Tattoos have definitely gone mainstream. Anyone who has watched Survivor or watches MTV is well aware of the popularity of tattoos. Recently, I went with my family to the local amusement park and it seemed as if literally everyone there had a tattoo. I have had baby sitters with tattoos; a myriad of young patients, neighbors. Tattooing has a long and celebrated history, however, there are dermatology concerns that should be recognized if you are considering getting a tattoo.

Tattooing has been dated back to ancient Egypt, roughly 2000 years BEFORE the pyramids were built. They have been traced to many an ancient people. The Mayans were known to have tattoos, as were the Aztecs and Incas. The ancient Polynesians are thought to be most responsible for the distribution of tattooing. Ancient rites denoting tribal ranks and marital status incorporated tattooing. Tattoos were used in Rome to label slaves as well as criminals. Europe frowned upon tattoos during the dark ages, however with the discovery of the New World, exposure to island civilizations actively performing tattoo artistry made them desirable and highly sought after. Even King George V of England is reported to have had tattoos.

The term tattoo literally means to puncture the skin. Tattoo pigment is placed into the layer of skin known as the dermis. It is a permanent placement, although over time some of the colors may fade. Tattoos may be for artistry, cosmetic uses such as permanent cosmetics or reconstructive purposes. The use of tattooing for reconstructive issues includes that artistic replacement of the areola for some post-mastectomy patient. Tattooing of permanent makeup includes eyeliner, lip liner, full lip color, beauty marks, eyebrow restoration as well as scar camouflage.

How tattooing is performed:

As tattooing involves multiple punctures of the skin to instill pigment into the dermal layer, pain as well as some minor bleeding is involved. Because of this, the use of topical anesthetics such as LMX 4% Topical Anesthetic Cream - 15gm may be used to diminish the discomfort.

The use of topical liquid agents such as Monsels or Drysol, which stop the bleeding, may be used as a method of hemostasis.

A scab or shiny skin patch will form over the tattoo and will remain for approximately 3-7 days. Wound care is vital to prevent secondary bacterial infections, just like any open wound.

Recommendations:

Just because tattoos are not my favorite thing does not mean that the rest of the world necessarily agrees with me. However, from a medical point of view, here are some things to keep in mind to make this as positive an experience as you can:

Make sure the place is reputable, perhaps check with the health department to see if there have been past claims against the parlor in question if you still have doubts.

Check for these:

• Does the artist autoclave multi-use items? (This is the best way to sterilize instruments)
• Anything that is autoclaved for multiple use must be sealed and dated to ensure sterility.
• Does the artist use single-use sterile disposable needles and tubing?
• Does the artist throwaway leftover ointments, tray, razors, pigments, etc. after completing a tattoo? (Single-use items)
• Does the artist wear gloves?
• Are sterile techniques used during the tattoo process?
• Are needles disposed of in properly labeled containers?
• Does the artist wipe down surfaces with a viricidal/germicidal agent in-between clients?
• Has the artist been vaccinated for Hepatitis B?
• In other words, are Universal Precautions performed, just as they would (or should be) in a physician's office?
• From an artistic point of view, have you reviewed the artist's portfolio? Make sure that the tattoos have sharp lines and smooth edges?

Select a symbol you can live with for the rest of your life. Remember that tattoos are still somewhat out of the mainstream in the professional world can you picture yourself as a lawyer in the courtroom wearing a skirt with a dragon going up the entire length of your leg? Can you picture yourself at 80 with the tattoo you have in mind? You may laugh at these analogies, but young people choose many tattoos before they are really out in the professional work force, and this can present itself as a future issue for them. So can having a lover's name on your arm, particularly when you end up with someone else!

Consider selecting a body surface that is more private so that you can enjoy the tattoo.

Do NOT try to self-tattoo. These are the types that not only turn out to look crude in appearance, (remember good old pencil lead traumatic tattoos from childhood?), but also are far more difficult to remove down the road. The pigment is often deposited at irregular depths within the skin. You also stand a greater risk of developing an infection.

If any sign of infection (redness, oozing, streaking or the appearance of pus draining from the site, increased tenderness or the formation of an ulcer) is NOT a good thing. Get yourself to a dermatologist right away.

What's In Tattoo Ink?

