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


Abstract and Figures

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 reactions.Patients/materials/methodsWe administered a survey about adverse tattoo reactions to 300 randomly selected tattooed people in Central Park, New York City.ResultsOf 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.Conclusions This study shows that tattoo reactions are relatively common, and that further investigation into the underlying causes is merited.
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Contact Dermatitis Original Article COD
Contact Dermatitis
Self-reported adverse tattoo reactions: a New York City Central Park
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
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-
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 specic colour lasting for >4months. Forty-four per cent of colour-specic
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-specic 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:
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,
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
Contact Dermatitis,73,9199 91
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 denitions of reaction
types, which makes it somewhat difcult 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 afliated 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
Chronic, colour-specic 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-specic 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.
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,73,9199
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,73,9199 93
surveyors introduced themselves and described the study,
most citing time concerns.
For the purposes of this study, we dened 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 dened 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-specic
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 signicance mea-
sured at p<0.05. Values in the text and gures are either
raw data or means ±standard errors.
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
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 signicantly
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
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
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94 Contact Dermatitis,73,9199
Tabl e 3 . Tattoo characteristics of 300 participants interviewed in
Central Park, New York City
Category of
characteristic Characteristic
No. with
Number of
6– 10 36 12.0
11– 20 18 6.0
21 10 3.3
Body part with
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
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
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-specic (Table 4), and
were described as itchy, scaly, raised, oedematous, or
a combination of these symptoms, involving only spe-
cic colours within a tattoo. Two chronic cases were
described as ‘scarring.’ One colour-specic 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
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-specic 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 signicantly 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 signicant
differences among participants with and without reac-
tions (F2,291 =8.1, p=0.0004). Specically, participants
with chronic reactions had signicantly 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 signicant differences in self-reported aller-
gies among participants with tattoo reactions (𝜒2=6.1,
p=0.0475). Of respondents with chronic colour-specic
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.
Although various types of tattoo reactions have been
reported in the literature, the prevalence of tattoo
reactions among tattooed persons remains uncertain,
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Contact Dermatitis,73,9199 95
Tabl e 4 . Chronic colour-specic reaction characteristics
Age (years)/
No. of
(%) Tattoo colours History, status, and symptoms Onset Duration
Doctor (MD),
34/M 6 18 bk, ru, bl, br, r Soft, red, crusting, raised, delayed
healing, remains elevated;
Immediate 11 years No MD, topical lotion
31/M 11 15 gf, g Itchy, worse with seasonal allergies;
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;
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;
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’;
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
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
46/F 10 18 r, bl, bk, g, pk, pu, y Itchy, elevation, swelling, scaly;
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-specic reactions are in bold.
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-specic
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-specic 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,73,9199
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-specic reactions lasting for
>4 months, after accounting for differences in tattoo number and
tattoo area among groups. Signicant (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 difcult to know precisely
what kind of information we captured by asking patients
whether they had ever experienced an adverse tattoo reac-
tion dened 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 classication 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 inammory/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 inammatory delayed chronic
reactions, as the authors note. Clinically, there is much
variability, and histologically these reactions can show a
variety of inammatory patterns, including eczematous,
lichenoid, granulomatous, lymphohistiocytic, and pseu-
dolymphomatous (9, 20– 22).
Classifying a tattoo reaction specically 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 specic 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 conned
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 inammatory
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 conrm 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 insignicant (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 denitive 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
Contact Dermatitis,73,9199 97
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 inammatory tattoo reactions were asso-
ciated with coloured ink, and only 12.5% were associ-
ated with black ink – a nding that was also reected 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-specic 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 veried 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
inuenced 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.
We thank Anibal Cortes for his contribution to the study
design, and two anonymous reviewers for their invaluable
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Contact Dermatitis,73,9199 99
... 34,35 Black is mainly associated with foreign-body granulomas and sarcoidosis. 34,47,48 Red shades are most problematic colours in persistent or chronic allergic reactions. 12,34,49 Photosensitive tattoos were reported frequently, for example, by 21.5% of the respondents in the 'beach study' from Denmark. ...
... 52 Exposure of tattoos to sunlight is frequent, most popular sites for tattooing are trunk, arms and legs. 47,48,53 Compared with people without tattoos, tattooed individuals more frequently use tanning beds, 4 another source of exposure to UV-light. ...
