© 2019 International Journal of Academic Medicine | Published by Wolters Kluwer - Medknow 19
Tattoo‑associated complications and related topics:
A comprehensive review
Jameson M. Petrochko, Andrew C. Krakowski1, Colin Donnelly2, John B. Wilson2, Jennifer Bruno Irick2,
Stanislaw P. Stawicki3
Temple/St. Luke’s School of Medicine, 3Department of Research and Innovaon, St. Luke’s University Health Network, University Hospital,
Bethlehem, Departments of 1Dermatology and 2Emergency Medicine, St. Luke’s University Health Network – Anderson Campus,
Easton Pennsylvania, USA
A tattoo can be defined as the intentional insertion
of pigment into one’s dermis using a punctate
instrument. In addition to serving a broad range of
decorative functions, tattooing (e.g., the procedure of
tattoo placement) also includes permanent makeup and
reconstructive dermatological/surgical applications.[2‑4]
Whenever foreign material is inserted into the body,
there exists an opportunity for complications,
including trauma related to implantation, infection,
the body’s reaction to the pigment, and many other
As tattoos become more prevalent,[6,7] the number
of tattoo‑related complications (TRCs) is also likely
As tattoos become more common, it is likely that practitioners will encounter adverse tattoo reactions with
increasing frequency. While some tattoo-related complications (TRCs) may be nonspecific and challenging
to diagnose, others present overtly and can be identified quickly by a well-informed practitioner. TRCs
occur at both of these extremes, highlighting the need for better awareness and knowledge sharing
regarding this heterogeneous group of morbidities. This review is a result of a compilation of the best
available clinical evidence across various groupings of TRCs. The authors’ intent was to provide the reader
with a comprehensive overview of the topic while creating a rich repository of referenced knowledge for
future investigations. From the standpoint of frontline health-care providers, effective recognition and
management of TRCs require an open-mind, high degree of clinical suspicion, and nonjudgmental approach
to a mainstream phenomenon that is still considered by many to be a taboo.
The following core competencies are addressed in this article: Medical knowledge, Patient care, and
Keywords: Complications, morbidity, review, tattoos, tattoo-related complications
Address for correspondence:
Dr. Stanislaw P. Stawicki, Department of Research and Innovaon, St. Luke’s University Health Network, University Hospital, Bethlehem,
Easton Pennsylvania, USA.
Received: 15.03.2019, Accepted: 25.03.2019
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Petrochko, et al.: Tattoo‑associated complications
20 International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019
to grow. Unfortunately, patients may avoid bringing
up issues related to their tattoos for fear of being
stigmatized. We set out to perform a comprehensive
review of TRCs with two main objectives. The
primary goal is to give health‑care providers an
appreciation for the wide variety of morbidities that
may arise from tattoos in their patients and to enhance
physicians’ understanding of these complications
so that they may provide better clinical care. Our
secondary goal is to increase awareness of TRCs and
to encourage physicians to inquire about tattoos in
a non‑judgmental fashion so that they may more
effectively care for patients with TRCs.
LITERATURE REVIEW METHODOLOGY
To optimize content for the current manuscript, we
performed a comprehensive literature search utilizing
PubMed and Google™ Scholar. Out of approximately
19,550 candidate manuscripts, we distilled more than
400 sources for this definitive review. This includes
both primary and secondary publications (e.g., those
referenced by articles from our primary literature
search). Finally, the authors also searched various
websites and discussion boards dedicated to tattoos
and related topics.
OVERVIEW OF SPECIFIC TATTOO‑RELATED
In the subsequent sections, we will outline a broad
range of TRCs, ranging from allergic reactions to
the tattoo ink material itself to magnetic resonance
imaging (MRI)‑associated burns. The focus of each
specific TRC section is to provide the reader with a
clinically relevant overview as well as a rich repository
of referenced knowledge, specifically intended to help
facilitate future research in this area of inquiry.
ANAPHYLACTIC REACTION TO TATTOO INK
Anaphylaxis has been reported following tattoo
placement and is a serious but uncommon TRC.[8,9]
Reported symptoms include generalized pallor, hives,
abdominal pain, and shortness of breath approximately
6–12 h after ink exposure (or re‑exposure).[8,9] In one
case, the patient underwent application of new color
ink to an existing dark ink tattoo, with an approximate
30‑day period between the two exposures. Moreover,
the patient had a multicolored tattoo placed 6 years
before the described episode of anaphylaxis without
adverse reaction; approximately 6 months after her first
bout of anaphylaxis, the patient had more color added
to the tattoo and experienced a second, similar but
more rapid anaphylactic reaction. In another case, the
patient presented to the emergency department (ED)
with redness and swelling of the left (tattooed) arm, lips,
and left cheek, approximately 6 h after, he had a black
and white tattoo placed on his left forearm to cover up
a tattoo he had received at least 30 years prior.
The pathophysiological mechanism is thought to
be a type 1 hypersensitivity, with reported positive
reaction to several tattoo inks. Patients may have had
prior tattoos without adverse reactions, suggesting
sensitization to the antigens. The reason the patients
did not experience an ongoing reaction is not clear,
and it is unlikely that a tolerance was acquired, as one
patient had a similar reaction when another tattoo
was applied 6 months later. The sequestration of
tattoo pigment in dermal fibroblasts may play a role
in preventing an ongoing reaction. Of note, it is
important to recognize that various tattoo pigments
contain different elements and chemical compounds,
often in different proportions. Commonly used
tattoo pigments are listed in Table 1.
All three anaphylactic episodes outlined above (two
in the first patient and one in the second patient)
were considered to be life‑threatening TRCs and
were treated successfully with combinations of
H1 antagonists, glucocorticoids, lorazepam, and
droperidol. Follow‑up information was not given
in either case report, so it is unclear if the tattoos
caused further symptoms. As laser removal of tattoo
ink has itself been associated with several cases of
hypersensitivity reactions,[12‑15] surgical excision could
be considered in this particular clinical scenario.
Reactions to laser tattoo removal (LTR) are discussed
in another section of this review.
Table 1: Listing of commonly used tattoo pigments/components
Tattoo color Pigment(s)
Black Carbon; iron oxide, logwood (extracted from
Blue Azure; cobalt blue
Violet Manganese ammonium pyrophosphate
Green Chromium; curcumin green; ferro‑ferric cyanide;
lead chromate; malachite green
Red Mercury sulﬁde (cinnabar); cadmium selenide
Yellow Cadmium sulﬁde (cadmium yellow; curcumin
White Titanium dioxide; zinc oxide
Source: Barua S. J Cutan Aesthet Surg 2015;8 (1):5‑8. Used under
the terms of the Creative Commons Attribution‑Noncommercial‑Share
Alike 3.0 Unported, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited
Petrochko, et al.: Tattoo‑associated complications
International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019 21
Within the general context of this section, other
types of more localized reactions include documented
cutaneous responses to pigment materials such as
henna. Used mainly in the placement of temporary
tattoos, this type of pigment can result in reactions
of noticeable severity, not infrequently with a slight
temporal delay.[17,18] An example of a severe localized
cutaneous reaction to traditional henna can be seen
in Figure 1.
UVEITIS WITH INFLAMMATION OF NONOCULAR
TATTOOS (WITHOUT SIGNS OF SYSTEMIC
There are reports of unilateral or bilateral uveitis
that occurs with simultaneous tattoo inflammation,
and this is likely an underreported phenomenon.
Tattoo reactions can occur with uveitis in the setting
of systemic sarcoidosis; however, such cases
are excluded from this section. Ocular complaints
include pain[19,21] and vision problems,[21,22] and
tattoo symptoms include pruritus, redness,
and swelling.[19,21] Some instances were severe
enough to threaten vision. Cases have occurred
related to tattoos anywhere on the body, with
variable temporal relationship, from immediate
posttattoo period to years later.[21,23] Most of
the tattoo reactions were granulomatous (when
biopsied),[19,21,24,25] while most of the uveitides
were nongranulomatous. There is a confirmed
case of nongranulomatous uveitis presenting with
granulomatous tattoo inflammation. A case of
posterior uveitis with retinal vasculitis and cystoid
macular edema was temporally attributed to tattoo
placement in one case, but the evidence is largely
Of importance, cases in this section occur without
signs or symptoms of systemic sarcoidosis.[19,21‑25]
The mechanism for simultaneous uveitis and tattoo
inflammation is not known, although hypotheses
include subclinical sarcoid (e.g., ocular inflammation
alongside tattoo inflammation in the presence of
systemic sarcoid has also occurred[20,27]) or a special
granulomatous hypersensitivity to cobalt.[23,24]
However, this phenomenon has been observed in
nonblue tattoo ink[19,25] (cobalt is traditionally used
as a blue pigment). Screening patients presenting
with uveitis for tattoo‑related symptoms is a quick
and inexpensive way to identify this phenomenon,
and systemic sarcoidosis should be considered when
this phenomenon is observed. Excision has been
shown to result in resolution of the uveitis.[19,21] If
the tattoo is too large to remove, oral prednisone
and immunosuppression have been shown to be
efficacious in treating ocular inflammation, often
with a simultaneous resolution of tattoo‑related
COMPLICATIONS OF OCULAR TATTOOS
Cosmetic applications of the so‑called “ocular
tattoos” (OT) are relatively new and are sometimes
referred to as “corneal” or “conjunctival” tattoos.
The goal of the procedure is to inject ink just beneath
the conjunctiva at several sites without penetrating
the sclera. The ink then diffuses to uniformly
alter the pigmentation of the sclera, without corneal
involvement [Figure 2a and b]. Several cases of
complications arising from OT were found in the
medical literature.[28,30‑33] Two cases presented with
ocular inflammation and globe penetration,[31,33]
two with ocular inflammation without globe
penetration,[30,32] and two involved painless nodules
that did not affect visual acuity.[28,30] Cases were
reported within several weeks of OT placement.
Clinical management of inflammation and globe
penetration comprises surgery to remove the injected
dye, with concurrent control of the inflammatory
response.[31,33] Increased intraocular pressure may be
present, with the potential for long‑term sequelae
including decreased visual acuity. Patients with
inflammation and no globe penetration were
treated with steroids, antibiotics, and tropicamide
Figure 1: An example of an allergic reaction to traditional henna used in
temporary tattooing. Used under the terms of the Creative Commons
Attribution License, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original author and source
Petrochko, et al.: Tattoo‑associated complications
22 International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019
and recovered well.[30,32] One patient with painless
nodules was diagnosed with episcleritis and treated
with prednisone and moxifloxacin, and another
was monitored without active treatment, with no
sequelae during 6‑month follow‑up. Although the
eye is a relatively uncommon site for tattoo placement,
associated TRCs can be vision‑threatening.
COMPLICATIONS SPECIFIC TO LASER TATTOO
The number of LTRs is increasing as the incidence
of tattooing increases. Complications can include
local pruritus,[34,35] local urticaria, generalized
urticaria, generalized eczema, systemic allergic
response, inflammation of tattoos distant from
the one being removed,[12,37] lymphadenopathy with
or without upper respiratory and constitutional
symptoms, an anaphylaxis‑like systemic reaction
with lack of peripheral eosinophilia, fungal
infection, and darkening of the tattoo.[39,40]
Complications that are specifically thought to be due
to suboptimal laser technique or aftercare include
blistering, hypertrophic scarring, hypopigmentation,
hyperpigmentation or depigmentation, keloid
formation, and persistent erythema.[41,42]
Although not an adverse effect per se, treatment
of nontattoo‑pigmented lesions with a laser may
confound the clinical examination and thus delay
diagnosis (and treatment) of melanoma.