The vast majority of tattoo pigments are derived from metals, which makes them a potential source for developing a skin reaction. Some pigments do have non-metallic options for those who have concerns or a past history of allergic reactions to these compounds.

Red is the color most commonly associated with reactions within a tattoo. Mercury is the base metal in red tattoo dye, and may be known by the names mercury sulphide, cinnabar, vermillion and red cinnabar.

Reactions within the tattoo may be eczematous or granulomatous. These reactions are often seen several years from the time the tattoo is placed and may be associated with exposure to cross reactants. These include such chemicals as thimerasol (a widely used preservative), mercurochrome and some vaccines that also contain thimerasol. For those with known thimerasol allergies who are set upon having red within their tattoos, there are a variety of non-metallic pigments that lend a red color to the skin such as carmine (derived from dried insect carcasses) and scarlet lake, sandalwood and brazilwood which are organic red pigments.

Another option, cadmium red is related to the metal family and may have potential reactivity and cadmium sulfide may be a byproduct within some red dyes which may result in a phototoxic swelling of the area when exposed to light.

Black is most commonly achieved from carbon. Sensitivity to carbon is rare. Other sources of black tattoo color may be found in black ink and logwood. Neither of these are metal derivatives, however, the black waterproof ink contains phenol solution in which charcoal particles are suspended and may be the source of other reactions.

Yellow is achieved from the use of Cadmium and is a common cause of reactions within tattoos. Not only may cadmium produce local or generalized eczematous reactions; it has also been associated with phototoxic reactions when exposed to light. Cadmium sulfide is the most common material used in yellow tattoo ink.

Blue dyes are derived from a variety of Cobalt salts and is notorious for deep granulomas as well as causing localized hypersensitivity reactions and a few reported cases of uveitis (an inflammation of the eyes). Light blue colors are also derived from cobalt and may again cause granulomas. Watch for the names cobalt blue and cobaltous aluminate that are terms for this blue pigment.

Green comes from Chromium and is a common cause of eczematous reactions both within the tattoo, as well as generalized eczematous reactions on the body. Chromium oxide has a variety of names including Chrome green, Casalic green and Guignet's green. These variations while mixed in different suspensions may all cause such significant and long term itching and other eczematous reactions that complete removal of the tattoo may be required. The allergic reaction may arise several years after the tattoo has been placed. Other shades of green such as emerald green are formed from another type of chromium salt called chromium sesquioxide (aka veridan) or copper salt derivatives.

Purple is derived from the metal Manganese which may cause the formation of tattoo granulomas.

Violet again comes from Manganese and may also result in granulomas.

Brown dye may be formed via the use of either Venetian Red which is derived from Ferric Oxide or from Cadmium salts, associated with phototoxic swelling upon exposure to sunlight.

White tattoos are achieved usually from titanium or zinc oxide or from the use of lead carbonates. These may have the potential to contain metallic derivatives.

New trendy colors I have seen in tattoos such as "hot" turquoise, pink, coral, etc. may also be potential allergens, depending upon the compounds mixed to achieve these colors. I have seen patients who are allergic to fluoroscene used to give some highlighter colors a neon appearance and this may also be used in some tattoo dyes, so take this into account as well. Should you have a past history of a tattoo reaction, make sure you discuss the chemical make-up of the specific dye your artist uses before you go ahead with your tattoo. There may be other pigment options available to you.

Since most tattoo inks contain metal, MRI exams may cause tattoos to have a burning or stinging sensation. Redness may even occur. This should be temporary and the presence of a tattoo is not a contraindication to having an MRI.

Infectious Concerns

Tattooing may potentially result in the accidental inoculation of infectious particles into the skin. The potential risk of infectious spread from tattooing (particularly due to Hepatitis B) is high enough that it is a practice that should be avoided by pregnant women to safeguard the health of the baby, not just the pregnant woman whose immune system is down regulated and is much more vulnerable to these types of infection.

