care for their symptoms, with only 5 participants, all
with chronic reactions, seeking care from dermatolo-
gists. Most treatments included topical or intralesional
corticosteroids.
Participants with acute reactions had signi-
cantly more tattoos (15.7 ±1.7) and greater tattooed
area (17.3 ±2.6%) than participants with chronic
colour-specic reactions (tattoo number, 7.1 ±1.4; area,
9.4 ±2.2%) or participants who reported no reactions
(tattoo number, 4.0 ±0.4; area, 6.5 ±1.0%; tattoo
number, F2,297 =25.1, p<0.0001; area, F2,297 =9.0,
p=0.0002). Additionally, participants with both chronic
and acute reactions had signicantly more tattoo colours
than participants with no reaction (acute, 4.0 ±0.5;
chronic, 4.2 ±0.5; no reaction, 2.4 ±0.1; F2,297 =11.9,
p<0.0001). After accounting for differences in the num-
ber of tattoos and area covered, there were still signicant
differences among participants with and without reac-
tions (F2,291 =8.1, p=0.0004). Specically, participants
with chronic reactions had signicantly more colours
than other participants, but participants with acute
reactions no longer differed from other participants with
respect to the number of colours in their tattoos (Fig. 1).
The two ink colours most commonly involved in
chronic colour-associated reactions were red (8/18) and
black (6/18), although other colours were also reported
(Table 4). Forty-four per cent of chronic reactions were
to red ink, which is a somewhat higher frequency than
would be expected based on the frequency of red ink
in respondents’ tattoos (36%). Thirty-three per cent
of chronic reactions were to blank ink, which was a
lower frequency than would be expected based on the
prevalence of black ink among participants (90.3%).
There were signicant differences in self-reported aller-
gies among participants with tattoo reactions (𝜒2=6.1,
p=0.0475). Of respondents with chronic colour-specic
reactions, 61.1% (11/18) reported having allergies, ver-
sus an allergy prevalence of 38.5% (5/13) in respondents
with acute reactions and of 32.7% (88/269) in partici-
pants with no reaction.
Discussion
Although various types of tattoo reactions have been
reported in the literature, the prevalence of tattoo
reactions among tattooed persons remains uncertain,
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TATTOO REACTIONS: A CENTRAL PARK STUDY •BRADY ET AL.
Tabl e 4 . Chronic colour-specic reaction characteristics
Age (years)/
sex
No. of
tattoos
Area
(%) Tattoo colours History, status, and symptoms Onset Duration
Doctor (MD),
treatment
34/M 6 18 bk, ru, bl, br, r Soft, red, crusting, raised, delayed
healing, remains elevated;
unresolved
Immediate 11 years No MD, topical lotion
31/M 11 15 gf, g Itchy, worse with seasonal allergies;
unresolved
Immediate 6 years No MD
31/F 3 5 pk, r, bk, bl, g Itchy, elevation, ‘red bumps’ over
pink and red areas; unresolved
4 years 1 year MD, steroid cream
33/M 40 30 bk, bl, o, pu, r, y Elevation, worse with seasonal
allergies; unresolved
0.5– 1 year Unknown No MD, lotion
26/F 10 9 r, bk, bl, g, o, pu, y Immediate elevation for a few
months, reoccurs periodically;
unresolved
Immediate Unknown MD, antibiotics
26/F 4 9 r, bl, g, pk, pu, y ‘Red bubbles’ and extremely itchy
and raised over red while healing,
remains itchy, elevated, scaly;
unresolved
Immediate 1 year MD, topical steroids
34/F 5 5 w, bk, pe, pk Initially infected, now elevation with
‘pink/red dots’; unresolved
Immediate 6 months MD, steroid injections
32/F 3 5 pu, r, bl, g, y Itchy, elevation; unresolved Immediate 7 years No MD
NA/F 5 2 r, y, bl, bk Itchy, elevation, colours ‘faded’;
unresolved
3 years 7 years MD, petroleum jelly,
steroid injections
33/F 1 2 bk, bl, g, o Itchy, elevation of tattoo ‘outline’
after initial healing; resolved
6 months 1 year No MD, OTC topical
steroids
35/F 3 3 w, bk, pk Itchy, elevation, delayed healing,
‘wrinkly skin’, scaly; unresolved
Immediate 2 years MD*, topical and
injectable steroids
29/F 2 2 bk Itchy, elevation, worse with seasonal
allergies; unresolved
Immediate 5 years No MD
26/M 7 9 r, bk, g, w, y Elevation, associated with seasonal
allergies; unresolved
6– 9 months 1.5 years No MD
34/F 1 1 bk Itchy, delayed healing, elevation with
light exposure; unresolved
Immediate 19 years No MD, petroleum
jelly
46/F 10 18 r, bl, bk, g, pk, pu, y Itchy, elevation, swelling, scaly;
resolved
1 month 8 years MD*, topical steroid
34/M 7 15 r, bk, bl, g Itchy, elevation of red 2 weeks after
tattoo; 1 week later, same response
in red of 8-year-old tattoo. All red
ink involved; unresolved
2 weeks 3 months MD, topical steroids
27/F 9 18 bk, bl, br, g, pk, pu, o, r, y ‘Bad scarring’, raised since the
healing process; unresolved
Immediate Unknown No MD
27/M 1 3 bk Raised and scarred; unresolved Immediate 10 years No MD
bk, black; bl, blue; br, brown; F, female; g, green; gf, uorescent green; M, male; NA, not available; o, orange; OTC, over the counter; pe, peach;
pk, pink; pu, purple; r, red; ru, rust; w, white; y, yellow.