Lasers are useful tools for removing tattoos, although
different types of lasers have advantages and
disadvantages. For example, CO2 lasers nonselectively
ablate the skin and work well for many colors of
tattoos, although frequently result in hypopigmented
scarring. On the other hand, Neodymium:yttrium
aluminum garnet lasers, for example, work via
selective photothermolysis of certain colors of tattoos
and cause less damage to tissue but also do not
always work for all colors. Proposed mechanisms for
LTR‑related inflammatory symptoms include release
of tattoo pigment that was sequestered in fibroblasts,
mast cells, and macrophages (and subsequent immune
system exposure); systemic distribution of released
pigment particles; and alteration of pigments to
create new antigens. Cases in which a distant tattoo
develops symptoms[12,37] support the first and second
mechanisms, as mast cell lysis can cause systemic
symptoms without singling out the distant tattoo, and
sensitization of the immune system to neoantigens
should not result in inflammation of a distant tattoo
that does not contain these neoantigens. Finally,
alexandrite laser as well as Q‑switched ruby,
Q‑switched Nd:YAG, and pulsed green dye laser
treatments have caused darkening of areolar tattoos.
The mechanism is thought to involve iron dioxide[39,40]
and possibly titanium dioxide.
Management of LTR reactions varies according
to clinical presentation/extent of the problem. In
mild cases limited to isolated lymphadenopathy, no
specific treatment may be needed. For more severe
reactions, 3 days of prophylaxis with prednisone,
cetirizine, and ranitidine has effectively prevented a
local urticarial/erythematous reaction in at least one
patient, although the cutaneous reactions resolved
spontaneously shortly after the first two laser
treatments, for which prophylaxis was not given. A
patient with evidence of a mild systemic inflammatory
response did well following a 3‑day course of oral
prednisone but experienced a rebound anaphylaxis‑like
reaction that required treatment with epinephrine
and intravenous (IV) corticosteroids in the ED.
Intralesional triamcinolone, topical clobetasol
propionate, and oral diphenhydramine are usually
sufficient to effectively manage nongeneralized pruritic
reactions that extend beyond the tattoo. Bullae
resulting from LTR usually resolve after drainage.
To minimize the risk of complications, the laser as well
as the spot size, fluence, and pulse duration should be
selected based on the color of the tattoo pigment and
the patient’s skin.
Figure 2: (a: Top) An example of a complication of scleral tattooing.
The patient developed axial proptosis, restricted ocular movements,
eyelid edema, green conjunctival pigmentation, superior conjunctival
hemorrhage, and diffuse chemosis; (b: Bottom) Approximately 30 days
later, the patient was functionally close to baseline, with the tattoo effect
closer to the intended effect, but some unintentional staining of the lower
eyelid. Used under the terms of the CC BY‑NC‑ND license (http://
Petrochko, et al.: Tattoo‑associated complications
International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019 23
TATTOO COMPLICATIONS FOLLOWING LASER
Tattoo reactions to laser hair removal (LHR) over
the site of the tattoo have been reported.[45,46] Specific
reported complications included keloid formation
and local burns. The previous history of keloid
formation was thought to be an important factor in
new keloid formation. Mechanistically, LHR is
based on selective photothermolysis.[45,46] The process
is selective in that the laser only heats a target that
absorbs light at a specific wavelength. The melanin
in the hair shaft allows the hair shaft to be targeted
while sparing the surrounding tissue.[45,46] However,
if a tattoo pigment is present, the dye may compete
for absorption of the light, heat up, and cause the skin
to burn. Fading of the tattoo after LHR procedure
Management of the reported keloid comprised
intralesional triamcinolone acetonide injections,
resulting in improvement. It was noted that
post‑LHR burns might result in an atrophic scar
6 months after the procedure. To prevent the above
occurrences, the best approach is avoidance of LHR
over a tattoo.
Pseudolymphomas are uncommon benign
lymphoproliferative disorders that mimic lymphomas
histologically and clinically and have been reported in
association with tattoos.[47,48] Clinical presentation may
include asymptomatic erythema,[49,50] asymptomatic
nodules or plaques,[51‑55] pruritic erythema,
erythematous papules, pruritic nodules or
polypoid lesions,[58‑62] pruritic plaques,[47,63] indurated
swelling,[64,65] or photosensitivity.[50,66] An example
of a tattoo‑associated pseudolymphoma is shown
in Figure 3. Chronic presentation several decades
following tattoo placement has been described,
with localized pruritus and nodularity after infrared
radiation exposure. In another case, a light‑induced
reaction was noted involving yellow areas of a tattoo
near a biopsy‑confirmed pseudolymphoma. At least
one case of malignant transformation to lymphoma
has been reported, although the lesions were not
restricted to the tattoo.
Given the nonspecific clinical findings, biopsy is
required in this uncommon setting. Microscopically,
pseudolymphoma displays a dense lymphocytic
infiltrate that may easily be confused with malignant
lymphoma. Although differentiation of
pseudolymphoma from lymphoma can be difficult,
evidence of polyclonality via immunohistochemistry
or polymerase chain reaction (PCR) suggests the
former.[63,69] The etiology of pseudolymphoma
occurring in a tattoo is not completely known,
although it is likely not completely attributable to
mercury, as pseudolymphomas have been reported in
colors other than red (the usual tattoo ink color that
may contain mercury).[49,51,54,56,66] Various treatment
options have been attempted for tattoo‑associated
pseudolymphomas, with full excision being the
recommended treatment. Laser removal has been
shown to be effective,[28,67] although adverse effects of
LTR are possible.[12‑15]
Granulomas can be defined as “relatively discrete
collections of histiocytes or epithelioid histiocytes
with variable numbers of admixed multinucleate giant
cells of varying types and other inflammatory cells.”
Granulomatous tattoo reactions (GTRs) can be difficult
to diagnose because the differential diagnosis is long,
and many of the diagnoses have overlapping clinical
and histologic findings. The patient may present with a
variety of nonspecific signs/symptoms [Table 2] after a
variable amount of time. This often necessitates
a biopsy for a definitive diagnosis. Top diagnoses
include foreign body granulomatous reaction,
allergic/hypersensitivity granulomatous reaction,
sarcoidosis, granuloma annulare (GA), necrobiosis
lipoidica (NL), and infection.
Figure 3: An example of a tattoo‑associated pseudolymphoma. Used
under the terms of a Creative Commons Attribution NonCommercial
3.0 License (CC BY‑NC 3.0)
Petrochko, et al.: Tattoo‑associated complications
24 International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019
Granulomas caused by sarcoidosis, foreign body
granulomas, and allergic/hypersensitivity granulomas
can be challenging to distinguish. It is difficult to
histologically differentiate a foreign body granuloma
from a granuloma of sarcoidosis,[25,85,93,102,109,115,116]
especially because there is some degree of overlap[117‑120]
and foreign bodies are expected to be present in tattoos.
It is similarly difficult to differentiate a granuloma
caused by sarcoidosis from an allergic/hypersensitivity
granuloma[115,121] with low reliability of patch
testing.[85,121] Diagnosis of sarcoidosis can also include
extracutaneous findings and should not be made based
solely on a single granulomatous lesion on biopsy, such
as that of a tattoo.[103,109,122] A clear chest X‑ray does
not rule out sarcoidosis, and angiotensin‑converting
enzyme levels are not sufficiently accurate.[123,124]
The all‑encompassing term “cutaneous sarcoidosis”
represents a heterogeneous group of conditions.
Consequently, the reader should be aware of the
vastness of this important topic and should consider
our subsequent discussions within the appropriate
clinical context relevant to this review.[70,81,88,96,118,125,126]
SARCOID‑LIKE GRANULOMATOUS DISEASE OF
Cases of GTRs may occur without clear
evidence of systemic sarcoidosis, either
because the workup was negative or not
Table 3 lists some of the terms related to GTRs, as
reported in the literature.
The diagnosis of GTR will generally be made after
a biopsy is performed of the involved cutaneous
area. As previously outlined, GTRs should raise
suspicion of underlying systemic sarcoidosis[71,127] or
an infectious etiology, and these entities, as well
as GA and NL, should be considered before a tattoo
reaction is diagnosed as a “sarcoid‑like granulomatous
disease of unknown significance.”[25,85,93,95,105,109,115‑120]
Hypothesized mechanisms of granuloma formation
are not fully understood, and include altered immune
response, retention of a foreign substance, altered
neural signaling, or a combination thereof.
Interestingly, tattooing with red poster paint comprising
monoazopigments in a Danish prison reliably caused
pruritic lesions whose histology was compatible
with sarcoidosis. Long‑term follow‑up would be
necessary to determine if the cases of GTRs that occur
without signs or symptoms of systemic sarcoidosis are
truly independent of systemic sarcoidosis, or merely
the initial overt manifestation of otherwise subclinical
A variety of treatments have been tried in the setting
of GTR [Table 4], with varying degrees of success.
LTR may cause a significant reaction,[12‑15] especially in
a patient demonstrating a previous negative reaction
to tattoo pigment. Of note, spontaneous resolution
following punch biopsy has been observed.[95,108]
SARCOIDOSIS ASSOCIATED WITH TATTOO
According to the American Thoracic Society and
European Respiratory Society, “Sarcoidosis is a
Table 3: Summary of the collected body of literature terms
used in conjunction with granulomatous tattoo reactions
Granulomatous reactions caused by tattoo pigment
Delayed granulomatous reaction to tattoo ink
Foreign body granulomatous reaction to tattoo pigment
Sarcoid tattoo granuloma
Granulomatous reaction due to the development of allergic sensitivity
Delayed allergic reaction in the form of a granuloma
Delayed granulomatous reaction to cosmetic tattoo
Allergic granulomatous reaction to the tattoo pigment
Delayed‑hypersensitivity granulomatous reaction
Granulomatous dermatitis[111 ]
Granulomatous dermatitis and perifolliculitis with tattoo; AKA “tattoo
Sarcoidal granulomatous reaction due to tattoo pigment
Mercurial granuloma occurring in a tattoo
Sarcoidal‑type foreign‑body reaction to tattoo pigments
Inoculation sarcoidal granulomas
Sarcoid reaction in a tattoo
Table 2: The list of sign/symptoms reported in the setting of
tattoo‑related granulomatous reactions is extensive, making
the diagnosis challenging
Blistering and welting
Erythema nodosum[110 ]
Palpable black pigment in a multicolored tattoo
Petrochko, et al.: Tattoo‑associated complications
International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019 25
systemic granulomatous disease that primarily
affects the lung and lymphatic systems of the
body.”[124,132‑134] Cutaneous manifestations of systemic
sarcoidosis are common, affecting approximately
15%–25% of all sarcoidosis patients and having a
variety of presentations.[124,132‑134] The most common
presentations of sarcoidosis involving tattoos include
nodules, plaques, papules, or infiltrates that were
sometimes scaly but usually not painful. Tattoo
sarcoidosis does not appear to be an all‑or‑nothing
phenomenon, as there have been cases, in which all
tattoos or only certain colors of a tattoo[27,84,87,98,114,135]
were affected. Tattoo granuloma may or may not be the
only cutaneous sign of sarcoidosis,[20,82,87,104,107,109,136]
as there may be extracutaneous or constitutional
symptoms as well.[20,27,82‑84,94,102,107,109,132,136,137] The
time between tattooing and clinical presentation is
highly variable, with some authors reporting a range
of 1–10 years, while others describing lag times as
long as 30–40 years.[103,104]
The mechanism of sarcoidosis is unknown, but there
are many hypotheses about why it may manifest in
the setting of tattoos.[20,94,98,103] One is that foreign
bodies such as tattoo ink may serve as inciting factors
for granuloma formation.[82,98,107,109,103] Sarcoidosis
manifesting within a tattoo may also represent “scar
sarcoidosis,”[20,98] which tends to occur at sites of
old injury (e.g., surgical scars or tattoos).[134,135] The
so‑called Koebner response (e.g., the appearance of
skin lesions within lines of trauma) is yet another
There is no formal therapeutic recommendation
for this phenomenon, and various treatment
regimens have been described.[75,83,94,102‑107,109,113,136,138]
Systemic corticosteroid treatment has demonstrated
effectiveness in nearly 79% of patients and failed in
only 7% of cases.[75,83,94,102‑107,109,113,136,138] Interestingly,
simultaneous spontaneous resolution of the tattoo
lesions and the pulmonary radiographical findings
have been observed.
