People have been marking the skin with pigments for at least 4,000 years.1 Tattoos have been found on Egyptian mummies, and Roman gladiators are known to have used tattoos for identification.2 Tattooing was considered fashionable among royalty in the first half of the 20th century.3 And today it is perhaps more popular than ever.
But tattooing is not confined to popular culture and decoration. It has established uses in medicine, as well as other medically related uses that represent more recent trends. In this review, we explore the range of medical tattooing.
MEDICAL ALERT TATTOOING
Medical alert tattooing is a form of medical identification similar to medical alert jewelry, ie, bracelets and necklaces, to alert first-responders to a medical condition or to specific desires for care, such as do-not-resuscitate (DNR) directives.
Some people choose to have their medical condition tattooed rather than wear medical alert jewelry, which can break or be misplaced. 4–6
This practice is currently unregulated by the medical community, and the few reports of its use published to date include two people with diabetes who had the word “diabetic” tattooed on their bodies,4,5 and a woman with a tattoo warning of a past severe reaction to succinylcholine during anesthesia.6 She had been advised to wear medical alert jewelry, but she instead chose a tattoo.
Blood-type tattooing was briefly used in a few communities in the United States in the early 1950s as part of a program to provide a “walking blood bank.”7 However, the practice fell out of favor as physicians questioned the reliability of tattoos for medical information.7
This type of tattooing could also benefit patients with adrenal insufficiency, O-negative blood type, and allergies, and patients taking an anticoagulant drug (after discussing the risks of bleeding with their primary physician).
Emergency medical technicians are trained to search unresponsive patients for health-related items, including medical alert necklaces and bracelets. Since tattooing for disease identification purposes is not an officially recognized procedure, these personnel need to be aware that this practice is increasing among the general public. Identifying medical alert tattoos in emergency situations is much more difficult in people with extensive decorative tattooing.
Tattoos indicating health directives
Reports of people with tattoos indicating health directives (DNR, do-not-defibrillate) have prompted debate over the validity of tattoos as a type of advance directive.8–13 These types of tattoos pose practical and ethical problems: they may not reflect a person’s current wishes, and they may have even been applied as a joke.13 Furthermore, they are not recognized as meeting any of the legal requirements for advance directives, so they cannot be considered as valid health directives, but only as a way to guide treatment decisions.14
The same is true for the other ways of notifying first-responders to one’s treatment wishes, ie, wallet cards and medical alert bracelets and necklaces. One manufacturer of medical alert bracelets and necklaces offers to engrave that the wearer has a living will and to keep on file a copy of the document, which they can fax or read out loud to paramedics if they are contacted.11
Organ donor tattoo
In the case of a man who had his consent to be an organ donor tattooed on his chest,15 the tattoo was viewed as not equivalent to signed documentation; however, such tattoos can be used to help guide management.15
DIABETIC PATIENTS AND MEDICAL ALERT TATTOOS
Medical alert tattooing is increasingly common in people with diabetes. Discussions on social-networking sites on the Internet indicate that diabetic patients often do this on their own without consulting their physician.
In our clinic, we have encountered patients with tattoos on the wrist (Figure 1), similar to those seen on the Internet, typically displaying a six-pointed star of life, a caduceus (physician’s staff), and the word “diabetic.” Patients we have encountered in the past 3 to 4 years have cited the same rationale for resorting to medical tattooing—ie, the cost of repeatedly replacing broken and lost medical alert jewelry.
We believe there is a convincing rationale for diabetic patients to undergo medical tattooing, and we believe that diabetes organizations need to evaluate this and provide education to patients and clinicians about it, so that patients can discuss it with their care providers before taking action on their own.
Risks of tattooing in diabetic patients
Diabetic patients who ask their physician about getting a diabetes-alert tattoo should be informed about the dangers of tattooing in diabetes. The diabetes should be optimally controlled, as gauged by both hemoglobin A1c and mean blood glucose profile at the time of tattooing, in order to promote healing of the tattooed area and to prevent wound infection.
Also helpful is to advise diabetic patients to avoid tattooing of the feet or lower legs in view of the risk of diabetes-related neurovascular disease that may impair healing or incite infection.