... This is documented by great heterogeneity in prevalence numbers, which differ between 3% and 76% in selfdisclosures of patients. [4][5][6]48,50,[54][55][56] The minority of these reactions were defined as systemic (7%) or persistent (6%-27%), the majority consists of minor symptoms like itch, inflammation or rash/eczema. 4 In an American cross-sectional study, tattoo customers assessed the knowledgeability of tattooist and dermatologists on the same level, tattoo artists are usually first line contact point in case of complications. ...
We outline constituents of tattoo and permanent make-up ink with regard to inflammatory tattoo reactions and population-based confounders. The comprehensive review of patch tested tattoo patients between 1997-2022 shows that tattoo allergy cannot be reliably diagnosed via patch testing with today's knowledge. Weak penetration and slow haptenization of pigments, unavailability of pigments as test allergens, and a lack of knowledge concerning relevant epitopes hamper the diagnosis of tattoo allergy. Patch testing p-phenylenediamine and disperse (textile) dyes is not able to close this gap. Sensitization to metals was associated with all types of tattoo complications, although often not clinically relevant for the tattoo reaction. Binders and industrial biocides are frequently missing on ink declarations and should be patch tested. The pigment carbon black (C.I. 77266) is no skin sensitizer. Patch tests with culprit inks were usually positive with cheap ink products for non-professional use or with professionally used inks in patients with eczematous reactions characterized by papules and infiltration. Tape stripping prior to patch testing and patch test readings on Day 8 or 10 may improve the diagnostic quality. The meaningfulness of the categorical EU-wide ban of Pigment Green 7 and Pigment Blue 15:3 is not substantiated by the presented data. This article is protected by copyright. All rights reserved.
... As any foreign body introduced into the skin, tattoo ink creates a risk for a broad range of adverse events: inter alia photosensitivity, infection, trauma related to needle insertion or allergic response to the pigment [3,4]. Some studies estimate that 6% to 8% of tattooed people are affected by a tattoo complication which requires professional help [5]. Diversity of adverse tattoo reactions may be attributed to the color of tattoo ink used [2]. ...
... In line with the presumed pathophysiology, chronic allergic tattoo reactions occur months or years following body art completion. They typically present as, localized to the red tattoo area, swelling, granulomas, ulceration, pruritis or hyperkeratosis [4,5,13]. Very rarely, systemic response, as in the case of our patient, occurs [13,19]. ...
Full-text available
The aim of this report is to present a case of a patient who developed unusual systemic hypersensitivity reaction to a red-pigmented tattoo and to discuss diagnostic difficulties in case of systemic reactions to tattoo ink. The patient reported erythroderma on his arms and chest accompanied by plaque elevation of red parts of his most recently performed forearm tattoo as his primary symptoms. His health condition entailed a prolonged topical and intravenous immunosuppressive therapy, which proved ineffective. Over a year after emergence of initial symptoms, he presented to the Plastic Surgery Clinic with generalized erythroderma, systemic lymphadenopathy, elevation and granuloma formation in red tattoos on his forearm and complaints of fatigue and inability to participate fully in work-related and social activities. The patient underwent six staged excisions with direct closures, flap plasties and full-thickness skin grafts. Following completion of each surgical resection, the patient’s symptoms gradually subsided. We find this case illustrative of a clinical challenge that delayed hypersensitivity reactions to red tattoos may pose. Furthermore, we provide insights on management of hypersensitivity reactions. This report underlines the importance of social awareness of and public health approach to tattoo complications as key to successful prevention, identification and treatment of adverse reactions to tattoos.
... Furthermore, induced structural changes and particles' distribution have been described using histological analysis [43], but detailed structural and cellular changes induced by tattooing over time have been missing. Using animal models or excised human skin, many tattoos have been investigated for inflammation, adverse reactions, and poor cosmetic outcome [44], which limits the feasibility of detailed in vivo studies on tattoo particle distribution under physiological conditions. ...
