Medical Complications of Tattoos

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ABSTRACT
Decorative tattooing involves the process of inserting external pigments and/or dyes into the dermis to create a permanent design. Tattooing
is an application that has been widely practiced worldwide since ancient times. The popularity of permanent decorative skin tattooing has
increased over the past thirty years. It will increase in patients with tattoo complications who apply to dermatologists due to the increase
tattooing. Although tattooing is mostly for entertainment purposes, it can also be used for aesthetic and medical purposes. Although
complications have decreased in modern, professional tattoos, these tattoing procedures may be associated with a wide variety of cutaneous
and extracutaneous complications. Herein, we review the complications that can occur after tattooing, based on a comprehensive review of
the literature. This review ensures an overview of the current aspects of medical complications associated with permanent tattooing based
on previous reviews, studies, case series and related case reports.
Keywords: Tattoo, Complication, Adverse reaction, Pigment, Cancer
Selami Aykut Temiz1, Emin Özlü2
Medical Complications of Tattoos
J Turk Acad Dermatol 2021;15(1):1-7
DOI: 10.4274/jtad.galenos.2021.02486
REVIEWREVIEW
1Konya Eregli State Hospital, Clinic of Dermatology, Konya, Turkey
2Duzce University Faculty of Medicine, Department of Dermatology, Duzce, Turkey
Ad dress for Cor res pon den ce: Selami Aykut Temiz MD, Konya Eregli State Hospital, Clinic of Dermatology, Konya, Turkey
Phone: +90 535 843 00 68 E-mail: aykutmd42@gmail.com ORCID ID: orcid.org/0000-0003-4878-0045
Received: 06.08.2020 Ac cep ted: 04.01.2021
©Copyright 2021 by the Society of Academy of Cosmetology and Dermatology / Journal of the Turkish Academy of Dermatology published by Galenos Publishing House.
Introduction
Decorative tattooing involves the process of inserting external
pigments and/or dyes into the dermis to create a permanent design
[1]. Tattooing is an application that has been widely practiced
worldwide since ancient times. The popularity of permanent
decorative skin tattooing has increased over the past thirty years. In
Western countries, 10% of the general population has skin tattoos,
while 25% between the ages of 18-50 have tattoos [1]. It will increase
in patients with tattoo complications who apply to dermatologists
due to the increase tattooing.
Although tattooing is mostly for entertainment purposes, it can also
be used for cosmetic purposes (permanent eyebrows in alopecia
areata, etc.). Some tattoo applications for aesthetic and therapeutic
purposes (medical) are given in Table 1. Tattooing is done by inserting
pigments and dyes into the dermis [2]. Tattoo inks have changed in
recent years, with metal salts that were previously used frequently,
replaced by azo pigments, an industrial pigment [3]. Azo pigments
are preferred because of their more vivid colors and longevity.
Although cutaneous reaction is less common in azo pigments, the
long-term safety of these pigments is largely unknown. Møller and
Wallin [4] evaluated azo pigments as genotoxic and carcinogenic.
The modern professional permanent tattoo process typically
involves repeated injection of ink into the dermis using an
electrically powered tattoo machine that can pierce the skin 3,000
times per minute. In professional tattoo parlors, items that come
into contact with customers and potentially contaminate are
usually disposable or autoclaved before each use [3]. Although
complications have decreased in modern, professional tattoos,
these tattooing procedures may be associated with a wide variety of
cutaneous and extracutaneous complications [5].
In this review, we examined the cutaneous and systemic
complications of tattooing (although they may intertwine from time
to time, for example malignant melanoma (MM) can be classified as
both a cutaneous and systemic complication) separately.
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Temiz and Özlü. Complications of Tattoos

J Turk Acad Dermatol 2021;15(1):1-7Temiz and Özlü. Complications of Tattoos
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1. Cutaneous Complications of Tattooing
The frequency of cutaneous complications related to tattooing is
not clearly known. There are studies reporting the prevalence of
complications between 2% and 43% [6,7,8]. In a survey conducted
with tattooed people, it was found that 42.6% complained about
their tattoos. The three most common of these complaints are; wax
and waning swelling (57%), transient itching (45.7%) and swelling
after sun exposure (23%) [8]. However, it may not be the right
approach to evaluate all these complaints as pathological. We think
the same that this type of cutaneous complaints should not be
considered as a complication since it is an expected side effect in
many tattoos.