GA occurring at the site of tattoos is well
described,[78,129,131,139,140] in addition to cutaneous
reactions that are considered to be GA‑like.[141‑144]
Symptomatically, GA tattoo reactions are similar
to the aforementioned GTRs[129,141,142] but are
histologically distinct (e.g., the presence of necrobiotic
reaction).[70,129,131,141] In general, GA lesions may
have the tendency to bleed.[131,140] Although the exact
mechanism underlying GA is unknown, these lesions
can be triggered by a variety of events including
insect bites, trauma, warts, conditions (e.g., diabetes,
human immunodeficiency virus [HIV], etc.), and
medications, in addition to tattoos. Although the
main trigger for GA is thought to be trauma, the
prevailing theory for the mechanism of GA formation
in tattoos is a delayed hypersensitivity involving the
pigment or another chemical in the ink.[129,131,139‑142]
Sparing of certain ink colors supports this theory.
Treatment modalities include butyrate hydrocortisone
cream (transient relief but relapse after treatment
disruption), clobetasol dipropionate (unknown
effect and patient lost to follow‑up), clobetasol
propionate (some improvement), intralesional
Kenalog and topical steroids (unsuccessful),
and resection (successful with no recurrence or scar
complication). Additional workup to rule out
sarcoidosis and fungal or mycobacterial causes should
NL is a noninfectious palisading granulomatous
disease that manifests clinically as atrophic yellowish
plaques with erythematous edges and can progress to
sclerosis and ulceration. NL has been reported in
the setting of tattoo,[81,145,146] including a case that the
authors refer to as an “NL‑like tattoo reaction.” The
other case presented as more classic NL, with atrophic
yellowish patches or plaques and erythema.
Delayed onset after tattoo can range from several
weeks to 3.5 years, with possible predisposition for
Table 4: A variety of treatments have been attempted in the
setting of granulomatous tattoo reaction, with mixed results
Laser tattoo removal with topical medication (corticosteroid,
imiquimod, erbium; some improvement)
Hydroxychloroquine with intralesional steroid injection (unknown
response [patient lost to follow‑up], moderate improvement)
Intralesional glucocorticoid injection (unsuccessful, slight
improvement, signiﬁcant improvement but relapse occurred,[89,97]
Oral corticosteroids (effective, moderate improvement, ineffective)
Allopurinol (signiﬁcant improvement but relapse after medication
Antihistamines (signiﬁcant improvement)
Topical steroids alone (transient improvement, partial/moderate
improvement,[93,115,130,131] complete resolution[73,85])
Topical hydroquinone with topical corticosteroid (unsuccessful)
Oral steroids and tobramycin‑dexamethasone ointment (initial
improvement then relapse)
Resection (ineffective, partially effective, effective[3,86,88,97])
Resection and oral steroids (effective)
Petrochko, et al.: Tattoo‑associated complications
26 International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019
women in the third decade of life.[81,145,146] The etiology
of NL is not known, although it is more common in
patients with diabetes. The association between
the tattoo and NL may be hypersensitivity or related
to Koebnerization, with the former being favored.
In terms of management, various strategies have been
described, from antibiotics to surgical excision
and the intralesional application of triamcinolone
acetonide and topical betamethasone valerate.[145,146]
There have been several reported cases of necrotizing
granulomatous reactions that did not fit neatly
into any other category.[88,96,147] These presented
with scaly plaques/crusts, or painful, ulcerated
lesions[88,96] at the site of the tattoos. One patient’s
reaction occurred only on the red tattoo areas on the
arm and leg within a year of tattoo placement.
Another occurred on the eyelids nearly 10 years after
cosmetic tattoo placement and was refractory to
multiple therapies, while the third occurred on the
wrist after an unknown amount of time. Proposed
etiologic factors have varied from “reaction to red
ink” to “allergic granulomatous reaction to
blepharopigmentation,” to a reaction associated
with the use of undiluted phosphorescent pigment not
intended for use in humans as tattoo ink.[88,96,147,148]
Reported treatment approaches include excision,
triamcinolone acetonide injections, a combination
of both of these modalities.
INFECTIOUS GRANULOMAS IN THE SETTING OF
When inoculated into the skin with a needle,
mycobacteria species can infect tattoos and cause
granulomatous reactions. The presentation varies
but often takes the form of an erythematous,
pruritic, popular, or pustular rash over a recent
tattoo[149,150] with or without constitutional
symptoms.[151‑162] Asymptomatic presentations have
also been described.[155,160] Diagnosis is usually made
on biopsy and may be delayed due to the ambiguity
of these lesions.[149,153‑155,157‑160,163,164] As mycobacterial
infections can present without granulomas or
acid‑fast bacilli on histology,[153,154,165] it is important
to perform testing for mycobacteria specifically,
with DNA sequencing being the most sensitive
testing method.[153,155,166] High clinical suspicion
combined with epidemiological evidence is needed
to make a diagnosis. The source of infection
varies, but the main reservoir of nontuberculosis
mycobacteria (NTM) is considered to be tap water.
This may explain the association between black
or gray tattoos[151‑155,157,158,165] and mycobacterial
outbreaks, as black ink is often diluted with tap
Mycobacterium chelonae appears to be the most
common NTM tattoo infection, with nearly 100 cases
reported in the literature.[150,151,153‑158165,167‑170]
M. chelonae has also been implicated in “outbreaks”
of tattoo infections[153‑158,165,167] and has been found
in contaminated tattoo inks, likely related to impure
water supply. Kennedy et al. described successful
treatment of M. chelonae with empiric macrolides.
Other strategies, such as “watch and wait”[157,165]
or clarithromycin monotherapy, have also been
Other nonlepromatous, NTM infections
described in association with tattoos include M.
abscessus,[168,171‑175] Mycobacterium fortuitum,[159,163]
Mycobacterium immunogenum, Mycobacterium
haemophilum,[160,166,176] and Mycobacterium franklinii.
In some cases, the exact species of mycobacteria
could not be determined.[178‑181] Reported antibiotic
regimens have varied; typically, empiric treatment
is initiated and then modified based on specific
susceptibility data. Permanent makeup tattoos tended
to present with lymphadenopathy,[176,178] and in one
outbreak, abscesses and fistulae. Most patients
with abscesses and/or fistulae underwent surgical
intervention, with good clinical and cosmetic results.
TUBERCULOSIS TATTOO INFECTION
Mycobacterium tuberculosis tattoo infection (MTTI)
is an uncommon occurrence, with cases reported as
far back as 1895. The presentation is nonspecific
like the aforementioned NTM infections, with
ulceration, plaques, and/or pustules. There
may be no constitutional symptoms or a personal
or family history of M. tuberculosis infection (MTI).
Lymphadenopathy can occur with MTI.[184,185]
Cases of MTTI were reported at the turn of the
20th century and were attributed to a patient
with advanced pulmonary tuberculosis (TB) who
tattooed others using ink he made from his saliva and
India ink. Another case presented with papules
involving areas of a tattoo that had been touched‑up
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International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019 27
about 22 months prior. A significant proportion
of contemporary published cases of MTTI occurred
in India, where TB is endemic and tattoo artists
occasionally use saliva to moisten the pigment/needle
during the procedure and use the same needles for
multiple clients.[186‑188] In 1985, a case occurred in
the United States, where the prison inmate placing
the tattoo had sputum culture‑confirmed active
pulmonary MTI, so a similar route of transmission
is suggested but not confirmed. Finally, one case
reported in Singapore involved a commercial tattoo
parlor, with unknown route of infection.
The epidemiology of MTTI differs from other NTM
tattoo infections in that the reservoir of M. tuberculosis
is humans, not tap water or the environment. The
primary route of tattoo inoculation is thought to be
saliva.[184,185,187,188] Transmission through soil that is
sometimes applied to the tattoo after its placement
(for presumed antiseptic properties) has also been
proposed as a source for TB, although this seems
less likely than person‑to‑person transmission.
Several approaches to MTTI management have been
described, including X‑ray therapy, rifampicin,
isoniazid ethambutol, and pyrazinamide.[186,187]
Other authors generically mention good response to
“standard antitubercular treatment.”
LEPROMATOUS TATTOO INFECTION
Tattoo‑related leprosy (TRL) has been reported as
early as 1939 and usually presents with some
combination of a hypopigmented/discolored[192‑194]
or erythematous[87,194‑197] lesion involving the tattoo,
hypoesthesia/anesthesia over the lesion,[192,193,195‑197]
nearby neuropathy (sensory/motor/paresthesia),[87,193]
and thickening of a nearby nerve.[191,193‑197] Time
from tattooing to onset of symptoms can range
from 5 months to >50 years. Most
described cases are paucibacillary, while a few are
multibacillary. Lepromin reactions are often
positive.[193,195] Pathology showed granulomas with
or without caseation/necrosis.[87,192,193,195] Acid‑fast
bacilli are usually seen.[87,191‑193,195‑197] Mycobacterium
leprae DNA can be detected on a diagnostic biopsy.
Upgrading reactions have been noted;[195,197] one
patient presented initially with an upgrading
reaction while another experienced upgrading
after starting leprosy therapy. In one case, leprosy
manifested on a previously asymptomatic tattoo that
had been placed 2 years prior when the patient was
treated for MTI. It was theorized that this was
a HIV‑negative immune reconstitution syndrome
that occurs upon initiation of TB treatment. The
prevailing theory of transmission in TRL is direct
inoculation by unsterile needles, similar to the
method of transmission for cutaneous TB tattoo
infection. Many cases occurred in India, where
needle sterilization is sometimes lacking. Successful
treatments include dapsone/rifampicin,[191,196]
dapsone/rifampicin/clofazimine for multibacillary
leprosy and one upgrading reaction,[191,195] and
dapsone/rifampicin/prednisone for other upgrading
reaction. Clofazimine/minocycline/ofloxacin with
prednisolone for accompanying ulnar neuropathy was
NEOPLASMS IN THE SETTING OF TATTOO
The key question surrounding tattoos and neoplasms
of the skin revolves around potential causality. There
are insufficient data to evaluate the frequency of
neoplasms on tattoos, so causality (or lack thereof) is
inferred via biologic plausibility and the occurrence
of unique presentations that are extraordinarily
unlikely to occur by chance. Theorized mechanisms
by which tattoos could contribute to neoplasm
initiation/propagation include trauma via needle
puncture,[94,132,198‑209] injection of carcinogenic
chemicals,[132,202,205,206,208,210,211] altered absorption of
UV rays,[203,209] and a chronic local inflammatory
state.[94,110,198,200,202,205,211‑215] Although there is no proof
for any particular type of neoplasm, causality seems
more likely in some variants than others. Here, we will
discuss the best available knowledge regarding tattoo
association with neoplasms in the following order: basal
cell carcinoma (BCC)/melanoma, keratoacanthoma
(KA)/pseudoepitheliomatous hyperplasia (PEH),
and squamous cell carcinoma (SCC). Isolated
cases of leiomyosarcoma, dermatofibrosarcoma
protuberans (DFSP), cutaneous lymphoma, and
dermatofibroma (DF) will be reviewed as well.
BASAL CELL CARCINOMA AND MELANOMA
There are limited data to link tattoo creation with
BCC or melanoma,[119,202‑207,214,216‑229] with no evidence
of linkage between said cancers and tattoos. The
presenting lesions tend to be typical for the type of
cancer, generally do not follow the contours of the
tattoo, and are only present on part of the tattoo. The
time between tattooing and presentation varies from
months to many years. Thus, the occurrence of
BCC/melanoma on a tattoo is usually considered to
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28 International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019
be coincidental.[202,207,208,210,218,223,227] The occurrence
of skin cancer in locations that are not exposed to the
sun[203,217] and the occurrence in younger patients
does increase suspicion, but certainly does not prove
causation. In one case, a patient presented with four
melanomatous lesions on his chest, all within the
red ink of a tattoo. Biopsies showed a primary
melanoma and three metastases, which the authors
suggest could be due to seeding of the red ink after
the tattoo artist tattooed over what was to become the
primary tumor and dipped the needle back into the
Independent of causality, tattoos certainly
present a challenge in terms of early detection of
melanoma.[57,119,220,222,223,226,228] The tattoo pattern
and design distract from the possible presence of a
lesion, and dark ink may make detection of changes
difficult.[206,208,210] Dark ink may also confound the
histopathology or clinical appearance of a lymph node
that has been biopsied to evaluate for the presence of
melanoma[222,226,231‑238] or other cancers.[239‑241] Of note,
confounding of mammography due to tattoo pigment
has also occurred.[240,242]
Due to a lack of consensus on distinguishing criteria
of PEH [KA, Figure 4] and SCC, there is a
variety of ways to break these entities up for review.