Background: The knowledge about the location and kinetics of tattoo pigments in human skin after application and during the recovery is restricted due to the limitation of in vivo methods for visualizing pigments. Here, the localization and distribution of tattoo ink pigments in freshly and old tattooed human skin during the regeneration of the epidermis and dermis were investigated in vivo. Methods: Two-photon excited fluorescence lifetime imaging (TPE-FLIM) was used to identify tattoo ink pigments in human skin in vivo down to the reticular dermis. One subject with a freshly applied tattoo and 10 subjects with tattoos applied over 3 years ago were investigated in the epidermal and dermal layers in vivo. One histological slide of tattooed skin was used to localize skin-resident tattoo pigment using light microscopy. Results: The carbon black particles deposited around the incision have still been visible 84 days after tattoo application, showing delayed recovery of the epidermis. The TPE-FLIM parameters of carbon black tattoo ink pigments were found to be different to all skin components except for melanin. Distinction from melanin in the skin was based on higher fluorescence intensity and agglomerate size. Using TPE-FLIM in vivo tattoo pigment was found in 75% of tattoos applied up to 9 years ago in the epidermis within keratinocytes, dendritic cells and basal cells and in the dermis within the macrophages, mast cells and fibroblasts. Loading of highly fluorescent carbon black particles enables in vivo imaging of dendritic cells in the epidermis and fibroblasts in the dermis, which cannot be visualized in native conditions. The collagen I structures showed a higher directionality similar to scar tissue resulting in a greater firmness and decreased elasticity of the tattooed skin. Conclusions: Here we show the kinetics and location of carbon black tattoo ink pigment immediately after application for the first time in vivo in human skin. Carbon black particles are located exclusively intracellularly in the skin of fresh and old tattoos. They are found within macrophages, mast cells and fibroblasts in the dermis and within keratinocytes, dendritic cells and basal cells in the continuously renewed epidermis even in 9-year-old tattoos in skin showing no inflammation.
... Studies have shown, that people with different colors in their tattoos are at higher risk of developing chronic reactions than the ones with single-colored tattoos. The two ink colors most commonly involved in chronic color-associated reactions were red (8/18) and black (6/18), although other colors were also reported [7]. Red tattoo pigment can be either organic or inorganic. ...
... 18 A study conducted in New YorkCity estimated that, undesirable effects of tattoos are common. 20 People with tattoos may develop keratoacanthomas commonly. Usually, red ink is involved in developing 82% of keratoacanthomas. ...
Full-text available
Background:The trend of tattoos increases day-by-day in many of the countries but unfortunately there is no evaluation of this practice in Pakistan.The term “tattoo” is the art of making colourful designs beneath the skin. There are different types of tattoos with different colour of inks. This practice is done for many reasons including fashion, beauty, to hide skin marks, addiction to pain, to memorize something or due to any personal reasons. Some people hide their tattoos due to some restrictions. Tattooed people may face restriction in jobs. They may cause different type of skin infections and other medical conditions. Objective:Our motive of research is to evaluate the relation of tattoos with disease conditions and reasons for adaptation of tattoos in Pakistan. Methodology:The data was collected by online interviews and face-to-face interactions with participants and tattoo artists. All the participants (N=181) with permanent tattoos were asked about different questions regarding age, gender, motivations for being tattooed, opinions and side effects following tattooing etc. Results: In Pakistan, tattooing is more common among males (74.03%) than females (25.96%). The highest motivation of being tattooed was found to be fashion (31.57%) and beauty (36.31%). Greater number of participants considered tattooing as harmless (66%) and less considered it as harmful (28%), while few (N=6%) have mixed opinions. Common side effect experienced by participants was inflammation (23.36%) and then allergy (11.41%) but majority of the participants did not experience any severe side effects. People belonging to any occupation were equally influenced by tattooing but it is more common in teenagers. Conclusion:In Pakistan, tattoos trend seems to be increasing day-by-day. Most people regardless of age, occupation, religion and side effects got tattoos because of fashion and beauty and there were no severe side effects of tattooing in Pakistan. Bangladesh Journal of Medical Science Vol. 21 No. 03 July’22 Page: 730-740
Background: Tattoo aftercare instructions describe how to care for a new tattoo. Unfortunately, tattoo artists often base their advice on personal experience rather than best practices in medical wound management. The diversity of recommendations in these instructions is currently unknown. Objectives: Our review was performed to determine current recommendations in tattoo aftercare instructions in the United States. Methods: Using a Google search, a total of 700 aftercare instructions from all 50 states and Washington D.C. were collected and their contents analyzed. Results: Most instructions encouraged washing new tattoos with antibiotic soaps, including chlorhexidine, and 14.9% encouraged using topical antibiotics. Few instructed individuals to wash their hands before touching a healing tattoo. A total of 70 moisturizers were recommended. Of these 22 were niche products made specifically for tattoo aftercare. Only a subset of instructions provided parameters about when to contact the tattooist (49.9%) and/or a physician (19.4%) should there be a complication in the healing process. Conclusion: The content and recommendations of the 700 instructions vary tremendously. Many lacked instructions on appropriate hygiene and when to seek medical care. As skin and wound care experts, there may be an opportunity for the dermatology community to partner with tattooists to create more useful evidence-based tattoo aftercare practices.
