Tattoo, side effects

Tattoos are not a European invention. The Englishman James Cook first reported tattooed people in the South Seas. Tatau" was the name of this art of the Polynesians, which became "tattoo" in English and "tattooing" in German. "Tatau" means "artful hammering".

To be distinguished are:

Acute side effects

• Technical errors during tattooing (e.g. incorrect depth of the injectate)
• Wound healing disorders
• Acute local infections
• Allergic local or systemic acute reactions

Chronic side effects

• Areactive deposition of pigments in lymphatic organs (e.g., lymph node anthracosis)
• Allergic local or systemic late reactions
• Toxic/allergic reactions due to UV exposure
• Chronic infections (bacterial/viral)
• Isomorphies (Köbner effects - psoriasis/ichen planus)
• Granulomatous immune reactions (sarcoid local or systemic reactions/uveitis)
• Non-allergic other reactions

Other tattoo side effects

• Keloid formation at injection sites
• Benign/malignant neoplasms (epithelial/lymphatic)
• In the case of large-area tattoos, reduced sweat secretion in the tattooed area

The process of tattooing basically consists of a perforating puncture of the skin, whereby simultaneously with the piercing a color, usually of metallic origin, is injected into the skin.

Care must be taken to ensure that the puncture is neither too superficial nor too deep. In the first case, the injected colorant would only be introduced into the cell layers of the epidermis, from where it would be rapidly eliminated by epithelial regeneration. In the second case, if the pigments are placed too deeply, there is a risk of bleeding, which would cause the colors to run, which would be tantamount to an artistic catastrophe, because, after all, local fidelity is the be-all and end-all of "tattooing".

Basically, it must be emphasized that the pigments used in tattooing are not medical products in the sense of the law. They are therefore not developed for applications that would be necessary to guarantee a permanent stay in the dermis or a contact with body fluids without danger. Furthermore, standardized approval studies are lacking, as they are an indispensable prerequisite for any drug.

The pigments are essentially metallic and metalloid substances. In a larger cross-sectional study of 226 analyzed tattoo inks, the following elements were found:titanium, iron, chromium, copper, zirconium, manganese, bromine, nickel, niobium, strontium, zinc, barium, molybdenum, lead, vanadium, tungsten (Kiszla BM et al. 2023). Titanium was found in high concentrations in almost 91% of the samples; titanium dioxide is a well-known brightener used in tattoo inks. However, titanium dioxideis rated as non-toxic to humans even at high doses. Zirconium (zirconia), used as a pigment additive to coat titanium dioxide particles, was found in over 40% of tattoo inks. It is also considered relatively nontoxic. Iron (ferric oxide) was found in nearly 90% of the samples and serves as a darkening agent. Iron is also generally not considered toxic. Only exceptionally high concentrations of iron can be potentially harmful. However, the metals of greatest concern are chromium, nickel, copper, barium and lead.

In descending order, concentrations of cadmium, barium, mercury, soluble copper, arsenic, zinc, antimony, and lead violated regulations, whereas levels of cobalt and tin did not (Kiszla BM et al. 2023).

Side effects that may occur during tattooing can be attributed to consequences caused on the one hand by the injuries to the skin itself, and on the other hand by the introduced foreign substances themselves. Exact incidences of adverse health effects after tattooing are not available, because corresponding studies are missing. In this respect, the publications refer either to cross-sectional studies of the applied materials or to individual case reports of side effects in which the various ingredients can be associated with dermatological complications.

Decorative tattoos have become a mass phenomenon, especially in industrialized countries. Every 4th German over 18 has them, almost every 5th woman. France is not behind. There, the proportion of those under 35 is > 30%. In the US, there was a tattoo increase from 16% to 21% between 2003 and 2013 (Tighe ME et al. 2017). And further, but more medically concerning, in all Western industrialized countries, the trend of large-scale tattoos is steadily increasing (Bagot M et al. 2017). The consequences of this trend are currently not yet foreseeable.

The stinging of a tattoo is indisputably an invasive procedure. Here, the health condition of the client, the skill and experience of the tattoo artists, the ambience of the institution, hygiene measures and, above all, the composition and quality of the injectate are to be checked.