Since SCC is the one that is generally agreed to be
malignant, we have chosen to review it separately
from KA and PEH. KA is being reviewed with PEH
because the two behave very similarly to each other,
both clinically and histologically.[132,200,212,243‑249]
Differentiating KA and PEH from each other
can be difficult.[132,200,212,245,250] They both present
within a few months of tattoo placement as a
or plaque,[212,244,246‑248,251] that is, sometimes
scaly[213,246,251] or verrucous.[198,200,212,244,250,252,254]
Ulceration and tenderness[200,244,246,247] have been
noted in PEH. Pruritus has been noted in KA and
PEH.[200,212,213,246‑248,250‑252] The lesion generally
follows the contours of the tattoo[212,244] or a certain
color.[132,200,201,212,243,246‑248,250,251,254] Since these lesions
are symptomatically and clinically nonspecific, biopsy
is required to make a diagnosis.
KA/PEH can appear histologically[132,200,212,213,244,247,249]
and clinically[132,200,201,212,213] similar to SCC and other
pathologies such as lichen planus, mycobacterial,
or fungal infection. In fact, KA and PEH are
histologically similar to the point that it has been
hypothesized that they are a single entity or exist on a
spectrum of reactive squamous proliferation. Thus,
differentiating them is beyond the scope of this review.
Clinically, KA[110,211] and PEH tend to occur within a
year of tattoo placement, while SCC tends to occur
years later. The strong tendency for KA/PEH to
follow the contour of or stay within the border of a
tattoo suggest a causal relationship. In summary,
the pathogenesis of KA/PEH is not fully understood,
although hypotheses include hypersensitivity,
viral involvement,[118,132,199,247,253] and
immunosuppression.[132,199] Chronic wounds
and inflammation[253,255] have been implicated in the
pathogenesis of PEH.
SQUAMOUS CELL CARCINOMA
There are several cases of SCC that present similarly
to KA/PEH, following the contours or presenting
with multiple lesions in the same tattoo.[94,215,257]
However, there are also cases that present in a manner
similar to BCC/melanoma,[215,258] without clear
preference for the contours or border of the tattoo.
The SCCs that presented similarly to KA/PEH also
presented in a similar time frame,[256,257] months
as opposed to years as for SCCs that are dissimilar
from KA/PEH.[110,215] Schmitz et al. proposed a
relationship between KA, PEH, and some forms of
SCC. We hypothesize that some forms of SCC share
common causative factors and pathological traits with
KA/PEH, explaining the cases of SCC that present in
the manner of KA/PEH. Two cases of SCC and KA
Figure 4: Photograph of a keratoacanthoma arising within an area of
the skin tattooed with red pigment. Used under the terms of the CC
BY‑NC‑ND license (http://creativecommons.org/licenses/by‑nc‑nd/4.0/)
Petrochko, et al.: Tattoo‑associated complications
International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019 29
developing in the same tattoo[94,215] support the theory
that there may be a common developmental pathway.
The cases of SCC that presented differently from
KA/PEH were likely forms of SCC that developed
via a different pathway than KA/PEH.
Only one case of cutaneous leiomyosarcoma associated
with a tattoo has been described. It involved a
41‑year‑old male who had a lump under a 10‑year‑old,
black‑and‑red tattoo removed by his family physician,
with subsequent pathological determination of
cutaneous leiomyosarcoma. Wide excision with clean
margins was performed.
The only case of DFSP occurring on a tattoo involved
a 35‑year‑old male who presented after a 7‑year history
of a slowly enlarging mass under a tattoo which had
been placed a year before he noticed the mass. Local
excision of the mass was carried out, with subsequent
re‑excision featuring 4‑cm margins performed after the
pathology report indicated DFSP. Given the rarity
of DFSP, causation is not provable.
PRIMARY CUTANEOUS NON‑HODGKIN
In an interesting case, a 32‑year‑old male reported a
2‑year history of intermittent bumps under the red part
of a tattoo that had been placed 17 years earlier.
There was improvement with topical steroids, but
one bump persisted and grew, prompting surgical
excision. Subsequent histological evaluation showed
“histiocytic lymphoma.” The authors of the report
hypothesized that chronic dermatitis may have played
a role in the development of the tumor. Mercury
was sometimes used in red pigments at this time,
which is known to cause chronic dermatitis. Given
very limited evidence, any causation is questionable
DF is a benign scar‑like proliferative lesion of
unknown etiology. DFs have been known to occur
on tattoos, usually within 2 years of placement. DF
tends to be nodular and may be asymptomatic or
tender.[262,264] The lesions can be red in color,[262,264]
with some being mobile.[262,264] The pathogenesis of
DF is controversial, and the two prevailing theories
are that it is a fibrosing postinflammatory reactive
change, or that it is a benign neoplasm. It has been
associated with trauma.[262,264] DFs are considered
benign, although metastases have rarely occurred.
Histology is important to rule out malignancy, as the
differential includes DFSP and BCC. Surgical
excision is usually curative and has been shown to
be effective in cases of DF on tattoo.
TINEA AND OTHER FUNGAL INFECTIONS
Tinea on tattoo presents as a scaly erythematous
plaque with vesiculopustular borders and central
clearing that is usually pruritic. Literature reports
suggest the occurrence of this fungal infection within a
month of tattoo placement.[2,266] Immunosuppression
may be associated with the appearance of tinea over
a longer time frame (e.g., several years). Tinea is
known to be spread by direct contact, and a likely
source of infection can usually be identified. In
all cases, the vulnerability of the skin from barrier
disruption or immunosuppression likely allowed
these fungi to spread from nearby sources and infect
the skin of the tattoo. Microscopic examination of
scrapings from the lesion or a fungal culture is used
to make the diagnosis. The causative organisms have
been identified as Microsporum canis or Trichophyton
tonsurans. Treatment involves discontinuation
of any immunosuppressants (when possible) and
administration of either or both topical and oral
antifungals such as ketoconazole cream and oral
Fungal infections at tattoo sites have been
described,[268‑270] including a case of fungal eye
infection thought to be related to a tattoo. One
instance of a “homemade” tattoo involved the
appearance of necrotic Aspergillus fumigatus papules
within a month of placement. In another case,
a ritual Samoan tattoo developed nodular lesions
containing Sporothrix schenckii within 3 weeks of
placement. A third patient developed an ulcerative
lesion 7 years after tattoo placement (zygomycosis
from Saksenaea vasiformis). Finally, another patient
developed candida endophthalmitis presenting with
decreased visual acuity within a week of tattooing.
Of note, the latter case (candida endophthalmitis)
occurred 4 days after a tattoo was placed in an asplenic
All patients in the aforementioned cases were able
to clear their infections. The A. fumigatus was
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30 International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019
treated uneventfully with oral voriconazole and
local terbinafine, while the Sporothrix was treated
successfully with itraconazole. The zygomycosis
showed improvement with potassium iodide.
Amphotericin B given as an outpatient three times a
week for several months was curative. The patient
with candida endophthalmitis responded well to
amphotericin B after diagnostic vitrectomy.
In summary, it is reasonable to suggest that proper
aseptic technique during tattooing and proper
wound care would significantly lower the risk of
these infections. In the asplenic patient, antimicrobial
prophylaxis could be considered, although this would
require that a detailed medical history be taken before
embarking on tattoo placement. Education of asplenic
patients and other key stakeholders to this possible
occurrence could prevent a delay in diagnosis and
treatment of a sight‑threatening infection. Finally,
aspergillosis infection associated with LTR has
been described, with the hypothetical mechanism
involving the creation of microscopic skin defects that
served as a portal of entry for the fungus.
Hepatitis B (HB) has been referred to as
“serum hepatitis,” long‑incubation hepatitis, or
Australia/hepatitis‑associated antigen hepatitis.
The incubation time is around 50–150 days, and
presentation involves jaundice and malaise typical of
this disease. Although local tattoo reactions were not
reported, evidence of causality includes biological
plausibility, case series,[273‑276] and epidemiologic
studies.[274,277] HB is known to be transmissible by
very small amounts of blood[274,278] and tattoo shops
in the mid‑20th century were known to share needles
and ink between clients.[273,274,278,279] Outbreaks
of HB have been associated with single tattoo
shops[273,275,276,278‑281] making the diagnosis challenging
or even a single tattoo shop on a single day.[278,280,282]
Given the parenteral nature of HB transmission, tattoo
transmission seems the most likely explanation for this
In one report, an outbreak of HB was traced to an
acupuncture facility, supporting the hypothesis that
small amounts of blood on needles can transmit the
virus. Several epidemiologic studies supported
a correlation between tattooing and HB.[274,277]
However, the propensity for some individuals who get
tattoos to engage in other high‑risk activities may be
a confounder that was only occasionally accounted
for.[274,277,286] One case–control series suggesting no
increased risk of chronic viral hepatitis excluded
patients with a known history of viral hepatitis or liver
disease, weakening the study.
The vast majority of patients survive symptomatic
HB infection, and there is no treatment specific
to tattoo‑acquired HB. With prevention being the
best approach, the parenteral nature of transmission
suggests that using sterile, patient‑specific tattoo
needles and ink would prevent transmission via
tattooing. Options for ensuring sterility include using
disposable equipment or intense sterilization.
Given that HB is difficult to destroy,[273,278] disposable
materials would likely be the safer option.
Hepatitis C (HC) was formally known as non‑A
non‑B hepatitis, and the presentation tends to be
similar to HB, although the symptoms may present
sooner. HC is more frequently asymptomatic
than HB, and its transmission by tattoo may be
more likely to result in subclinical or occult infection
compared to IV drug use (IVDU) transmission.
Tattoo reactions were not noted in cases of HC that
were thought to be acquired via tattooing.
The transmission of HC is parenteral and can
theoretically be transmitted via the same mechanism
as HB. However, likely due to the greater tendency
to remain asymptomatic and result in chronic
infection, case reports linked to a single tattoo shop
are less common. HC from tattoos is thought
to be less likely to result in acute hepatitis due to
the presumably lower viral load than HC acquired
via IVDU. Isolated case reports linking unsafe
tattooing to HC do suggest causality. Most
of the evidence connecting tattooing to HC is
epidemiological,[168,185,288,291,294‑296] however, often
relying on sample testing and not clinical presentation
to discover cases. The improvements in the hygiene
of tattooing would apply only to regulated
legitimate tattooing studios, which explains why
receiving a tattoo in prison or by a nonprofessional
may confer a higher risk for HC.[168,291,297,298] This
also explains the low number of case reports, as
tracing the source of an outbreak to an illegitimate
tattoo artist would be challenging. Tattooing was
often shown to be a risk factor even when a history
of IVDU was excluded.[294,295,297]
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International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019 31
Although treatments exist for HC, prevention is
preferable. Given that HC contributes to significant
overall infectious disease mortality, improvement
must be made on slowing the spread of this disease.
At a population level, enforcement of proper hygiene
and improving screening for populations at risk
could be beneficial. Educational initiatives aimed
at individuals should discourage being tattooed by
anyone other than a professional tattooist.
Human immunodeficiency virus infection
It is theoretically possible to transmit HIV via tattooing
from infected needles or ink.[4,6,300] Epidemiologic
studies disagree over whether tattooing is a risk factor
for HIV, although most suggest that it is not.[4,300‑302] It
is difficult to determine if tattooing acts as a surrogate
for high‑risk activity as there are many confounders.
