Cosmetic tattooing, also known as micropigmentation or permanent makeup, is a technique in which tattooing is performed to address cosmetic skin imperfections. It is often used to create eyeliner or lip liner, but it can also be used to camouflage stable patches of vitiligo, to create eyebrows on those who have lost them due to alopecia areata or chemotherapy, to create areolas for women who have had mastectomies, or to correct the shape of a reconstructed cleft lip. Cosmetic tattooing is also useful in women who want to wear makeup, but who have trouble applying it due to visual deficits, tremor, stroke, multiple sclerosis, or Parkinson’s disease.
In Asian cultures, cosmetic tattooing is not uncommon. Many women have cosmetic tattooing procedures to create permanent eyeliner and eyebrows, since many Asian women have sparse brows at baseline that often become thinner with aging. Cosmetic tattooing of eyeliner also enhances the natural almond shape of the eyes.
In darker ethnic skin types, where vitiligo is more visible, stable patches can be effectively camouflaged by cosmetic tattooing. However, cosmetic tattooing is not recommended unless these patches have been stable for several years and the patient has failed other therapies. The best candidate would be the darker-skinned patient with long-standing segmental vitiligo, for whom pigment grafting would also be highly considered.
Individuals who wish to perform cosmetic tattooing can receive training and certification in micropigmentology. Many also undergo apprenticeships to receive more hands-on training. I have firsthand knowledge of this process because my mother received this training and performed cosmetic tattooing on her clients when I was growing up. Good training is key, as not every tattoo ink will have the same result in every skin tone. For example, brown eyeliner might eventually turn pink on skin that has a red undertone. On someone with yellow undertones or olive skin, black pigment liner might turn greenish. So the experienced practitioner will often use different color hues depending on the person’s underlying skin color and tone to prevent this discoloration. The best results of cosmetic tattooing are achieved when others can’t tell that the work has been done.
Pitfalls with cosmetic tattooing, as with tattooing in general, include infection, allergic reaction to the tattoo ink, scarring, photocytotoxicity, and cosmetic disfigurement if the tattoo is placed improperly. Delayed granulomatous response has also been reported in cases of permanent eyebrow tattooing. In addition to typical skin infections caused by staphylococcus or streptococcus, cases of mycobacterium infection with tattooing have been reported (although such infections have been reported more often with traditional tattooing than with permanent makeup).
Red ink is the more commonly reported allergen. Titanium dioxide (TiO2) is widely used in tattoo inks to achieve certain colors. When TiO2 is exposed to certain wavelengths of light, including UV light and certain lasers, hydroxyl radicals can form, leading to photocytotoxicity (also called paradoxical darkening), which often results in a change or darkening of the pigment color. This condition is more common with pink, peach, or white tattoo colors where TiO2 is used in the color. Q-switched lasers are the most effective at removing tattoos.
If performed correctly by a properly trained person, cosmetic tattooing can be a useful aesthetic solution to various cosmetic and medical skin concerns.
This column, "Skin of Color," regularly appears in Dermatology News, a publication of Frontline Medical Communications. Dr. Wesley practices dermatology in Beverly Hills, Calif.
Do you have questions about treating patients with dark skin? If so, send them to sknews@elsevier.com.