Tattooing: Medical uses and problems
ABSTRACTDecorative tattooing is a custom thousands of years old and is growing in popularity today. Medical professionals may be less familiar with its medical applications—medical alert tattooing, reconstructive and cosmetic applications, endoscopic tattooing, corneal tattooing, tattooing in radiation oncology, and uses in forensic medicine. We review current medically related tattooing applications and discuss their potential risks and benefits.
KEY POINTS
- Tattoos that state an advance directive for health care are not recognized as meeting the legal requirements for advance directives. They should only be considered as a guide to treatment decisions.
- Tattooing for medical-alert purposes is part of current culture. People with diabetes should avoid tattooing of feet or lower legs in view of impaired healing.
- Endoscopic tattooing is commonly used to aid visualization of diseased bowel segments during laparoscopic surgical procedures. Complications are rare but include mild chronic inflammation, abscesses, inflammatory pseudotumors, focal peritonitis, and peritoneal staining.
- Improper sterilization of tattooing needles can cause a wide range of infectious diseases and skin reactions.
GENERAL RISKS AND COMPLICATIONS OF TATTOOING
Improper sterilization of tattooing needles and tattoo ink in public tattoo parlors can cause a wide range of diseases and skin reactions.36–44
Infection
Pyodermal infections can include temporary inflammation at the sites of needle punctures, superficial infections such as impetigo and ecthyma, and deeper infections such as cellulitis, erysipelas, and furunculosis.
Other transmissible infections include hepatitis, syphilis, leprosy, tuberculosis cutis, rubella, chancroid, tetanus, and molluscum contagiosum. An outbreak of infection with Mycobacterium chelonae from premixed tattoo ink has also been reported.44
Hepatitis C has been shown in epidemiologic studies to be transmissible via nonsterile needles. Human immunodeficiency virus is also theoretically transmissible this way, but this is difficult to confirm because the virus has a long incubation period.36
Cutaneous reactions
Skin reactions to tattooing include aseptic inflammation and acquired sensitivity to tattoo dyes, especially red dyes, but also to chromium in green dyes, cadmium in yellow dyes, and cobalt in blue dyes.38 The reaction can manifest as either allergic contact dermatitis or photoallergic 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 conditions include keloid, sarcoidal granuloma, erythema multiforme, localized scleroderma, and lymphadenopathy.36,37
Malignancy
Malignancies reported to arise within tattoos include squamous cell carcinoma, basal cell carcinoma, malignant melanoma, leiomyosarcoma, primary non-Hodgkin lymphoma, and dermatofibrosarcoma protuberans.39 These malignancies may be considered coincidental, but carcinogenicity of the tattooing colorants is a concern to be addressed. Nevertheless, a malignancy within a tattoo is more difficult to identify on skin examination.
Burns during magnetic resonance imaging
The metallic ferric acid pigments used in tattoos can conduct heat on the skin during magnetic resonance imaging,40 resulting in traumatic burns. This has also been reported to occur with tattoos with nonferrous pigments. 41 Patients should be asked before this procedure if they have tattooing so that this complication can be avoided.
Two other complications
Two interesting complications of tattooing have been described. First, tattoo pigments have been noted within lymph nodes in patients with melanoma.42 This finding during surgery could cause the surgeon to mistake tattoo pigment for disease and to complete a regional lymph node dissection if biopsy of the sentinel node is not performed.
The other involved disseminated hyperalgesia after volar wrist tattooing. The authors speculated that the pain associated with volar tattooing may have been related to the proximity of the tattoo to the palmar cutaneous branch of the median nerve.43
Acknowledgment: The authors would like to acknowledge the patients in Figure 1 for their permission to use their photos and Nicolas Kluger, MD, Departments of Dermatology, Allergology, and Venereology, University of Helsinki, Finland, for his input into an early draft of this manuscript.