Looking at case reports of prisoners who allegedly
contracted HIV due to tattooing, the evidence is
largely circumstantial and does not fully consider other
risk behaviors. A case report of HIV transmission
by acupuncture suggests that tattooing is a plausible
mechanism.[195,303] The paucity of case reports describing
HIV transmission is likely due to increased tattoo safety
in professional parlors. Unregulated tattooists are
unlikely to submit reports of complication or infection.
Furthermore, HIV’s lower infectivity relative to HC
may explain the lack of epidemiologic support for this
method of transmission. In summary, while HIV
transmission via tattooing is theoretically possible and
may rarely occur, it is likely not an epidemiologically
significant mode of transmission.
Herpes simplex virus (HSV) has been identified in
tattoos, both clinically and with PCR.[305,306] The
symptoms start 2–3 days after tattooing as a painful
erythematous rash.[304‑306] One case was not limited
to the tattoo in a patient whose history of herpes
is unknown. A patient with a known history
of herpes labialis experienced an attack of herpes
labialis much more severe than usual after cosmetic
lip tattooing. Another patient with no previous
HSV history presented with herpes confined to the
There is disagreement over the mechanism behind
HSV infection of a fresh tattoo and given
the different presentations, different mechanisms
could explain different cases. Possible mechanisms
include contamination of the tattooing needle,[304,306]
superinfection of a fresh wound,[305,306] and a local
altered immune response. Regarding a case of
a tattoo with no previous herpes history, needle
contamination from herpetic whitlow or an unnoticed
herpetic lesion on the patient that was tattooed
over could help explain the distribution of lesions.
Superinfection could also explain this, but only if
the entire area was exposed. Of note, all of the above
cases experienced resolution of their symptoms with
valaciclovir or famciclovir. In addition to
reiterating the importance of sterile technique, these
case reports highlight the possibility of tattooing
as a potential trigger in patients with a history of
HSV, raising the possibility of potential benefit to
Molluscum contagiosum (MC) is a viral infection
caused by a poxvirus that is transmitted by direct
contact. It presents similarly to verrucae; both
often present as multiple asymptomatic papules
restricted to a tattoo. The symptomatic presentation
has occurred. Unlike verrucae, MC is often
umbilicated.[309‑312] Presentation occurs weeks[308,313,314]
to months[310,311,315] after tattooing, and diagnosis is
confirmed by biopsy.
Possible mechanisms of transmission include
contamination of the instruments used for
tattooing[308,309,313,314,316] or the ink,[308,309,311,313] or
reduction in immunity from the ink. A Koebner
or pseudo‑Koebner response may be involved in
the development of these lesions. As with verrucae,
the presence of lesions on only one of several colors in
a tattoo[310,311,315] suggests an effect of that specific ink
and not just an effect of trauma, which would affect
multiple colors. One case involved a patient whose
tattoo had been applied in stages, with the MC‑affected
color being done all at once, separately from the rest
of the tattoo. In this case, it was possible that
inoculation occurred due to contamination that was
only present on that occasion.
Treatments for MC include destructive (most
common), immunomodulatory, and antiviral
interventions, although most MC papules
will resolve without treatment. Specifically
referring to tattoo‑associated MC, curettage has been
Verrucae have been reported in association with
tattoos in various patterns. The presentation
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32 International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019
usually consists of papules[317‑325] that are often
asymptomatic[317,320,326] and stay within the borders of
a tattoo.[317,327] In some cases, involvement is limited
to a single color within the tattoo,[319,321,325,328‑330] or
follows a line of the tattoo.[324,331] Incubation time can
be months[320,323‑325,329] to years.[224,317,319,321,324,327,328]
Presentations include both verrucae plana[224,320,322]
and verrucae vulgaris.[317‑319,321,323‑325,330] Diagnosis is
clinical, with the support of histology if necessary. It
can be challenging to differentiate HPV verrucae from
seborrheic keratosis [SK, Figure 5] clinically. PCR
to characterize/confirm the type of HPV is performed
Possible mechanisms for this include contamination
of the tattooing equipment or ink;[317‑320,322,324,325,330]
contamination via the artist’s saliva;[224,322,324,325] direct
inoculation of viruses already present on the skin or in
a hair follicle;[224,318,322‑324,329,330] reactivation of latent
virus;[327,329] or immune modulation that lowers the
local ability to fight infection.[326,328,332] Similarly, a
Koebner[317,320] or pseudo‑Koebner response has
been proposed. Cases of warts appearing within one
tattoo color but not others suggest contamination or
an immunomodulatory effect specific to that ink, while
warts on multiple colors support the theory of traumatic
induction/immunomodulation. Delayed onset has
occurred after sunburn, thought to be due to immune
modulation by UV light, as well as postpartum
from pregnancy‑associated immunosuppression.
One case appeared in a patient with known discoid
lupus erythematosus. Causative agents include
HPV 27, 47, and 6B.
Treatments include curettage,[325,328] topical
imiquimod alone[317,318,322] or with tretinoin,
cryotherapy,[321,323,324] local treatment such as retinoid
or fluorouracil, and electrocautery. Primary
prevention consists of ensuring that the tattooing
materials and skin are both free of contamination.
This includes not tattooing over any lesions which
could lead to more widespread viral verrucae
throughout the tattoo.
BACTERIAL INFECTIONS: SYPHILIS
Syphilis can be transmitted in association with tattoo
placement in one of two ways – with the tattoo being
the primary inoculation site or as a localization site
for the lesions of secondary syphilis. Syphilis can be
transmitted through the saliva of the tattooist.[8,333,334]
This was prevalent in the 19th century, when artists
frequently exposed the tattoo and/or the needle to their
saliva, such as to mix with dried pigments to create
ink or to wipe away blood or excess ink. Affected
patients would develop one or more chancres typical
of primary syphilis at the tattoo site within days to
months before progressing to systemic signs/symptoms
of syphilis.[4,336] Patients with tattoos and syphilis (even
if tattooing was not the inoculation site) can develop
lesions characteristic of secondary syphilis or even
gumma localized to their tattoos.[4,333]
Syphilis is inoculated via tattooing by breaking
the skin barrier and providing Treponema access.
Epidemiologically, several outbreaks of syphilis in the
past have been traced to individual tattoo artists who
used saliva during the tattooing process.[336‑338] The
lesions of secondary syphilis are thought to localize
to tattoos due to a decreased immune response,[336,339]
perhaps as a result of chronic inflammation or injury.
This could be the result of a Koebner response which
is thought to be associated with other TRCs. Of
interest, the lesions on tattoos may spare the red
areas, likely due to the antisyphilitic properties of
mercury[4,7,333,336,339] which was a commonly used
pigment in red tattoo ink before its concentration
was limited to 3 ppm by the U.S. Food and Drug
Administration. Due to increased awareness and the
adoption of aseptic techniques, transmission of syphilis
by tattooing is much less frequent today.[233,234,302,334] In
the exceedingly rare event of syphilis inoculation via
tattooing, prompt antibacterial therapy is indicated. In
the event of a secondary syphilis‑like lesion appearing
in a tattoo, clinicians should be aware of this possibility
and test the patient for syphilis.
Figure 5: An example of tattoo‑associated seborrheic keratosis‑like
lesions. Source: Bakke JR, et al. JAAD Case Rep 2019;5 (3):274‑276.
Used under terms of the CC BY‑NC‑ND license (http://creativecommons.
Petrochko, et al.: Tattoo‑associated complications
International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019 33
UNCOMPLICATED SUPERFICIAL BACTERIAL
Although the incidence of tattoo‑related infection (TRI)
has been reported as high as 3.2%, there are relatively
few reported cases of uncomplicated superficial skin
infections aside from Mycobacterium. Such superficial
infections tend to present as erythematous,[235,236,340,341]
swollen,[235,236,340] painful, hot,[340,341]
edematous[340,341] areas over tattoos sometimes
accompanied by fever.[236,340] Some of the reported
causative organisms include Serratia marcescens;
Streptococcus pyogenes, and Staphylococcus aureus.
A case of staphylococcal‑scalded skin syndrome
involving a homemade tattoo presenting with
generalized erythema, purulent fissures, and areas of
dry crusting of the skin. Other reports of TRIs may
warrant mention, but granular details are beyond the
scope of this review.[199,238,340‑342]
It is likely that uncomplicated skin infections are
far more common than published case reports
would indicate. Although tattoo inks are not always
sterile, even sterile ink and equipment will not
protect a patient from commensal/environmental
organisms that survive on the skin after improper
sterilization or enter the wound later due to improper
aftercare. Treatment consists of prompt recognition
and appropriate antimicrobial therapy – initially
broad, but preferably narrowed based on subsequent
Cases of necrotizing fasciitis following tattoo
placement have been reported, with presentations
typical of necrotizing soft‑tissue infections with
localized pain,[198,343] erythema,[198,343] swelling,
cellulitis,[198,249,343] skin breakdown/necrosis,[198,249,343]
purulent discharge,[197,249] fevers,[198,249,343] shortness
of breath, rigors,[198,249,343] hypotension,[198,343] and
decreased urine output.[198,343] Majority of infections
originated between the lower trunk and thighs, and
all patients required surgical debridement and IV
antibiotics. Risk of mortality is significant.
Causative organisms include S. aureus,[198,249,343]
Group C Streptococcus, S. pyogenes,[198,249,343]
Pseudomonas aeruginosa,[198,249,343] Corynebacterium
species, and Klebsiella oxytoca.[249,343] Infections are
usually polymicrobial, and the unsanitary conditions
of the traditional tattooing may play a role in their
development.[198,249,343] Patients are treated with
surgical debridement plus broad‑spectrum antibiotic
regimen. Many patients require subsequent skin graft
placement. Since necrotizing soft‑tissue infections
require prompt recognition and treatment post tattoo
education is essential. Tattoo artists must inform their
customers of the signs and symptoms that should
prompt urgent medical attention.
TOXIC SHOCK SYNDROME
Toxic shock syndrome (TSS) posttattooing has
been reported,[251,344,345] although the connection is
somewhat speculative.[251,345] Presenting complaints
may include fever,[251,342,345] rigors,[251,344] syncope,
headache,[251,344] abdominal pain, anorexia,
nausea, diarrhea,[344,345] vomiting, with
potential for progression to necrotizing infections.
Additional reported complaints included orthostasis,
syncope, acute confusion, and cutaneous
rashes.[344,345] The associated rash may subsequently
desquamate. The contribution of the tattoo may
be obvious, but one should not assume this in the
absence of overt findings.[251,345]
TSS is caused by a soft‑tissue infection with
exotoxin‑producing S. aureus or S. pyogenes.
These exotoxins are also sometimes referred to as
superantigens, and clinically, TSS can be difficult
to distinguish from staphylococcal septic shock. In
one case, a tattoo had been placed on the anterior
abdominal wall 2 weeks earlier, and a computed
tomography scan showed subcutaneous inflammation
in the area of the tattoo. In another case, a patient
was admitted for nonspecific signs of sepsis and severe
groin pain which turned out to be necrotizing iliopsoas
myositis. She quickly died of Streptococcal TSS.
Hematogenous spread of bacteria from the tattoo
was suspected when postmortem examination
revealed punctate hemorrhages of the parietal pleura
and a purulent empyema deep to the tattoo site.
Blood cultures were eventually positive for group A
Streptococcus. The third case presented with
nonspecific systemic symptoms and an erythematous
rash featuring greenish papules on the tattoo which
made the diagnosis of a soft‑tissue infection somewhat
easier. Desquamation of the patient’s fingers and
tattoo site on the back several days after his condition
had stabilized supported the diagnosis of TSS.
However, this was after he had been treated for TSS, as
desquamation may occur after the onset of symptoms
and thus should not be relied upon for diagnosis.
Petrochko, et al.: Tattoo‑associated complications
34 International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019
Methicillin‑sensitive S. aureus (MSSA) grew from
a skin culture of the tattoo site, but blood cultures
remained negative. This is typical of staphylococcal
TSS, with streptococcal TSS being more likely to
produce positive blood cultures.