Certainly Universal Precautions practiced by many excellent tattoo parlors minimizes potential infectious risks for the consumer. However, just as not all medical facilities are perfectly fastidious, so too some tattoo parlors may not be up to code. While most commonly thought to be a risk for the tattoo client, realistically a needle stick from the client into the artist also exposes the artist to these risks. Here is a list of some of the most common infectious agents that may be transmitted via needle stick:

• Hepatitis B and C The number one risk from a needle stick whether from a tattoo or for a medical professional in the U.S. is hepatitis B, which accounts for 25% of all medical professionals being exposed to this virus. Ask if your tattoo artist has been vaccinated against Hepatitis B. It is a very good idea for their as well as your protection.
• Tuberculosis - While most people think TB has been eliminated; it is actually on the rise due to the development of resistant strains. May definitely be transferred via needle stick (not just respiratory spread).
• Mycobacteria - Other strains of Mycobacterium (not just those that cause TB) may potentially be passed via needle stick. Atypical Mycobacterium may be found in association with fish tanks for instance, so handlers of exotic fish may be carriers of this infection. (Note my photo of a tattoo inoculated with Mycobacterium)
• Syphilis This epidemic venereal disease is contagious through exposure to infected blood in addition to other bodily fluids.
• HIV While feared as the major risk to both client as well as tattoo artist, the virus responsible for this disease is very fragile and much harder to spread via needle stick than a hardy virus like Hepatitis B. Still, a reported 26 medical workers have been reported to have been infected with HIV from accidental needle sticks, so there is a potential. This will be more of a risk for the artist if they are using new sterile, single use needles and instruments for each client and autoclaving those that are multi-use.
• Malaria More likely in indigenous regions, however, your artist (or client) may have been infected from previous travels. If it seems possible, ask.
• Hanson's Disease (a.k.a. Leprosy) There have been reports primarily from endemic areas in eastern portions of the world of infectious spread via tattooing.

Skin Reactions

Some skin diseases may flare when insulted by local skin injury. Psoriasis may flare locally at the tattoo site. This is called the Koebner phenomenon.

Tattoo inks are typically derived from metals that may cause a wide array of skin reactions. While these can be significant if you are the person affected, they tend to be unusual and affect a limited percentage of the tattooed population.

Patch testing to confirm skin reactions is typically positive for eczematous tattoo reactions, but usually is negative for granulomatous reactions.

Initial reactions from the tattoo include local swelling, redness, bleeding and scab formation. This is expected and considered an acute inflammatory response. It usually resolves within a few weeks. Certainly infection of the open wound is also a potential problem. However, the following are problems that may be seen later on with tattoos, even years down the road:

• Lichenoid (small bumps or papules of reactive tissue)
• Sarcoidal granulomas (firm balls of reactive tissue beneath the surface of the skin)
• Scaling
• Itching
• Swelling (often due to a photosensitive/phototoxic reaction)
• Ulceration (the formation of a sore)
• Delayed hypersensitivity (a reaction separated by a significant period of time from getting the tattoo, also referred to within the trade as the red reaction)
• Lymphocytoma Cutis (a skin reaction that mimics lymphoma of the skin and has been associated with tattoos in addition to other causes such as insect bites, some drugs and allergy shots).

Large, raised scars may develop known as keloids. Tattooing is not recommended to known keloid formers. Keloids while not easily removable may be improved or flattened with the use of topical or preferably injectable steroids directly into the keloid. This may need to be done on an interval basis to keep them flat. Medical insurance does not tend to cover this as scars usually fall into the "cosmetic" category on policies. Topical steroid creams/ointments/tape may help, but do not tend to be as effective for keloids. The use of Mederma on a freshly healed wound may help expedite the healing process and work to improve the ultimate aesthetics of the keloid. Silicone gels and patches have become more available for use in keloid treatment. With the prior side effects claimed to have arisen due to silicone breast implants, I am less inclined to use silicone topically. It is no longer available for injectable use into wrinkles.

Granulomas are one of the most commonly reported problems with an allergic reaction to typically a specific tattoo ink. So you may find that anywhere a red pigment (derived from Mercury, for instance) was applied, there will be a firm, localized swelling of that portion of the tattoo. These may be single granulomas consisting of the entire color area or multiple tiny granulomas within the affected color region. Granulomas are difficult to treat. Usually the use of topical or injectable steroids will be attempted. If this fails, removal of the tattoo may be required for aesthetic reasons.

