Q&A: On National Tattoo Day, dermatologist talks history, uses, risks of longtime art form
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Key takeaways:
- Deborah S. Sarnoff, MD, FAAD, FACP, discussed the benefits of tattoos as well as their short- and long-term complications.
- She also provided advice to dermatologists on how to manage these medical implications.
While the art of tattooing has been present for centuries, the medical implications are only recently coming to light with modern medicine.
Every July 17, the country celebrates National Tattoo Day in honor of the stories these bodily markings tell and their personal meanings for many individuals. However, while tattoos may be symbols of culture and self-expression, they can cause complications.
Healio spoke with Deborah S. Sarnoff, MD, FAAD, FACP, clinical professor in the department of dermatology at New York University, president of the Skin Cancer Foundation and a private practitioner in Manhattan and Long Island, about the history of tattoos, their applications and the complications that may arise from them.
Healio: Why are tattoos so prevalent?
Sarnoff: Tattooing is an art form that has existed for thousands of years in cultures around the world. Cosmetic tattoos can be traced back 7,000 years to a tattooed mustache found in South America. The earliest examples of therapeutic tattoos were from mummified remains from 3000 B.C. The mummies found had skin markings used as a form of pain relief acupuncture. Tribal and indigenous populations have incorporated tattoos into their religious ceremonies and rituals and social traditions for centuries.
Nowadays, at least 24% of the people in the U.S. have tattoos. Tattoos have become more socially acceptable. They are no longer seen as associated with gangs or bikers or fringe groups. They are seen as a form of art. Celebrities, athletes and people in the fashion industry have popularized tattoos as a form of self-expression. While tattoos were once considered a taboo practice, they have now become mainstream and celebrated.
Healio: What types of tattoos are there?
Sarnoff: First there are decorative tattoos, which involve tattooing for people to express their uniqueness, creativity or religious convictions. They are often quite colorful and may involve large areas of the body, such as an arm, sometimes referred to as a “sleeve.”
Second, there are cosmetic tattoos, otherwise known as “permanent makeup.” This may enhance the appearance of eyebrows in the form of micro pigmentation or micro blading. Permanent makeup may also be used to line areas around the eyes or the lips. This will often boost the confidence and self-esteem of women who seek out these treatments to enhance their appearance.
Third are corrective tattoos, which are often done to improve the appearance of deformities. For example, nipple and areolar tattooing can be done following mastectomy to aid in reconstruction of the breast. Tattooing of the scalp can be done to improve the appearance of areas of alopecia areata or male -pattern baldness. Scars or areas of vitiligo can be cosmetically improved with flesh-tone tattooing to camouflage or conceal these hypopigmented abnormalities.
Fourth are medical tattoos. These can be done in cancer patients, to demarcate the area where radiation therapy should be administered.
Fifth are traumatic tattoos, which can result from accidents. For example, falling off of a bicycle or motorcycle might involve gravel or other particulate matter entering the skin. Explosions can result in gunpowder or combustible material entering the skin, creating a tattoo.
Healio: What are some contraindications to getting a tattoo?
Sarnoff: Women should not have a tattoo placed during the time that they are pregnant or breastfeeding. In case of a complication or infection, treatment with medication may be problematic. However, there is no problem if the pregnant or the lactating woman already has had tattoos placed in the past.
People with chronic skin conditions, such as lichen planus or psoriasis, are at risk for the Koebnerization phenomenon, where they may develop lichenoid or psoriatic lesions in areas that are tattooed.
Certain people may also be at a higher risk for adverse events. People who are immunosuppressed are at higher risk for possible infection; those with a history of keloids are at a higher risk for scarring; individuals on anticoagulants are at higher risk for bleeding.
People with a personal or family history of melanoma are advised to avoid tattoos near pigmented lesions as this can make it harder to detect possible development of malignant melanoma if it is within a decorative tattoo with dark ink that could camouflage the pigmented lesion. The tattoo process itself could also traumatize a previously benign mole and cause malignant transformation.
Healio: What are the most common complications from tattoos?
Sarnoff: Infection is one problem and that can include bacterial, viral, fungal or mycobacterial infections. The usual bacterial culprits are Staphylococcus aureus, Streptococcus, Pseudomonas or Escherichia coli. Viral transmission of hepatitis B or hepatitis C, herpes simplex, verruca vulgaris, molluscum contagiosum or even HIV, can also occur.
