Associated Health Risks
Tattoos
The most common complications that result from tattooing are skin infections and allergic reactions to the tattoo ink. Extensive skin puncturing can result in bleeding and prolonged leaking of serosanguinous fluid. Pyodermal infections can include temporary inflammation at the site of needle puncture, superficial infections such as impetigo and ecthyma, and deeper infections such as cellulitis, erysipelas, and furunculosis [11]. Unsterile equipment and needles can transmit infectious diseases such as hepatitis [2]. Human immunodeficiency virus is theoretically transmissible this way, but no cases of HIV infection caused by tattooing have been documented [12].
Skin reactions to tattooing include aseptic inflammation and acquired sensitivity to tattoo ink, especially red ink, but also to chromium in green ink, cadmium in yellow ink, and cobalt in blue ink [13]. The reaction can manifest as either allergic contact dermatitis or photo-allergic dermatitis. Cutaneous conditions that localize in tattooed areas include vaccinia, verruca vulgaris, herpes simplex, herpes zoster, psoriasis, lichen planus, keratosis follicularis (Darier disease), chronic discoid lupus erythematosus, and keratoacanthoma. Other possible but less common conditions include keloid, sarcoidal granuloma, erythema multiforme, localized scleroderma, and lymphadenopathy [12].
A recent outbreak of nontuburculous nycobacterial infection was linked to contaminated tattoo inks [14]. Contamination can occur during the manufacturing process due to use of contaminated ingredients or when inks are diluted with nonsterile water by tattoo artists [15]. Investigations of 22 cases of tattoo-associated NTM skin infections in 4 states that occurred during 2011–2012 found that ink was contaminated with NTM before use [16]. M. chelonae, one of several disease-causing NTM species, can cause lung disease, joint infection, eye problems and other organ infections. These infections can be difficult to diagnose and can require treatment lasting 6 months or more [15].
Tattoo laws and regulations vary by state. The inks and ink colorings (pigments) used for tattoos are subject to regulation by the US Food and Drug Administration as cosmetics and color additives. However, the FDA has not traditionally enforced its authority over tattoo inks. The FDA encourages reporting of tattoo-associated complications to its MedWatch program (www.fda.gov/Safety/MedWatch/).
Malignancies reported to develop within tattoos include squamous cell carcinoma, basal cell carcinoma, malignant melanoma, leiomyosarcoma, and dermatofibrosarcoma protuberans [17,18]. These malignancies may be coincidental, but carcinogenicity of the tattoo is as yet unknown. Another concern is that a malignancy within a tattoo is more difficult to identify on skin examination [11,17].
Rarely, tattoos or permanent makeup might cause swelling or burning in the affected areas during magnetic resonance imaging (MRI) exams. The metallic ferric acid pigments used in tattoos can conduct heat on the skin during MRI, resulting in traumatic burns [19]. This has also been reported to occur with tattoos with nonferrous pigments. In some cases, tattoo pigments can interfere with the quality of the image, such as when a person with permanent eyeliner has an MRI of the eye [19].
Patients may self-administer tattoos using sewing needles, forks, paper clips, or pens, and colorants may include charcoal, soot, mascara, or ink. The use of unprofessional tattooists and piercers, who often have limited knowledge of health and hygiene precautions, is more likely to lead to complications [10].