Management of TSS requires prompt
administration of broad‑spectrum IV antibiotics,
including robust Gram‑positive coverage, plus
hemodynamic/vasopressor support in the intensive
care unit (ICU) as indicated.[251,345] Antibiotics
can subsequently be narrowed once culture (and
sensitivity) confirmation of the microorganism is
finalized. In summary, it is important to consider
the possibility of TSS in the setting of a patient with
a sepsis‑like picture even if the tattoo itself does not
appear infected. Finally, in addition to antibiotics,
surgical consultation is important due to the likely
need for operative debridement.
Bacteremia has been reported in association with
tattooing, with the primary infection usually
involving the tattoo site, up to and including
necrotizing fasciitis.[199,200,249,254] At times, the trauma
of tattooing may introduce a metastatic infection such
as endocarditis,[213,244,247,348] pyelonephritis, septic
arthritis, or a distant soft‑tissue infection[208,228,350]
that may further propagate the bacteremia.
The presentation is typical of a septic patient,
including complaints/findings of malaise,[228,244,247]
fevers,[200,213,229,247,249,254,348,349] rigors,[244,249,254] nausea
and vomiting[249,350] plus specific symptoms related
to the site of infection such as blisters,[200,249]
erythema,[200,247,254,349] purulence,[208,249,254] abdominal
pain, muscle pain, back pain,[208,350]
paresthesias, lower extremity weakness,
dysuria, dyspnea,[247,348] and fatigue.[213,247]
Bacteremia may result from a primary tattoo
infection, the mechanism of which consists of
the introduction of bacteria into the wound from
improper aseptic technique, contaminated ink or
instruments, as well as poor aftercare.[200,254] Similar
mechanism is thought to cause a transient bacteremia
with infection spread to distant sites. This, in turn,
can fuel an ongoing bacteremia, with or without a
clinical tattoo infection being apparent. Among risk
factors for tattoo‑related bacteremia is neutropenia,
and providers should be aware of this potential
association. Causative organisms vary, but include
MSSA,[208,213,254] MRSA,[199,249,350] Staphylococcus
lugdunensis, Hemophilus influenzae, Group A
Streptococcus/S. pyogenes, P. aeruginosa,[200,249]
and Moraxella lacunata.
Management depends on the site of infection, but
fundamentally after blood cultures are taken, empiric
broad‑spectrum antibiotics should be immediately
started.[200,228,249,254,349] Antibiotic regimen can then be
tailored once sensitivities become available,[228,249,254]
and appropriate surgical or interventional treatment
is undertaken.[208,213,228,244,247,249,254,348‑350] As with
other tattoo infections, proper sanitation is critical
to preventing these occurrences. Of note, a delay
in treatment can have serious consequences.
Educating patients about the signs and symptoms of
infection and– perhaps more importantly – sepsis, as
well as the importance of prompt medical care could
mitigate the risk of morbidity or mortality.
Among several reported cases of bacterial
endocarditis (BE) following tattooing, three cases
had known prior valvular disease,[244,247,351] one case
showed myxoid degeneration of one of the two valves
affected, with others demonstrating no evidence of
other heart disease.[348,352] The presenting complaints
included fever,[213,247,348,351] rigors/night sweats,
malaise, fatigue,[213,247] and dyspnea[247,348] usually
starting within a week of tattooing. However,
presentation as late as 2 months after tattooing was
reported. Heart failure[244,247,348] and embolic
events[244,247,351] were noted. Signs of tattoo infection
were only present in approximately 20% of cases,
and the link between the tattoo and BE was presumed
in the other cases. The causative organisms identified
were S. lugdunensis, S. aureus,[213,244,351] and
Superficial skin infections are common with tattoos,
likely due to disruption of the epidermis which acts as
a microbial barrier. These infections are usually from
commensals, although infected ink is a possible
route of infection even if the skin is properly sterilized.
The frequency of infections suggests that bacteria are
frequently introduced to the body, although tattoo
infection is not a prerequisite for BE. Once inside the
body, it is possible that transient bacteremia may lead
to colonization of damaged heart valves. Although
the bacteria at the tattoo site may be successfully
eliminated by the immune system, BE is already
Petrochko, et al.: Tattoo‑associated complications
International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019 35
occurring.[353,354] This explains the occurrence of tattoo
endocarditis in patients with valvular damage, but not
the patient without valvular abnormalities.
Tattoo‑related BE should be treated like any other BE,
with sustained course of antibiotic therapy directed
against the organism identified from blood cultures,
and surgery when indicated. All five patients with
detailed reports required surgical valve replacement,
with one having an abscess at the base of the coronary
sinus noted at the time of surgery and another
developing a prosthetic valve abscess prompting a redo
valve replacement. All five patients recovered well,
although one required a pacemaker due to complete
heart block. Antibiotic prophylaxis for patients
with cardiac defects receiving a tattoo is not universally
recommended, although insufficient data exist
to make any definitive statements in this context.
Educating patients and tattoo artists of the potential
dangers is important, especially because the
awareness of BE following tattoo creation is low.
While localized tattoo infections are quite
common, it is possible for TRIs to become a
source of metastatic infections to other parts of
the body. Clinical presentations tend to be diverse,
including sepsis‑like symptoms, pain localized
to the involved area,[208,251,349,350] weakness, and
paresthesias. Specific reported anatomic locations
include epidural abscess,[208,350] xanthogranulomatous
pyelonephritis, iliopsoas myositis/abscess,[251,350]
and streptococcal empyema.
Most cases in the literature had some evidence
of infection or the potential for contamination,
including localized irritation and drainage, the
use of contaminated ink or after‑care materials,[251,349]
repeated equipment/ink use without sterilization,
and one had an erythematous tattoo that was
reported to have been placed with unsterile
equipment. It is proposed that bacterial spread is
hematogenous,[251,349,350] involving the appearance of
transient bacteremia. Even without evidence of an
overt tattoo infection, bacteria could be introduced
into the bloodstream via tattoo placement, similar to
the mechanism involved in IVDU.[353,354]
Treatment depends on the location of the remote
infection, and with general management strategies
being outside of the scope of the current review,
the reader is referred to definitive sources on the
topic.[208,349,350] In aggregate, reported cases on this
topic highlight the importance of proper sterilization
of the skin and equipment before tattooing, as well
as education of patients to seek medical attention if
the tattoo shows signs of infection. Clinicians should
be aware of recent tattoo placement or infection as a
risk factor for distant infections when building their
Leishmaniasis is a disease caused by the parasite
Leishmania which is endemic to parts of the tropics,
subtropics, and southern Europe, the most common
forms of which are cutaneous and visceral. It is
transmitted by the phlebotomine sand fly and
transmission specifically via tattooing has not been
reported. However, much like secondary syphilis,
cutaneous manifestations of the infection appear
to have a predilection for tattoos. Cutaneous
leishmaniasis (CL) tends to present as a painless
nodular or ulcerated lesion which may be indurated
and all reported cases of tattoo‑associated CL (TACL)
fit that description. In addition, there may be an
association between TACL‑ and HIV‑positive status
in the context of preexisting cutaneous and visceral
leishmaniasis.[240,357,358] Much remains to be learned
about the above factors, and the temporal relationship
between leishmaniasis infection, tattoo placement, and
TACL is poorly understood.
It is known that Leishmania parasites are found in the
blood and that CL lesions tend to develop at the site
of even minor trauma. The mechanism is thought
to involve infected dendritic cells or macrophages that
carry Leishmania to new areas of the body, especially
skin regions affected by active inflammation. There is
a documented tendency for leishmaniasis to occur in
areas of trauma or antigen‑specific hypersensitivity
reaction. Given that tattoos are traumatic and
cause inflammation, this is likely the mechanism
observed in tattoo leishmaniasis. Moreover, the high
prevalence of macrophages (which Leishmania utilize
for reproduction) within tattooed skin may predispose
a patient to TACL.
Leishmaniasis should be included on the differential list
for suspicious tattoo lesions in patients with a history
of travel to an endemic area or history of leishmaniasis,
especially if the patient has failed antibiotics and
other treatments or is immunocompromised. Among
Petrochko, et al.: Tattoo‑associated complications
36 International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019
other recent developments, it was proposed that
tattoo‑based interventions may help treat CL by
enhancing local drug delivery.
Tattoos can be associated with localized
lymphadenopathy, at least in the acute phase. This
may confound clinical decision‑making in the context of
infection or malignancy.[93,263,362] Usually, the patient
presents with a lump or swelling that may or may not be
painful or tender.[93,264,361‑364] On physical examination,
the node may be described as mobile.[93,263,364] It may be
firm[263,363] or rubbery. The lag time between tattoo
placement and finding/symptoms may be as short as
5 months or as long as years. While the tattoo
may be visible, tattoos are common enough that the
presence of a tattoo that is not obviously infected
or inflamed may not necessarily raise suspicion,
or there may be repeated episodes of low‑grade
inflammation.[93,364] When excised, the lymph
node may appear dark in color which is suspicious
for malignancy, especially melanoma.[263,348,363,364]
Furthermore, the presence of tattoo pigment in a lymph
node can make evaluation for melanoma difficult.
Biopsy, however, generally shows benign lymph
nodes, suggestive of reactive lymphadenopathy.
Tattoo lymphadenopathy may also be discovered on
radiography,[240,242] perioperatively, or on sentinel
lymph node biopsy.[233‑238,348]
The mechanism of tattoo‑associated lymphadenopathy
(TAL) involves macrophages taking up tattoo
pigment that migrates to lymph nodes via lymph
channels,[363,364] similar to the process used to identify
a sentinel lymph node for biopsy. Autopsy studies
suggest that patients with upper extremity tattoos
have pigmentation of the axillary lymph nodes,
with most being asymptomatic.
The majority of patients did not require treatment
after biopsy ruled out malignancy. One patient was
initially diagnosed with reactive lymphadenitis and
was treated for an ingrown toenail, the presumptive
cause. Biopsy showing tattoo lymphadenopathy
was only performed after the Zadek’s procedure
failed to resolve the painful swelling at the site of
the lymph nodes. TAL should be considered on the
differential for a palpable or tender mass proximal
to a tattoo. The decision to consider lymph node
biopsy/dissection should be based on the overall
clinical context and situation‑specific risks.
Eczematous tattoo reactions (ETRs) have been
reported in association with trauma, immune
reconstitution,[367,368] and implantation of an implant,
as well as both short‑ and long‑term interval after
tattoo placement.[72‑74,269,270,285,366‑368,370] The patient
tends to present with pruritic,[73,74,269,270,285,368‑370]
erythematous,[74,269,270,367,368] or eczematous[72,366,370]
lesions that are sometimes described as plaques[367,369,370]
and tend to be confined to, or prominent on a certain
color of a tattoo.[74,285,367‑370] Lesions have been known
to occur outside the tattoo,[269,270] including generalized
reactions.[72,366,368,369] Conjunctivitis after eyelash
tattooing has been observed. Diagnosis is generally
clinical, but biopsy can help rule out other conditions
such as sarcoidosis or infection (e.g., mycobacteria).
Such course of action is important in a patient who
fails initial therapy and an alternative diagnosis is
Many of these reactions are labeled as
allergies,[269,270,285,368,370] implying a type 1
hypersensitivity reaction. However, delayed‑type
hypersensitivity (including systemic contact
dermatitis) has also been proposed as a mechanism.