Beauticians, hairdressers, and barbers are among the occupations with the highest rates of work-related skin diseases, especially occupational contact dermatitis (OCD). Irritant contact dermatitis (ICD) due to chronic mild trauma (frictional dermatitis), contact with soaps, detergents, and wet work is frequent in beauty operators. Para-phenylenediamine (PPD), acrylates, essential oils, fragrances, colophony, and preservatives are most frequently responsible for allergic contact dermatitis (ACD) in these professional categories. Young women are mainly affected, with the most affected sites being the hands. Anamnesis, patch tests with the baseline, integrative series, and use products are important to understand possible sensitization. To reduce the risk, prevention is important, and workers should be adequately trained in the use of personal protective equipment (PPE).
Expounding upon social identity theory and the extended self-concept, this study examined the role of individuals’ motivations to get tattooed and their identities within their feelings of community connectedness. With the growing prevalence of tattooed individuals, antiquated notions of deviant behavior may be transitioning to a broader representation of the tattooed community in academic research. This study was designed with three objectives; first, we examined the effects of tattoo motivations on an individual’s self- and group-identity, second, we examined the effects of identities on community connectedness; and finally, we investigated the moderating effects of tattoo coverage on the body in relationship to tattoo motivations and identities. Findings revealed that uniqueness positively influenced group-identity, but not self-identity; spirituality positively influenced both self-identity and group-identity; belongingness positively influenced group-identity, while counter-culture negatively influenced group-identity. Furthermore, both self-identity and group-identity positively influenced community connectedness. Finally, the moderating effects of tattoo coverage existed for two relationships: (a) between uniqueness and self-identity and (b) between spirituality and self-identity.
Medical textbook on micropigmentation also known as permanent cosmetics, cosmetic tattooing is the updated clinical reference to instruct and orient the physician, nurse and/or non-medical practitioner who wish to become familiar with the various procedures of permanent cosmetic applications. Moreover, areas of potential complications are discussed as well as the various biochemical interactions of tattoo pigment in the human body.
Body piercings, tattoos, and permanent make-up have become very popular as a fashion statement in recent decades. This book guides the reader through the world of body art. An overview is first provided of the history and epidemiology of tattoos and piercings. Subsequent chapters go on to examine in detail the materials and devices used in various forms of body art, and the techniques employed. All relevant risks and potential complications are clearly described with the aid of color illustrations. Special attention is paid to allergic reactions and the management of complications. The closing chapter examines the techniques and devices used for tattoo removal, with a particular focus on the use of different lasers. © Springer-Verlag Berlin Heidelberg 2010. All rights are reserved.
› Complications after piercing are frequent. About every sixth person who has received a new piercing will suffer from health disturbances on the site of the piercing. Nickel allergy is still the most common cause of contact allergy in Europe and the predominant reason for allergic reactions to piercings. › Tattoo colors consist of (inorganic) pigments and (mostly organic) dyes, or both. Allergic reactions have been observed in the form of Type I, III, and IV reactions, according to Coombs and Gell classification. The most problematic colors are red and black. Tattoo reactions are not infrequent, occurring at an estimated incidence of over 150/100,000 new tattoos. › Steroids, laser therapy, and excision are the backbone of treatment for allergic reactions to tattoos and permanent make-up. Laser treatment itself may evoke additional reactions. No person with atopic history or immunologic disorders should acquire a tattoo, nor should children and adolescents. › Temporary tattoos, presented as “henna” paint-on motives, often contain illegally high amounts of paraphenylenediamine (PPD). Allergic reactions to PPD are not rare and frequently cause persisting pigmentation disorders; transferable picture tattoos must be rated alike. Health education for parents of especially younger children is urgently needed. › Tattoo stickers cause little problems with respect to allergy, but can irritate the skin due to occlusion.