Colours associated with colour-specic reactions are in bold.
*Dermatologist.
especially outside of European populations. The acquisi-
tion of this data in the United States is complicated by a
lack of FDA regulation, by the absence of a centralized
reporting system for adverse tattoo events, and because
those experiencing tattoo reactions often do not seek
medical care. From our own clinical experience, we
hypothesized that adverse tattoo reactions were relatively
common. Indeed, in our survey, >10% of people with tat-
toos reported some type of adverse tattoo event, with 6% of
tattooed individuals reporting a chronic, colour-specic
reaction. This relatively high rate of adverse events is
consistent with one study (4), but much lower than the
rates found in two Danish studies (5, 6) that sought to
more broadly evaluate patient complaints about any
deviation from normal skin sensation or appearance.
For the vast majority of people who we surveyed, these
chronic, colour-specic reactions are ongoing and have
remained unresolved for many years, even for partici-
pants who have sought medical treatment. It is of note
that only approximately one-third of those surveyed
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96 Contact Dermatitis,73,91–99
TATTOO REACTIONS: A CENTRAL PARK STUDY •BRADY ET AL.
Number of colours
Fig. 1. Comparisons of the number of tattoo colours among
participants who reported no reaction, acute reactions lasting for
<4 months, or chronic colour-specic reactions lasting for
>4 months, after accounting for differences in tattoo number and
tattoo area among groups. Signicant (p<0.05) differences among
groups, determined with Tukey’s HSD tests, are represented by
different letters.
sought medical care for their tattoo complaints, a gure
that, even though low, is slightly higher than reported in
the studies addressing tattoo complaints (5, 6).
It is not possible to derive a precise diagnosis of chronic
tattoo reactions from the self-reported symptoms of our
survey participants. Indeed, it is difcult to know precisely
what kind of information we captured by asking patients
whether they had ever experienced an adverse tattoo reac-
tion dened as ‘any skin sign or symptom that differs from
what you would consider a normal part of tattooing or
tattoo healing.’ Although some of the positive responses
that we discuss here may have been more consistent with
minor complaints than with true adverse reactions, we
suspect that this was not the case for most respondents.
Indeed, if our data are compared with the Danish results,
it seems more likely that we did not capture all minor
patient complaints and discomforts with their tattoos, as
the number of complaints was much higher in the Danish
studies. The classication of adverse tattoo reactions is not
straightforward, even under controlled clinical circum-
stances (9). A recent literature review of adverse tattoo
events in 280 patients divided them into three categories:
infectious, malignant and inammory/immune reac-
tions. Of these, approximately one-third (96) t into the
third category, with granulomatous, lichenoid or hyper-
sensitivity allergic reactions presenting days to years after
the tattoo had been placed. It is particularly challenging
to classify this subset of inammatory delayed chronic
reactions, as the authors note. Clinically, there is much
variability, and histologically these reactions can show a
variety of inammatory patterns, including eczematous,
lichenoid, granulomatous, lymphohistiocytic, and pseu-
dolymphomatous (9, 20– 22).