It is difficult to argue against the hypothesis that
the tattoos are the cause of the reactions given the
temporality and/or geography of lesions. However,
patch tests are generally not considered useful, and
it is thought that haptenization or dissociation plays a
role in the pathology. In one study of 90 patients
with a variety of tattoo reactions, the authors
suggested the importance of haptens in the genesis of
said reactions. Among other features, histological
characteristics include lymphocytic infiltration,[366,368]
spongiotic dermatitis[368,369] and granulomatous[72‑74]
patterns. In the setting of trauma, it is thought that
the injury releases mercury into circulation and
causes rapid sensitization. In cases of immune
reconstitution (e.g., bone marrow transplant), the
immune system is “seeing” pigment for the first time
and reacting as if the tattoo had just been placed.[367,368]
Another proposed mechanism involves immune
cross‑reactivity between various materials, including
implants and the tattoo ink.[269,369]
The mainstay of treatment for ETRs includes either
topical,[73,269,285,368,369] intralesional,[368,369] or systemic
steroids.[366,368] Effectiveness may vary from complete
response[73,269] to partial or no response.[270,285,369]
LTR may also be effective,[285,370] although adverse
Petrochko, et al.: Tattoo‑associated complications
International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019 37
reactions have been reported.[13,35] In refractory cases,
excision has been effective in ETRs.[72,366,368] Removal
of the implant associated with the ETR may help but
is usually difficult or not possible. Spontaneous
remission has been reported.
Occasionally, tattoos will react to sunlight, with
presentations such as localized swelling,
inflammation, bullae formation, and
eczema. The time between tattoo placement
and reaction varies from months to years.
The mechanism is unclear, and it is not known if
these reactions are photoallergic or phototoxic.
Cadmium sulfate is thought to be contributory;
however, there have been reactions to tattoos
without cadmium sulfate. Histologic appearance
includes lichenoid, granulomatous, and
acanthosis with spongiosis. Treatment consists
of systemic prednisone plus topical cortisone cream
for photoreaction, with other therapeutic options
considered on an as‑needed basis.[275,341]
The lichenoid tattoo reaction is thought to be
the most common tattoo reaction,[81,281,283,371]
and tends to present as raised,[273,276,371]
pruritic,[272,274,276,277,279,281,283,284,286,287,371,372] and possibly
erythematous lesions that may be described as papules
or plaques.[55,272,277,279,281,283,284,286,372] Often the lesions
will be confined to the tattoo or a certain color of
a tattoo (most commonly red).[272,273,276,279,287,371,372]
There are reports of generalized reactions, some
of which started in, or have a preference for a
tattoo.[273,277,281,283,284,286] One report describes lichenoid
reaction on lower extremity tattoos just after superficial
trauma involving other tattoos. Attributed lag time
between tattoo placement and onset of symptoms can
be as little as 2 days or as long as years, with most
reactions occurring within a year.[273272,276,277] Exposure
to sunlight may aggravate the pruritus.
Histology is generally consistent with a lichenoid
reaction, although not necessarily specific for
it.[272‑274,277,281,283,286,372] However, nodular and
granulomatous patterns were also noted on lesions
that were grossly considered lichenoid. The
presence of eosinophils may favor a hypersensitivity
rather than lichenoid etiology, with one source
using the term “lichenoid tattoo hypersensitivity.”
Diagnostically, patch tests are considered unreliable and
are often negative in this specific setting.[272,276,277,371]
The mechanism for the lichenoid reaction is unknown,
but one theory is delayed type hypersensitivity
simulating graft versus host reaction.[273,277] The
mechanism for the generalized nature of some of
the reactions is thought to be dissemination of the
tattoo pigment through the body or a local reaction
that leads to similar reactions at distant sites.[281,283,286]
A Koebner or pseudo‑Koebner phenomenon has
been proposed mechanistically, although the more
generalized response is still poorly understood.
The occurrence of lichenoid reactions (localized to the
red areas of tattoos) among patients tattooed by the
same artist within 6 months of each other also raises
the possibility that a contaminant (including possibly
a microorganism) could be contributory. Finally,
the presence of lesions localized to the tattoo points
away from true lichen planus.
Management includes local steroids, oral nonsteroid
pharmacotherapy, LTR, surgical excision, and
combinations of the above. Reported local
pharmacotherapy of various effectiveness includes
fluorinated topical steroid cream, topical clobetasol
propionate,[272,274,276] halobetasol propionate,
intradermal triamcinolone acetonide, other
intralesional steroids, and tacrolimus.
Intralesional steroids plus oral antihistamines were
partially effective in one case. Nd:YAG and
Erbium‑doped yittrium aluminium garnet laser
LTR approaches were shown to be effective, including
Nd:YAG LTR in combination with clobetasol
propionate in a patient who did not respond to
clobetasol propionate alone. Although it has shown
to be effective in treating lichenoid reactions, LTR
has been associated with generalized reactions.[281,283]
An approach consisting of excision using a skin knife
to only remove the elevated portions of the tattoo
was successful and preserved the tattoo with an
overall good cosmetic result. Finally, spontaneous
resolution of lichenoid reaction was described.
The localization of psoriasis to tattoos was described by
Heinrich Koebner as early as 1876.[292,373] The so‑called
Koebner phenomenon features well‑defined,[288,293,295,296]
and occasionally pruritic[288,291] plaques associated
with tattoos. The plaques usually appear within a
few weeks of tattoo placement (although in unusual
Petrochko, et al.: Tattoo‑associated complications
38 International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019
circumstances this may happen several months after
placement of the tattoo). Although most cases are
localized to the tattoo, there are examples that are
clearly associated with the tattoo that extends beyond
its border or start in the tattoo and progress to
involve other areas.[291,296,376] Generalized reactions
have occurred,[288,295] including instances where there
was documented preference for the tattoo.[374,377]
Psoriatic arthritis has occurred parallel to new‑onset
psoriasis. The association between tattoos and
psoriasis has occurred in patients with and without
a known history of psoriasis.[288,292,293,295,374,375,377]
Diagnosis is usually clinical although biopsies can be
Despite significant advances in Heinrich Koebner’s
original paper, the mechanism of the Koebner
phenomenon, which occurs in about 25% of psoriasis
patients, is still unclear.[293,295,373] Hypotheses include
trauma,[296,375] hypersensitivity to tattoo pigment,[296,375]
a cutaneous manifestation of immune compromise,
increased vasoactivity, and increased cytokine/CD4
lymphocytes/adhesion molecular synthesis. The
term “isotattootopic” has been proposed to refer to an
isomorphic or isotopic skin reaction at a tattoo site.
In one report, a patient developed guttate psoriasis
after starting penicillin for strep throat, which persisted
despite two courses of amoxicillin. This mechanism
was hypothesized to involve T‑cell activation against
endogenous keratin isotopes that mimic streptococcal
antigens. Subclinical inflammation of the tattoo
was thought to explain the reaction in a tattoo that
had been asymptomatic since placement 7 months
earlier. It is important to note that the appearance
of Koebner reaction (e.g., “Koebnerization”) may
merely be revealing otherwise subclinical psoriasis
or a predisposition to psoriasis.[296,375] As it can be
difficult to establish causality in some cases, the
possibility of coincidence is worth considering in
patients whose reaction did not start in a tattoo or
show a preference for it. Interestingly, one patient with
a previously known history of psoriasis was re‑tattooed
a month after his tattoo‑associated outbreak started
but did not develop another outbreak. In another
paradoxical case, a reaction occurred while a patient
was taking methotrexate. Taken together, the
above peculiarities highlight the need for better
understanding of the Koebner phenomenon, as well
as factors that modulate this as yet nebulous entity.
Koebnerization of psoriasis on a tattoo should be
treated as one usually treats psoriasis. Treatments
outlined in the literature include systemic methotrexate
for a systemic reaction, over‑the‑counter 1% topical
hydrocortisone, topical fluticasone propionate,
triamcinolone acetonide, topical mometasone,
topical clobetasol, topical clobetasol propionate
and salicylic acid, and calcipotriene. One
patient with streptococcal‑induced guttate psoriasis
had improvement with hydroxyzine and topical
alclometasone and mometasone but noticed flares
after discontinuing amoxicillin therapy. Ultimately,
calcipotriene resulted in satisfactory improvement
Although not well described in the English literature,
a survey of psoriasis patients suggests that a
relationship between psoriasis and tattoos may not
be that uncommon. In fact, approximately 4.5%
of surveyed psoriasis patients with tattoos reported
developing psoriasis within weeks of tattooing.
Within this group, 75% had a history of Koebner
phenomenon. Accordingly, clinicians should
counsel psoriasis patients about the risks associated
with tattooing. Patients with a history of Koebner
phenomenon and those with active psoriasis at the time
of tattooing may be at increased risk of developing
tattoo psoriasis.[292,379] If the patient decides to
proceed with tattooing, they should be encouraged
to follow‑up for treatment of any flare‑ups.
Vitiligo has been reported in association with
tattoos. In one case, a patient presented 2 months
after cosmetic eyebrow tattooing with depigmentation
of the eyebrows, forehead, and left lower extremity.
She was diagnosed clinically with nonsegmental
vitiligo, presumably induced by tattooing. The
temporal relationship, as well as the fact that most of
the lesions appeared over the tattoos, suggests causal
association. This is supported by the fact that the
Koebner phenomenon (e.g., the formation of psoriatic
lesions in uninvolved skin of psoriatic patients after
trauma) can be seen in vitiligo. The simultaneous
appearance of lesions outside the boundaries of the
tattoo as well as distant from the tattoo suggests
that a systemic reaction may be involved, possibly
similar to lichenoid reactions, sclerosing reactions, or
reactions to LTR. The most likely explanation is the
presence of a multifactorial response which includes
local effects of tattoo pigment and/or trauma as
well as a systemic immune/inflammatory response
in a predisposed patient. In effect, it may be that
Petrochko, et al.: Tattoo‑associated complications
International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019 39
the tattoo actually “reveals” the vitiligo rather than
“inducing” it. The treatment and outcome were
not specified for the above‑mentioned case. Of
note, micropigmentation (a procedure similar to
tattooing) can be used to cover patches of vitiligo and
KELOID SCAR FORMATION
Keloids are rare in tattoos, although isolated
cases have been reported.[45,317] These lesions
extend beyond the site of injury (e.g., the affected
tattoo area), which helps differentiate keloids from
hypertrophic scars (which generally do not extend
beyond the tattoo). An example of such esthetically
pronounced scars is provided in Figure 6. In one
case, a keloid appeared after the patient was burned
at the tattoo site during a laser procedure for hair
removal. Causation is not assumed in this instance,
and the keloid is more likely to be a complication of
the burn, as opposed to a direct consequence of the
tattoo. The other case developed after tattooing, with
the keloid pattern appearing to follow the design of
Milia, or small superficial epidermal cysts, are
common and have occasionally been reported to occur
on tattoos. Presentation may include a pruritic
or asymptomatic rash over a tattoo that occurs
within a few months of tattoo placement. Physical
examination shows small (1 mm) papules distributed
throughout a tattoo[310,381] or throughout a single
These milia can be primary or may occur due to
traumatic implantation of epithelium or disrupted
follicular structures. As milia have been reported to
occur following trauma and needle biopsy, it can be
hypothesized that a similar mechanism causes tattoo
milia. The presence of milia throughout multiple
colors of two out of the three tattoos[310,381] supports
the traumatic etiology, but the preference for red areas
of one tattoo invites speculation as to a possible role
for the specific ink. While one patient had milia
strictly limited to the red areas of the tattoo, it seems
likely that the primary lichenoid reaction was limited
to the red areas and the lichenoid reaction gave rise
to the milia (a recognized phenomenon). Given this
association between milia and lichenoid reactions,
it has been proposed that a lichenoid or other reactive
process could be involved in the development of milia
in patients without an overt lichenoid reaction.
Treatments for tattoo milia include urea cream plus
salicylic acid. Spontaneous resolution may occur.
Other treatments of milia that were not specifically
used on tattoo milia include electrodesiccation,
laser ablation, or topical retinoid therapy.