In the legal sense, a tattoo represents a factual bodily injury, which is not illegal only if it is done impliedly with mutual consent. The consequence: As with a medical intervention it is to be demanded that each Tatoo aspirant is to be informed verbally and in writing about the risks and complications.

Further the § 294a SGB V obliges physicians in principle to report complications with tattoos to the health insurance companies. And professionally, in case of incapacity to work due to complications, there is no entitlement to continued payment of wages, because the employer only has to bear the "normal risk of illness" of the employee.

Technical errors during tattooing (incorrect depth of the injectate)

Technical tattooing errors can be caused by incorrect injection depths. On the one hand, an excessive injection depth leads to unsightly, blurred lines. On the other hand, pigments can spread via the lymph channels if the injection depth is too high. This means that the risks posed by the color or the color pigments themselves are further increased by an excessive penetration depth. Technical errors should be rare in professional tattoo studios today.

Acute complications

Acute infections: The majority of tattoo recipients report minor short-term discomfort and discomfort during the wound healing process after tattooing. Fresh, incompletely healed tattoos, like any other wound area, have an increased risk of bacterial infection.

The incidence of microbiological (mainly bacterial, rarely mycotic or viral) infections from contaminated inks, tools or procedures is unknown. Estimates range up to 5% of tattooed individuals. Although cases of transmission of leprosy, syphilis, skin tuberculosis, NTM infections (atypical mycobacterioses) or rare fungal diseases, e.g. caused by Nocardia species (Ji CH 2024)

are now the exception. The risk of transmission of hepatitis B, hepatitis C and HIV viruses has also been reduced by hygiene regulations, but has not disappeared. This mainly affects exotic countries where Europeans like to get tattoos for cost reasons (Bonadonna L 2015).

The lymphatic drainage situation: With full-body tattoos, up to 40 g (or more) of pigment is injected into the body. It is undisputed that tattooed pigments not only remain in the dermis, but also enter the lymphatic system, where they are usually deposited areactively (Beavis A et al. 2012). In the case of black pigments, the parenchyma becomes correspondingly dark in color (lymph node anthracosis / Biguria R et al. 2016; Manganoni AM et al. 2014). Lymph node anthracosis can pose differential diagnostic problems in malignant melanoma, especially when assessing a sentinel lymph node. More rarely, stained pigments in particular cause inflammatory lymphadenopathies. This raises differential diagnostic problems with regard to dignity (Beavis A et al. 2012; Manganoni AM et al. 2014).

Allergic reactions to inks: Numerous reports have been published on the allergic potential of inks over the last twenty years. In a larger Finnish series of 31 patients, 16 (52%) had allergic dermatitis to tattoos, mainly to the red ink (75%, 12/16). Symptoms included itching, redness and swelling, often combined with color bleeding. Logically, the treatment of an injected allergen represents a major medical challenge.

Contact dermatitis to a red tattoo ink: Sensitizations to p-phenylenediamine (PPD) have often been in the foreground in the past. PPD was often contained in inks up to 10 %, but in black henna up to 50 %, which sometimes led to bullous local reactions, occasionally even to anaphylactoid reactions. In PPD-sensitized individuals, massive swelling (e.g. facial oedema) can be observed after re-exposure, e.g. to hair dyes (Le Coz CJ et al. 2000; Barbaud A et al. 2005; Shavit I et al. 2008).

Tattooed chromium salts (green pigments) also lead to sensitization. Here too, external chromate contact (e.g. as occupationally induced chronic hand dermatitis) can lead to dermatitic reactions. Allergies to cobalt (blue pigments), azo dyes or quinocridone-based dyes (red pigments) are also known. For example, a tattooed person who became sensitized to a red cinnabar-based tattoo ink (mercury sulphide or cinnabar) developed a severely itchy exanthema after eating fish a few months after the tattoo. A high content of mercury derivatives was subsequently measured in this fish.

Inks and UV influence: Phototoxic local reactions have been observed with yellow tattoos based on cadmium salts (Greve B et al. 2003; Bjornberg A 1963). Newer inks, often in different colors, can change their physical and chemical properties under the influence of UV light, even years after tattooing. This can lead to the formation of toxic, sensitizing or potentially carcinogenic metabolites.