Delayed hypersensitivity is a condition in which several years out from the tattoo, suddenly local itching, scaling, and even redness or swelling may arise within a tattoo. This may be dye color specific or generalized within the tattoo. Again, treatment is limited to topical relief with steroid preparations and possibly some anti itching lotions such as Cortaid 1% Hydrocortisone Anti-Itch Cream or PrameGel. Use of systemic antihistamines may also be of use. Depending on the severity of the reaction, it may be self-limited or ultimately require removal of the tattoo.

Sun Sensitivity

Photosensitivity or phototoxicity basically results from a reaction between the sun and the tattoo dye. Photosensitive reactions mean that this is an allergic reaction, resulting in allergic types of symptoms. In phototoxic reactions, the blend of sun exposure with the chemical or dye in question results in sunburn of the area. Photosensitive reactions may also result in local swelling, itching, scaling, redness, etc. This is most commonly associated with Yellow (Cadmium) tattoo dye.

Wound care

A tattoo results initially in a raw open wound. Leave bandage on for at least 12 hours. Gently wash off dried exudate. Apply a coat of Polysporin First Aid Antibiotic Ointment (Neomycin containing antibiotic ointments have a higher rate of reactions contact dermatitis. Do this until healed. Do not emerse the tattoo, so do shower, not bath. The area may get dry, so using water based cream like Moisturel Therapeutic Cream 16 oz, Cetaphil Moisturizing Cream or Vanicream Moisturizing Skin Cream, 4 oz are good to apply if needed until the tattoo is fully healed. Do not pick at the area!

Tattoo Removal

What are you going to do if you ever decide that your tattoo needs to go the way of the old lover whose name is emblazoned upon your arm, or that a dragon on your leg just doesn't jive with your new corporate image? Remember tattoos are forever unless you actively try to have one removed. While there is still not a perfect remedy, there are a variety of options to eradicate an unwanted tattoo.

Cover-up: Specific cosmetics for camouflaging skin imperfections may be utilized to cover up the unwanted tattoo. Covermark by Lydia O'Leary or Dermablend are available. I tend to prefer Covermark as they offer a broader array of options and work with you to match your particular skin tone. Cover it with a more complicated tattoo if you still want a tattoo, just not the style or name you have imprinted upon the skin. Discuss this in depth with your tattoo artist to see if this is possible and plan it out well. This is usually going to be customized as opposed to an "off the shelf" pattern, so there may be more expense involved than you anticipated.

Excision: Works, but usually done in several stages particularly for larger tattoos and will most definitely leave scarring.

Dermabrasion: Results are often better for professionally performed tattoos as the pigment deposition should be pretty uniform depth within the dermis. Anytime you abrade down into the dermis, there will be permanent discoloration and/or scarring. Basically the skin is anesthetized, frozen and sanded down until the pigment is gone. May require different sessions for a complicated tattoo. Unlikely will provide 100% results.

Laser Resurfacing: Different tattoo ink colors require different wavelengths of laser light to break up the pigment. This is definitely improving, but not yet a perfected art. Expect several sessions. Lasers are not inexpensive, but may be worth it if you are looking for aesthetic results. Also, they are less effective for lighter colors like yellow or greens. The removal of blue and black tattoos yields the best results. Expect this to improve as technology catches up with demand. Some lasers now have the ability to offer more than 1 wavelength of light, providing more versatility for the laser surgeon. Various types of lasers used to help remove tattoos include the Q-switched lasers (Alexandrite, Nd:Yag and Ruby). Individuals with darker skin tones may be more prone to post laser discoloration, potentially a permanent problem.

All of these removal options may cause keloid formation (thickened, raised scars) in individuals prone to this condition. Those who have taken the drug Accutane should wait at least 3 years before considering any of these procedures. This diminishes the likelihood of keloid formation, which Accutane may cause.

Professional tattoos while more uniform tend to be placed deeper within the dermis, so may require extra sessions for removal for this reason as opposed to amateur tattoos which are more superficial. The corollary to this is whether or not the pigment has been randomly deposited at differing levels. This may require further spot treatment.

Tattooing has continued to be an art form for more than 6000 years, perhaps back to the Ice Age, and is likely going to continue to increase in popularity. By understanding the process, knowing how to avoid infection as well as recognize reactions can help you to achieve greater satisfaction from your tattoo.

Thank you for taking the time to read my newsletter. I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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