There is no single classification of post-tattoo cutaneous
complications and they have been classified in various ways in
the literature. For example, they can be classified according to
their clinical pathology (infection, hypersensitivity, etc.) as well as
acute and chronic reactions [1]. In this review, we tried to classify
cutaneous reactions according to their clinical types. In Table 2, we
classified all post-tattoo cutaneous reactions in the literature.
Pyogenic Cutaneous Infections
Local disinfectants are generally not applied during tattooing, so
failure to follow asepsis rules during or after the tattoo session
increases the risk of infection [1]. After tattooing, acute superficial
and deep pyogenic infections (folliculitis, acne varioliformis,
impetigo, furunculosis, ecthyma, erysipelas, cellulitis, etc.) may
occur [9]. Cutaneous pyogenic infections generally develop in
association with Staphylococcus aureus, Streptococcus pyogenes,
Corynebacterium, Pseudomonas, Clostridium and Klebsiella can be
detected as causative agents. Such complications can be reduced
with hygiene measures and modern aseptic tattooing techniques.
However, tattooing procedures that do not comply with hygiene and
asepsis rules can lead to dramatic consequences that can progress
to deep cutaneous abscesses and necrotizing fasciitis [9]. Cutaneous
pyogenic infections usually develop within days to weeks after the
tattooing procedure. The management of post-tattoo pyogenic
infections is not different from any other pyogenic infections.
Although serious and deep cutaneous infections have decreased
significantly with modern tattooing methods, several serious cases
of polybacterial cellulitis, necrotizing fasciitis and septicemia have
recently been reported from New Zealand [10]. It is observed
that such serious infections are generally not complied with
the acepsis conditions and especially in traditional tattooing.
Immunosuppressive patients are more inclined to such serious
cutaneous infections. Tendas et al. [11] reported the fatal case
of a 26-year-old man with a history of acute myeloid leukemia
developing a large skin ulcer after tattooing. Before the tattooing
procedure, the medical and drug history of the patients must be
questioned.
Viral Cutaneous Infections
Viral contamination during tattooing is thought to be due to the
presence of viral pathogens in the tattoo ink and tattoo needle [12].
Cutaneous viral infections due to human papilloma virus, herpes
simplex virus and pox virus (molloscum contaginosum etc.) have
been reported association with tattooing [2,12].
Fungal Cutaneous Infections
Fungal contamination during tattooing is thought to be due to
the presence of fungal pathogens in the tattoo needle. Cases of
superficial tinea infection infected with trichophyton rubrum and
epidermophyton floccosum have been reported association with
tattooing [2,13]. It has also been defined as a tattoo complication in
a case of zygomycosis, which is a rare mycotic infection [14].
Table 1. Tattoo applications for aesthetic and therapeutic purposes (medical)
Medical situations The purpose of tattoo usage
Patients receiving cancer radiotherapy It can be used to properly align the radiotherapy treatment areas
Patients undergoing endoscopic surgery It can be used to mark surgical intervention areas in patients before
endoscopic gastrointestinal surgery
Tattooing for medical alert purposes
- Diabetic patients using insulin
- Patients with allergies and anaphylaxis
- Patients with Alzheimer’s disease
Patients with corneal pathology It can be used for monitoring corneal pathology
Patients with reconstructive breast surgery It can be used three-dimensional tattooing of the areola and nipple after
surgery
Patients with alopecia It can be used to camouflage the areas with hair loss (especially
eyebrows)
Patients with vitiligo It can be used to camouflage areas with pigment loss
Patients with hemangioma, Klippel-trenaunay or weber syndrome It can be used to camouflage areas with vascular pathology

J Turk Acad Dermatol 2021;15(1):1-7 Temiz and Özlü. Complications of Tattoos
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Mycobacterial Cutaneous Infections
Mycobacterial agents are common in nature and are highly resistant
to disinfection methods [15]. Tattoo ink is a usual suspect in terms
of growth and contamination of mycobacterial infectious agents
[3]. Cases of cutaneous tuberculosis (tuberculosis verrucosa cutis,
primary inoculation tuberculosis, lupus vulgaris, scrofuloderma),
atypical mycobacterial infections and leprosy have been reported
association with tattooing in the literature [3,15,16,17,18].