Non-allergic other reactions

Nanoparticles: A number of tattoo inks now contain nanoparticles. Their effects on the organism are largely unknown. They cause oxidative stress, are possibly genotoxic and can cause inflammatory and immune reactions.

Dibutyl phthalate: Some black inks contain dibutyl phthalate. This substance is known as an endocrine disruptor.

Other inflammatory tattoo reactions

Isomorphs: Isomorphic reactions: In the presence of active psoriasis or eruptive lichen planus, a tattoo may cause a Köbner phenomenon. In general, psoriasis is realized in the tattooed area within days to 1 month after completion of the tattoo (Kluger N et al. 2017). The occurrence of lichen planus (pemphigoides) after body tattooing should also be considered an isomorphic stimulus effect with a correspondingly high eruption pressure (Lim A et al. 2020).

Keloids: Keloid reactions after tattoos are not predictable. Incidences are not known. However, they should not be underestimated. It is advisable not to tattoo clients who already have a history of keloids.

Tattoo-induced neoplasia: A direct causal relationship between tattoos and neoplasia (of the skin) has neither been proven nor ruled out, but can be assumed.

However, it is undisputed that tattoos can conceal the diagnosis of benign or malignant tumors. To date, well over 100 cases of epithelial pseudomalignant and malignant tumor formations within a tattoo have been reported. The occurrence of solitary but also multiple keratoacanthomas has been reported several times. The epithelial neoplasias often occurred exclusively within red ink areas of tattoos (Kluger N 2010; Healey B et al. 2018;Cui W et al.2007). The distal limbs, i.e. areas exposed to sunlight, are preferentially affected. This indicates a role of UV in the pathogenesis (Badavanis G et al. 2019).The occurrence in young and healthy people and the relatively short, usually only one-year period between tattoo application and tumor formation suggest that the coincidence is not purely coincidental (Rahbarinejad Y et al. 2023). It is noteworthy that red tattoos are most frequently mentioned in connection with epithelial tumor formation. Cinnabar red, which contains mercury sulfate, was frequently used. More recently, cinnabar has been replaced in red tattoos by organic dyes such as azo pigments, quinacridone and polycyclic compounds (Badavanis G et al. 2019; Rahbarinejad Y et al. 2023). It is foreseeable that the incidence of tumors will increase with the increasing age of tattoos and tattooed people.

Leiomyosarcomas/basal cell carcinomas: Reports of basal cell carcinomas or squamous cell carcinomas in tattooed areas; there are further individual reports of leiomyosarcomas and basal cell carcinomas.

Pseudolymphomas/cutaneous lymphomas: There are reports of pseudolymphomas (lymphadenosis chronica benigna) that developed in the tattoo area after tattooing (Chen YF et al. 2009; Campolmi P et al. 2011; Camilot D et al. 2012; Moulonguet I et al. 2014). Individual case reports concern the occurrence of cutaneous lymphomas in a tattoo area (Armiger WG et al. 1978). Kluger N et al. reported a cutaneous follicular lymphoma in 2022.

Inflammatory granulomatous reactions: Sarcoid cutaneous and systemic reactions can also be observed after tattoos. The cutaneous sarcoid reactions are usually difficult to distinguish from cutaneous sarcoidosis. It is possible that they are identical. This assumption could be supported by reports on the occurrence of systemic sarcoidosis after tattoos. Uveitis after tattoos has been reported for several years under the name TAGU (Tattoo Granulomas with Uveitis). These immunological remote reactions can occur with or without sarcoid reactions in the tattoos themselves. In combination with a sarcoid skin affection, this symptom complex is reminiscent of Vogt-Koyanagi-Harada syndrome or uveomeningoencephalitic syndrome.

On January 4, 2023, the Tattoo Annex of the so-called REACH Regulation came into force. It led to the EU-wide ban of "Pigment Blue 15:3 (copper phthalocyanine) and "Pigment Green 7". The ban has enormous tattoo implications, because these color pigments were previously "REACH-compliant", i.e. common for tattoos and contained in many mixed colors, such as violet, brown, turquoise or pink.

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