Classifying a tattoo reaction specically as an ‘allergy’
is additionally challenging. There is a subset of patients
described in the literature (and 1 in our study who gave
this classic clinical history) who have clearly developed
a particular reaction to a specic colour after repeat
exposures, which is characteristic of a type IV allergic
reaction (23–25). More commonly, patients present with
erythema, pruritus, induration and/or swelling conned
to the tattoo or a portion of the tattoo, but, histologically,
these reactions are variable and inconsistent, presenting
the same range of patterns as the general inammatory
tattoo reactions (9, 15). It is of note that type I and type III
allergic reactions have also been described in association
with tattoos (15). Patch testing, however, is an unreliable
way to conrm suspected tattoo allergies. In a recent
study of 90 patients with chronic tattoo reactions, even
when the individual inks known to be responsible for the
reaction were available, patch testing was mostly negative
or clinically insignicant (25). Even prick testing has not
been shown to be a reliable way of diagnosing tattoo reac-
tions (26). Serup and Hutton Carlsen hypothesize that
the unreliability of patch testing for diagnosing tattoo
allergies may be attributable to the fact that the allergen
itself is a byproduct of the tattoo ink, because the tattoo
pigments – azo dyes in particular – are poorly soluble
and unable to elicit a reaction when applied topically,
and/or because the allergens are formed in the dermis
via a process of haptenization (25). Because of these dif-
culties in making a denitive diagnosis of tattoo allergy,
one set of authors has suggested the term ‘tattoo-induced
immunologic reaction’ to encompass this broad category
of chronic tattoo reactions (15). This terminology has the
advantage of highlighting the fact that immune reactions
associated with tattoos may be highly variable. Even
patients with clearly immune-mediated reactions (e.g.
those who, with repeat exposures, develop reactions in
a particular ink colour) can have a variety of histolog-
ical and clinical patterns associated with their tattoos.
The problem with using this terminology too broadly,
however, is that it may mischaracterize reactions that
are not truly immune-mediated as immunological. This
terminology would not, for example, adequately capture
the suspected mechanism whereby black inks can cause
tattoo complaints, which is thought to be attributable
to the production of reactive oxygen species that may be
linked to the aggregation of nanoparticles in particular
inks (27, 28).
In our survey, red and black inks were most commonly
associated with chronic tattoo reactions, and the asso-
ciation with red ink was somewhat different from what
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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TATTOO REACTIONS: A CENTRAL PARK STUDY •BRADY ET AL.
would be expected from the distribution of red ink tat-
toos in our study population. Whereas it is appreciated
that red tattoos are often associated with tattoo reac-
tions (13, 15, 25), there has been some inconsistency
in the literature regarding how often black tattoos cause
reactions. For example, in the Wenzel literature review,
83.3% of the inammatory tattoo reactions were asso-
ciated with coloured ink, and only 12.5% were associ-
ated with black ink – a nding that was also reected in
the team’s German-language tattoo survey (9). However,
in the Danish sexually transmitted disease clinic study,
most complaints after 3 months (85%) were linked to
black tattoos, including many photosensitive reactions,
with only 9% being linked to red tattoos (5). In the Dan-
ish beach study, photosensitive reactions were most fre-
quently reported in black and red tattoos (6). There are
probably different mechanisms for the production of reac-
tions to black and to red inks, as discussed above. Black
and red inks, however, are also the most common inks
used in tattooing (9); thus, larger studies are needed to
determine whether red and black tattoo reactions occur
disproportionately to the use of these ink colours in tat-
tooed populations. Although red and black inks were
common sources of adverse reactions in our study, we
also observed a relationship between exposure to a larger
number of colours and the likelihood of a chronic tat-
too reaction. This may suggest that repeat exposures to
particular coloured inks can result in an immunogenic
response; however, larger studies would be needed to
understand this association.
We also observed an association between self-reported
allergies and chronic, colour-specic reactions: almost
two-thirds of participants reporting a chronic adverse
tattoo reaction also reported a history of allergies,
whereas just over one-third of participants with no tattoo
reactions reported allergies. Several participants with
tattoo reactions associated the uctuating severity of the
reaction with the status of their pre-existing allergy. These
data must be interpreted with caution, as the reported
allergies – described simply ‘as any known food, drug, or
other allergies’ – were not veried by a physician.
Finally, our study was a small survey of participants in
one location, and sampling error or bias may therefore
exist. The choice of Central Park as a venue allowed for
a rapid survey of a diverse population, but may have
inuenced the age and socioeconomic status of respon-
dents. For example, the majority of our respondents were
aged <30 years. In addition, because reactions were
self-reported and not evaluated clinically, we are unable
to ascertain the precise nature of reported reactions,
which probably span a wide range of conditions. Despite
these limitations, our results suggest that chronic tattoo
reactions are relatively common, although they may be
under-reported, and future studies of larger populations
are warranted. Although it would be ideal to gather
additional data from clinical evaluations, the reluctance
of people to seek medical attention for tattoo reactions
indicates that a survey approach, as employed here, may
be more effective in identifying the prevalence and nature
of tattoo reactions in the general population.
Acknowledgements
We thank Anibal Cortes for his contribution to the study
design, and two anonymous reviewers for their invaluable
comments.
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