Tattooing involves piercing the skin with needles bearing various pigments, to cause the permanent imprint of a design. The body responds to these incursions in specific and predictable ways, with initial sloughing of the overlying epidermis, variable dermal inflammation, and gradual assimilation of the pigment into macrophages. Eventually, much of the pigment is carried to the regional draining lymph nodes, with a residue staying within macrophages localized to dermal perivascular regions. The age of tattoos may be estimated, both grossly and microscopically. Tattooing can result in a variety of relatively uncommon complications and adverse reactions to the pigment, and certain infectious diseases may be inadvertently transmitted through tattooing when the instruments are inadequately sterilized, or when poor technique is used. This article, the second of three, describes the gross and microscopic pathology of both fresh and healed tattoos, and discusses the various complications (infectious and otherwise) that can occur. Tattooing has specific applications in both dermatology and plastic and reconstructive surgery, and these are also discussed.
Background Induction of delayed hypersensitivity reactions by red tattoos has been occasionally reported. Little is known about the inks used. Azo pigments have been implicated in some instances, but there is only one reported case involving quinacridones.Objectives To describe the clinical and pathological features and outcome of skin reactions induced by red tattoo pigments.Patients, materials, and methodsSix patients with a cutaneous reaction induced by a red tattoo pigment underwent biopsy and prick and patch testing with the inks supplied.ResultsWe observed seven reactions in the 6 patients. Histology showed various patterns: three lichenoid, two eczematous, and two pseudolymphomatous. Five reactions occurred with azo pigments, and two with quinacridones, in both cases with Violet 19 and Red 122. Four inks were tested. Only one patch test gave a positive result at a late reading (day 7). Prick tests gave negative results. The reactions required various treatments, including laser treatment for 2 patients. Activation of the reaction in 1 case was transient.Conclusion Azo pigments and quinacridones both triggered reactions with similar clinical aspects but with varying histological findings. Patch and prick test results were disappointing with both. Reactions occurred following laser use in 1 case.
Body art is increasingly popular, resulting in the raising occurrence of complications and adverse reactions, some of them related to the substances used. To identify the causative agent, it is essential to know the exact composition and nature of the materials applied. Nickel allergy is the most common complication of body piercing and can easily be avoided by the use of ornaments made of high-grade stainless steel or inert plastic material. Tattoo compounds in comparison to cosmetics are in general not officially controlled. Moreover, the origins as well as the chemical and toxicological specifications of these colouring agents are hardly known by the producers, the performers and by the consumers. From the medical perspective, uniform worldwide regulation would certainly offer opportunities to reduce the risks and complications involved in the use of chemical components that might be potentially hazardous and may threaten the health of the tattooed individual with special concern for heavy metals and carcinogenic aromatic amines. Recent studies have demonstrated that sunlight exposure and laser treatment of tattoos can induce decomposition products with carcino-genic properties. The clinical implications of these findings have not yet been identified. Recommendations on the hygienic conditions of piercing and of the application of tattoos and permanent make up (PMU) are available. Respecting these guidelines could minimise the risk of transmission of infectious diseases. The occurrence of contact allergy to temporary (henna) tattoos is linked to the presence of PPD in high concentration.
Background 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.Objectives 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).Methods Patients attending the ‘Tattoo Clinic’ at Bispebjerg University Hospital, Denmark with tattoo problems spanning more than 3 months were invited. Forty patients participated during September–November 2012. Patients attending their routine consultations completed the ISS and DLQI questionnaires.ResultsPatients 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.Conclusion/DiscussionSufferers 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.
Background 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.Objective To report the results of patch testing in 90 patients with non-infectious chronic tattoo reactions.Materials/methodsFrom 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.ResultsPatients 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.Discussion/conclusionThe 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.
Sarcoidosis is an autoimmune disease of unknown etiology characterized by the presence of non-caseating epithelioid cell granulomas in multiple organs. Cutaneous sarcoidosis occurs in approximately 25% of the cases. Sarcoid reactions on old scars, traumatized skin sites and around embedded foreign material have long been observed. For the past 70 years, sarcoidal granulomas on tattoos and permanent make-up have also been documented. Granulomatous and sarcoidal tattoo reactions may be the first and sometimes only cutaneous manifestation of systemic sarcoidosis. This review summarizes the currently available data on this topic and discusses the issues related to the diagnosis, management and physiopathogeny of sarcoidal reactions on tattoos.
: 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.