In the ideal world, tattoos should be placed in a sterile environment. Unfortunately, sometimes the hygienic practices in tattoo parlors are sub optimal, and sometimes infections can ensue during the placement or subsequently during the healing period.
Hypersensitivity reactions are also common complications. They may involve type IV hypersensitivity reactions, causing a spongiotic dermatitis-like reaction at the site of the tattoo placement. Sometimes the patient may have an allergy to a particular ink. When red ink is placed some patients have a sensitivity to an ingredient in this ink known as cinnabar, also called mercury sulfide. Granulomas or nodules, chronic pruritis or ulceration may occur at the site.
Additionally, some pigments may cause photosensitivity reactions when exposed to ultraviolet or infrared radiation.
Camouflaging the signs of skin cancer can be another complication from tattoos. In the case of malignant melanoma, it may be hard to detect changes in a prior mole or development of a malignant melanoma de novo if it is within a decorative tattoo with dark ink. The dark ink will mask the signs of melanoma. Early detection of melanoma can result in complete cure, but late diagnosis can prove to be lethal.
Nonmedical complications of tattoos include feelings of regret with approximately 16% of people later regretting their decision to get the tattoo, or dissatisfaction with design with approximately 21% reporting feeling unhappy with the outcome of their tattoo.
Healio: What are the serious long-term complications of having a tattoo?
Sarnoff: When tattoos are placed, macrophages engulf the pigment and transport it to regional lymph nodes. This may induce reactive lymphadenopathy, which may have serious diagnostic and clinical implications. Pigment in lymph nodes might compromise interpretation of a sentinel lymph node biopsy, and pigment deposition in the lymph node could even be mistaken for metastatic melanoma.
Healio: In light of more serious complications, how should dermatologists give advice regarding tattoos while maintaining sensitivity to cultural and personal significance?
Sarnoff: I think that dermatologists should be aware of the fact that these complications and contraindications do exist. For someone with many moles and a personal or family history of malignant melanoma, it would be good to counsel against getting more tattoos, particularly in areas near previous treatment of melanoma or benign-appearing moles. The concern is that the detection of melanoma would potentially be delayed because of the camouflage of the pigmented lesion by the dark tattoo ink.
For patients seeking out cosmetic tattoos to enhance eyebrows or to mask alopecia areata or vitiligo or those in need of nipple reconstruction, I would advise only recommending a tattoo artist who has impeccable credentials and strict attention to sterility and post-procedure detail whom you are familiar with. It is important to ensure the safety of your patients.
Healio: Is there anything else you want to add?
Sarnoff: Firstly, I’d like to bring attention to two studies. The first is a study published recently in a journal called Applied and Environmental Microbiology by author Seong-Jae Kim, PhD, a staff fellow in the division of microbiology at the FDA. He discussed the fact that over one-third of 75 tattoo and permanent makeup inks from 14 popular brands tested positive for bacteria. Thirty-five percent of those tested included inks which were sealed and unopened, yet they were contaminated with aerobic and anaerobic bacteria.
The other study, published in The Lancet in June 2024, is a study from Sweden, where they looked at all cases of lymphoma from the Swedish National Cancer Register in people aged 20 to 60 years between 2007 and 2017. They found that tattooed individuals had a 21% increased risk for overall lymphoma relative to nontattooed individuals. It was a large population-based study with a large sample size, but causality cannot be conferred. Further studies are warranted to ensure that there are no exogenous chemical carcinogens within tattoo ink.
As president of the Skin Cancer Foundation, I would like to mention that it is important to have annual skin exams with a board-certified dermatologist. Additionally, more frequent exams may be indicated for people with a personal history of malignant melanoma.
Any areas of a tattoo should be looked at closely during the exam. In addition, monthly self-exams are important, particularly in an area of a tattoo. If there is any bump, growth, raised lesion, sore, bleeding or raw area of a tattoo that is new, changing or unusual, it would be important to seek medical attention right away.
Sometimes a non-melanotic melanoma or non-melanoma skin cancer, such as basal cell carcinoma or squamous cell carcinoma, can develop within a tattoo. An early diagnosis can help lead to a complete cure.
References:
- Nielsen C, et al. EClinicalMedicine. 2024;doi:10.1016/j.eclinm.2024.102649.
- Yoon S, et al. Appl Environ Microbiol. 2024;doi:10.1128/aem.00276-24.
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