Allergic Disorders
Hypersensitivity reactions (or allergies) to tattoo inks are the most
common complications after tattooing. In addition, it is often not
possible to predict and prevent these complications [5]. The biggest
fear of permanent tattooing is these unpredictable allergic reactions.
Allergic Dermatitis
After tattooing, the type 1 allergic reactions and anaphylaxis are
very rare [19]. Usually a type 4 (delayed type) allergic reaction
develops [20]. In post-tattoo care, moisturizers and dexpanthenol
are often used, such as wound care [21]. Any topical agent used in
post-tattoo care can cause allergic contact dermatitis [22]. Localized
hypertrichosis has also been observed in some cases following this
contact dermatitis in the literature [23].
Urticaria
Urticarial reactions can be triggered, especially by rubbing the
blue-black tattooed areas [24]. Isolated urticaria and urticaria-
angioedema cases after tattoo have been reported in the literature
[25,26].
Photoallergic Reaction
Tattoos with yellow pigment containing cadmium sulfide are
blamed for photodermatoses. In addition, cadmium sulfide can be
found in minimal amounts in tattoos containing red color [2].
Granulomas
Like other exogenous materials injected into the skin, tattoo
pigments can be perceived as foreign bodies for the body and
cause granulomatous reactions [27]. Foreign body and sarcoid type
granulomatous tattoo reactions constitute the majority of cases [3].
A definitive diagnosis by punch skin biopsy and histopathological
examination is important. Because, any granulomatous reaction
can be indicative of the underlying idiopathic sarcoidosis [6].
Sarcoid Granulomas
Sarcoidosis is an autoinflammatory condition of unknown cause,
characterized by non-caseating epithelioid granulomas that can
involve the skin and internal organs [28]. Sarcoidal granulomas that
can develop from scars (scar sarcoid) and can also arise secondary
to foreign matter, including tattoos, have often been reported in the
literature [27,29]. The relationship of sarcoidal reactions to tattoos
is unique, with tattoo reactions typically presenting as papules,
nodules or plaques that are usually confined to tattooed area
[30]. The onset of skin lesions may develop weeks or even decades
after tattooing, the red pigment being responsible most often [31].
Patients with pre-existing sarcoidosis should be advised to avoid
tattooing.
Table 2. The post-tattoo cutaneous complications
Cutaneous
infections
Pyogenic infections
- Impetigo contagiosa
- Acne varioliformis
- Ecthyma
- Erysipelas
- Cellulitis
Viral infections
- Verruca vulgaris
- Herpes simplex virus infections
- Molluscumcontagiosum
Fungal infections
- Superficial tinea infections
- Zygomycosis
Mycobacterial infections
- Tuberculosis verrucosa cutis
- Atypical mycobacterial infections
- Primary inoculation tuberculosis
- Leprosy
Allergic disorders
Allergic dermatitis
Urticaria
Photoallergic reaction
Granulomas
Sarcoid granulomas
Allergic granulomatous reactions
Keloid scars
Foreign body granulomas
Skin disease
localized in
tattooed area
Psoriasis
Vitiligo
Lichen planus, lichen planus pemphigoides
Pseudolymphoma
Atopic dermatitis
Pyoderma gangrenosum
Darier’s disease
Perforating dermatosis
Eruptive xanthomas
Granuloma annulare
Necrobiosis lipoidica
Miliums
Epidermoid cysts
Lichen sclerosus
Morphea
Discoid lupus erythematosus
Neoplasms
Basal cell carcinoma
Squamous cell carcinoma
Melanoma
Dermatofibroma
Dermatofibrosarcoma protuberans
Pseudoepitheliomatous hyperplasia

J Turk Acad Dermatol 2021;15(1):1-7Temiz and Özlü. Complications of Tattoos
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Allergic Granulomatous Reactions
Allergic granulomatosis responses are difficult to treat reactions to
the dye pigment of the tattoo. The most risky color pigment for this
reaction is red, while the safest color pigment is black [6].