Sclerosing tattoo reactions have been reported.[308,313,383]
As with many tattoo reactions, the presentation tends
to be nonspecific and included pruritus[308,313,383]
and inflammation[308,313,383] over the entirety of a
multicolored tattoo or just over the red areas.[308,313]
One patient failed antibiotic therapy for presumed
cellulitis before a biopsy revealed the true nature of
the lesion. All three patients lacked examination
findings suggestive of systemic scleroderma,[308,313,383]
and no history of scleroderma was given for any
patient. Given the lack of evidence of systemic disease,
these lesions were referred to as “morphea‑like” or
The sclerosis is thought to be a response to chronic
inflammation induced by the tattoo pigment.[308,383]
Histologic findings of decreased/fragmented elastic
fibers in the lesion of one patient support the nonspecific
sclerosing response over a systemic disease. Of
interest, parallel to one patient’s main sclerosing
tattoo reaction, a distant tattoo that had been
performed previously to the sclerosing tattoo became
pruritic. This suggests that local hypersensitivity
can provoke a systemic reaction, such as lichenoid
tattoo reactions, vitiligous tattoo reactions, or
Figure 6: An example of keloids associated with the upper back/
shoulder tattoo. Credit: Wikimedia Commons/Dr. Michael H. Tirgan
Petrochko, et al.: Tattoo‑associated complications
40 International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019
reactions to LTR. One patient’s biopsy suggested
features of lupus erythematosus. Treatments
included betamethasone dipropionate ointment,
intralesional triamcinolone acetonide, and topical
SK has been reported following tattooing.[315,329]
Small, uniform papules appear over multiple colors
of a tattoo several months or years after the tattoo is
placed.[315,329] Diagnosis is confirmed via biopsy,
likely because SK can be difficult to differentiate
from HPV. The mechanism for SK in tattoos is
not well understood, although it has been proposed
that SK and HPV lesions exist on a spectrum,
or that HPV may play a role in the development of
nongenital SK. One patient improved with CO2
laser treatment, and treatment was not discussed
for the other patient.
CHRONIC FIBROSING VASCULITIS
Chronic fibrosing vasculitis on a tattoo has been
reported once in the medical literature that we
could find. A patient presented with hyperkeratotic,
verrucous plaques localized to red areas of a tattoo that
occurred a month after the tattoo was placed. The
patient had several prior tattoos using the same red ink
without a reaction, and the patient’s friend received a
tattoo with the same ink on the same day as the patient
without a reaction. Biopsies showed chronic fibrosing
vasculitis and Candida parapsilosis, the latter of which
was considered to be a secondary infection. This
reaction was theorized to be due to a futile attempt
by the immune system to clear an antigen (the
tattoo pigment) involving a type 4 hypersensitivity
reaction. Treatment was not indicated beyond “an
excisional biopsy of the plaques was performed”
and the further outcome is unknown.
Leukocytoclastic vasculitis (LCV) has been reported
in association with tattooing several times, presenting
several weeks after placement or touch‑up of a tattoo in
one of two ways: either as an erythematous excoriated
rash, or as a multitude of red/purple purpuric[321,332]
lesions. Either presentation may be pruritic.[332,386] The
excoriated, erythematous rash was limited to the red
ink of the multicolored tattoo, while other two
patients had more widespread/generalized lesions and
constitutional symptoms. One of the generalized
cases had a clear preference for the tattoo, while
the other did not and was likely assumed to be
related to the tattoo due to temporality. In all cases,
the diagnosis was made via biopsy.[321,332,386]
The mechanism of LCV is not completely understood,
and the etiology of tattoo‑associated LCV is an
area of active debate,[387,388], but hypotheses include
hypersensitivity to ink [Figure 7][321,332,387] and
infection. The case of generalized LCV without a
preference for the tattoo had cellulitis over some of the
lesions, but it is unclear whether the LCV or the
infection came first. The preference of one case for the
red tattoo ink supports a local role for specific inks,
while the more generalized reactions that occurred
with constitutional symptoms point toward a more
generalized systemic response. It seems possible that
tattoos could cause LCV via two distinct mechanisms
resulting in two distinct clinical presentations.
Treatment and outcome were not specified for
the localized case. The generalized case that
showed a preference for the tattoo was treated with
IV corticosteroids transitioned to prednisone and
colchicine with the improvement of skin lesions and
arthralgias at 4 weeks. However, the previously
healthy patient still required crutches for ambulation at
4 weeks. The generalized case without a preference
for the tattoo was treated with oral cephalexin and
prednisone, antiseptic baths, and topical mupirocin
which showed improvement in all lesions within a
Tattoo blow‑out is a phenomenon that is likely
underreported. Patients will present with tattoo ink
that has formed a “blurry halo”[322,323,389,390] outside of
the desired image. The process starts within days
Figure 7: An example of hypersensitivity specific to red tattoo
pigment (left) with long‑term appearance of telangiectasia and mild
atrophy. Credit: Wambier, et al. An Bras Dermatol 2017;92 (5):748‑750.
Images used under the terms of the Creative Commons Attribution
Non‑Commercial License which permits unrestricted non‑commercial
use, distribution, and reproduction in any medium provided the original
work is properly cited
Petrochko, et al.: Tattoo‑associated complications
International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019 41
of having the tattoo placed,[323,390] and most patients
do not report symptoms.[322,323,389,390]
The mechanism is thought to be migration of tattoo
ink that has been accidentally injected too deeply,
beyond the dermis.[322,389,390] Once in the hypodermis,
it migrates via an unknown mechanism that could be
wicking, fascial spread, lymphatic spread, or
vascular spread. This mechanism would explain the
predominance for female patients (whose skin tends to
have a thinner dermis than men) and locations on
the body with thinner skin, such as the dorsum of
the foot[323,390] and inner surface of the upper arm.
The chemical properties of the ink,[322,389] gravity,
and excessive ink may also affect the extent of
the “blow‑out.” Biopsies, when performed, show no
vascular or lymph involvement, and may show the
ink deeper than expected.
QS‑Nd:YAG laser therapy has been used successfully,
with good cosmetic result.[323,390] One patient failed
laser therapy, although he only underwent one
session, as opposed to nine and two. Four years
after the one session of laser therapy, the blow‑out
persisted but had not changed significantly.
Although edema following tattooing was reported
as a TRC in a large multi‑national survey (n = 3,411
participants), there was only one report of two
patients available in the English medical literature.
Both patients presented with localized edema, one
of which was erythematous and painful, while the
other was painless. One patient presented 10 days
after tattooing and the exact timeline was not
reported for the other patient. One patient had
been tattooed many times before (including on the
contralateral leg) but had not had an edematous
reaction before. Both were initially diagnosed with
cellulitis, which was thought to be incorrect due to
delayed onset and absence of fever/chills/cutaneous
inflammation in the asymptomatic patient, and
absence of fever/lymphangitis/local lymphadenopathy
with normal white blood cell/C‑reactive protein,
erythrocyte sedimentation rate, and blood cultures in
the patient with painful erythema. The ultimate
diagnosis was “sterile inflammatory edema.”
The edema is thought to be due to the acute
inflammatory reaction that occurs at the time of the
procedure, and resolves as the wound heals within
several weeks. A plane ride 48 h after the patient
without prior tattoo reactions was tattooed could have
contributed to the edema.
Both were initially misdiagnosed with cellulitis, and
one was given antibiotics. The antibiotics were
discontinued, the other patient was given paracetamol,
and both patients recovered with no further treatment
beyond a recommendation to rest and avoid sitting/
standing. Clinicians should be aware of this
phenomenon in order to avoid misdiagnosing the
reactions as cellulitis and/or ordering unnecessary
antibiotics and tests.
Much of this paper has been spent discussing
diseases and reactions surrounding tattoos, but it is
also important to mention an uncommon “sparing
phenomenon” that has occurred with tattoos. Also
called the “reverse Koebner phenomenon,” skin
diseases have been known to spare sites of injury,
including tattoos. Interestingly, both cases of this
phenomenon were related to palpable, reddish/purple
purpuric lesions mostly on the lower extremities. One
patient developed the lesions on day 5 of a hospital
admission for multifocal pneumonia but was unable
to comment on symptoms as he was intubated in
the ICU due to respiratory failure. The tattooed
areas as well as a well‑defined 2–3 cm halo around
each of the two separate tattoos was spared.
A biopsy was consistent with LCV. The other
patient presented to the ED with the skin lesions
and constitutional symptoms. Although some of
the lesions overlapped the tattoo slightly, none of the
lesions were centered on the tattoo. A quantitative
analysis showed that this was unlikely to have occurred
by chance. The lesions were thought to be LCV
but no biopsy was performed.
The reverse Koebner phenomenon is poorly
understood,[266,319] likely in part because it is so
uncommon. The mechanism for the first patient’s
response was hypothesized to be related to the
presence of toothpaste in his homemade tattoos, as
fluoride has been shown to have an effect on immune
function. Similarly, the second patient’s response
was thought to be due to hamamelitannin, a potentially
anti‑inflammatory chemical found in a type of witch
hazel used to create the tattoo ink. Dissimilar from
tattooing, the reverse Koebner had also occurred
when psoriasis or LCV spared an area that
Petrochko, et al.: Tattoo‑associated complications
42 International Journal of Academic Medicine | Volume 5 | Issue 1 | January-April 2019
pressure had been applied to, possibly due to decreased
blood flow and subsequently decreased deposition of
immune complexes. Although the pressure‑related
sparing phenomenon is also identified as a reverse
Koebner phenomenon, it is possible that multiple,
distinct mechanisms can all result in a common clinical
presentation. As the reverse Koebner phenomenon
is neutral or if anything, beneficial, the patients with
tattoo‑related reverse Koebner phenomenon did not
require any treatment for it.
MAGNETIC RESONANCE IMAGING‑ASSOCIATED
Burns associated with tattoos and MRI are fortunately
very rare, with fewer than 20 documented cases.
Untoward effects range from a slight tingling
sensation to burning pain.[394,395] In more severe
cases, first‑ and second‑degree burns have been
described. Although permanent sequalae secondary to
the burns have not been reported, completion of an
MRI examination can be challenging or impossible.
Mechanistically, the magnetic field is thought to
induce an electrical current within the heavy metals
of the tattoo pigment, giving off heat in a manner
similar to an induction stove. Tattoos with loop
patterns and ink containing iron oxide are considered
“high risk” for this occurrence. Of note, this effect
is rare even in such “high‑risk” tattoos. Nevertheless,
there has been a reported case of a burn in a tattoo
that did not contain iron oxide and likely did not
feature a loop.
The current guidelines recommend screening patients
for tattoos, including permanent makeup and
instructing the patient to inform the technologist
immediately if they notice a tingling or burning
sensation during the MRI examination. If
alternative imaging modalities are not appropriate,
applying a cold compress or wet towel may prevent
the rise in temperature and alleviate pain to a
tolerable level, thus facilitating the completion of
the MRI with no permanent sequelae. Resection
of the tattoo can also be considered to allow MRI
completion, but this option is very aggressive and
impractical (especially for larger tattoos).
The domain of TRCs, as evidenced in previous sections
of this review, is both vast and complex. Additional
topics that are beyond the scope of the current review
but may warrant a brief mention include pyoderma
gangrenosum following tattoo placement,[400,401] less
commonly reported TRCs of laser therapy, as well as
psychosocial and financial aspects of tattoo placement,
The many complications of tattooing are fascinating
and require a significant amount of expertise
spanning various specialties including infectious
disease, dermatology, immunology, rheumatology,
pathology, surgery, and epidemiology. The overarching
theme of this review is the need for better awareness
of TRCs, coupled with appropriate education of
patients, health‑care providers, and tattoo artists.
Primary prevention of TRCs should be the ultimate
goal; however, excellent knowledge of management
approaches specific to each TRC should be emphasized
given the significant heterogeneity of clinical
presentations and treatments alike. More systematic
study of TRCs will improve the care afforded to
tattooed patients and provide an excellent opportunity
for specialists from different fields to work with and
learn from each other. Of importance, TRCs often
constitute unique presentations of known diseases and
researching them may help elucidate their mechanisms,
many of which are incompletely understood. Finally,
the authors would like to emphasize the need for a
centralized reporting mechanism for TRCs. Such
infrastructure will be instrumental in improving the
safety of tattooing, an important aspect of managing
the continuous growth of this increasingly socially
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Ethical conduct of research
This manuscript represents a literature review.
Consequently, institutional board review was not
required before conducting/publishing our findings.
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