Keloid Scars
Mild fibrosis is usually seen as a result of the trauma of the tattoo
needle. Hypertrophic scar or keloid scar development may occur
in individuals susceptible to tattoos. It is very difficult to predict
this complication. This risk increases in areas such as the chest,
shoulders and upper arms, and in tattoos with damaged needles or
poor quality needles [32]. Nevertheless, this complication can occur
in any application and any localization.
Foreign Body Granulomas
Foreign body granulomas are relatively common after tattooing and
are characterized by pigment-laden foreign body-type giant cells.
The first-line approach is a trial of superpotent topical steroids or
intralesional corticosteroids. In most cases, the reaction can regress
over time [33].
Skin Disease Localized in Tattooed Area
Dermatoses that can develop after tattooing are quite common [34].
In many skin diseases known to develop Koebner phenomenon
(e.g. psoriasis, vitiligo and lichen planus etc.), post-tattoo activation
and active disease development in the tattoo area can be observed
[35]. Also, skin diseases with skin trauma in the etiology (e.g.
pseudolymphoma, pyoderma gangrenosum, granuloma annulare,
milium and epidermoid cyst etc.) can also develop after tattooing.
In the literature, psoriasis, vitiligo, lichen planus, pseudolymphoma,
atopic dermatitis, pyoderma gangrenosum, Darier’s disease,
perforating dermatosis, eruptive xanthoma, granuloma annulare,
necrobiosis lipoidica, milium, epidermoid cyst, lichen sclerosus,
morphea and discoid lupus erythematosus has been reported as
post-tattto skin diseases [2,5,6,34,35,36,37,38]. Patients with a
history of skin disease in their medical and family history should
be informed that their illness may flare before getting the tattooing.
Management of skin diseases on tattoos does not differ from non-
tattoo skin.
Laser epilation on tattooed areas requires special attention. Much
more laser burns and keloids may develop in laser hair removal
procedures performed on tattooed skin than normal skin [6].
Neoplasms
The relationship between tattoo and skin malignancies is controversy.
Some authors argue that this relationship is accidental, while others
draw attention to the potential carcinogenic effect of tattoo ink and
argue that this relationship is not accidental [3]. When the literature
is reviewed, there are many patient reports developing post-tattoo
basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and MM
[2,3,4,5,6]. Again in reports; while BCC and MM have been reported
to develop more frequently in black, dark blue or dark tattoos; SCC,
keratoacanthoma and benign pseudoepitheliomatous hyperplasia
have been reported to develop more frequently in red tattoos
[2,3,5,6,39].
The relationship between tattoo and MM is of particular importance
due to the mixing of pigmented lesions. MM cases occurring after
tattooing have been reported in many times. In addition, tattooing
causes difficulties in the diagnosis and treatment of MM. Tattooing
complicates the clinical and dermatoscopic examination of
melanocytic nevi [40]. Patients with multiple melanocytic lesions
should be advised to avoid tattooing, especially patients with
melanoma risk factors. Tattoo artists should be informed about
patients with multiple nevi, and these patients should definitely
meet with their dermatologists before tattooing.
In addition to all these negativities in melanocytic nevi, tattoos
can also cause negativities in patients who have already developed
melanoma. Pigment-loaded macrophages caused by tattoo pigment
can be confused with metastatic melanoma in the evaluation of
sentinel lymph nodes and cause unnecessary radical lymph node
dissection [41].
2. Systemic Complications of Tattooing
It is not always possible to divide tattoo complications into cutaneous
and systemic with a sharp margin [6]. Some complications may
start cutaneous and become systemic. In the literature, all systemic
complications reported after tattooing are shown in Table 3. In this
Table 3. The post-tattoo systemic complications
Systemic infections
Syphilis
Leprosy
Tetanus
Tuberculosis
Leishmaniasis
Endocarditis
Sepsis
Hepatitis B, C
AIDS
Psychosocial
complications
Depression
Internalized stigma
Dissatisfaction
Neoplasms
Basal cell carsinoma
Squamous cell carcinoma
Melanoma
Lymphoma
Other rare
complications
Uveitis
Vasculitis
Burning after magnetic resonance imaging

J Turk Acad Dermatol 2021;15(1):1-7 Temiz and Özlü. Complications of Tattoos
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part, we will only evaluate isolated systemic complications (we will
not repeat what we have examined in cutaneous complications
here).
In the literature, there are reported cases syphilis, leprosy,
tuberculosis, leishmaniasis, endocarditis, sepsis, hepatitis C,
hepatitis B and AIDS (HIV) after tattooing [2,3,5,6,42]. These systemic
infections are most frequently observed in conditions where asepsis
rules are not followed, such as traditional tattoos. Today, if the rules
of hygiene and asepsis are followed, the material is sterilized and
needles are not shared between customers, the risk of developing
these infections is considered to be absent [43]. Nevertheless, cases
have been reported in which these infections can develop more
easily and are fatal in immunocompromised individuals despite all
these antisepsis rules [42].
Tattooing is more common among adolescents and psychological
fluctuations are common in this period [44]. In some tattooed
people, regret due to getting a tattoo can go up to internal stigma
and depression over time [45]. In recent years, the interest of
researchers in the psychogenic effects of tattoos has increased
[46,47,48].
Clinically detectable lymphadenopathies can be seen due to the
migration of tattoo pigments to lymph nodes and is an expected
side effect. However, due to the carcinogenic effects of tattoo inks,
their contribution to the development of systemic lymphoma is
controversial [49]. Prospective controlled clinical trials are required
to enlighten the issue in terms of post-tattoo BCC, SCC, MM and
systemic lymphoma development. Although these devastating side
effects can often be controlled with treatment, they may require
excision of the tattooed area and serious immunosuppressive
treatments from time to time.
Rare complications such as uveitis and vasculitis have been reported
after tattooing in the literature [50]. Although such systemic side
effects are thought to be the result of sarcoidosis triggered after
tattooing, it has been reported in the literature in cases who
developed uveitis without sarcoidosis.
Also, complaints of burn in the tattoo areas have been reported
in tattooed patients after magnetic resonance imaging (MRI)
examination [6]. This situation is caused by the tattoo pigments
being affected by the magnetic field. This risk is higher in large
and dark pigment tattoos. In such risky patients, non-MRI imaging
methods should be preferred, if possible.
Conclusion
Tattoos can be complicated by a diversity of infectious, inflammatory
or neoplastic conditions. Over the years, complications have
changed course with the development of dyes and methods used
in tattooing. Cutaneous reactions are significantly reduced with the
use of azo dyes in tattoo pigments instead of metal salts and the
attention of tattoo artists to hygiene procedures. Hypersensitivity
reactions (or allergies) to tattoo pigments are currently the most
common complications in the tattooing. Unfortunately, it is not
possible to predict and prevent these reactions. Again, the potential
carcinogenic effects of azo dyes are not clearly known today. More
clinical studies are needed to further clarify the complications of
tattooing and to increase the knowledge.
It is important to raise more public awareness of tattooing and
its complications. Especially tattoo artists need to be aware of
tattoo complications and contraindications. Even the knowledge
of which patient to refer to the clinician before tattooing can be
vital for many complications. Patients with known skin diseases
should definitely consult their dermatologist and get information
about tattoo complications before tattooing. Patients with chronic
conditions and/or impaired immunity should discuss with their
physician about the complications of tattooing.
The management of tattoo complications must be done by
a dermatologist. Treatment of tattoo-related complications
is a specialized and experienced field that may include local
destructive measures (dermabrasion, chemical destruction,
cryotherapy, electro-surgery, ablative laser destruction), surgical
excision, and thermolysis of the pigment using Q-switched laser
therapy [51].
Ethics
Peer-review: Internally peer-reviewed.
Authorship Contributions
Surgical and Medical Practices: S.A.T., E.Ö., Concept: E.Ö., S.A.T.,
Design: E.Ö., S.A.T., Data Collection or Processing: S.A.T., E.Ö.,
Analysis or Interpretation: S.A.T., E.Ö., Literature Search: S.A.T., E.Ö.,
Writing: S.A.T., E.Ö.
Conflict of Interest: No conflict of interest was declared by the
authors.
Financial Disclosure: The authors declared that this study received
no financial support.
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