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Tattoo complications

by N.A. Ipenburg, dermatologist, tattoopoli Amsterdam UMC, Amsterdam

The popularity of tattoos and permanent make-up has increased enormously worldwide. Unfortunately, chronic tattoo complications occur in 6 to 8% of tattooed people. These complications range from infections and allergic reactions to autoimmune diseases such as sarcoidosis. This article discusses the complications and possible treatment.

Tattoos have been done for thousands of years. The first tattoos with ash or soot date back to 3370-3100 BC. Today, tattoo inks are complex industrial products, often a mixture of pigments, solvents, preservatives and other additives. In the past, colored inks usually contained inorganic pigments, such as the minerals cinnabar (red color) and cadmium (yellow color). Nowadays, organic pigments are more popular. [1]
The popularity of permanent tattoos and permanent make-up (PMU) is increasing. Worldwide, 18.5% of the population has a tattoo and among young adult Americans (18-29 years) this figure rises to as much as 38%. [2] Unfortunately, tattoos are not without risk. Chronic tattoo complications are reported by 6 to 8% of people with a tattoo. [3-4] Only a relatively small proportion of these patients present to their GP, dermatologist or a specialized tattoo clinic such as the Amsterdam University Medical Centers. This article will provide guidelines for the recognition and treatment of the most common tattoo complications, with the aim of ensuring that every dermatologist is well prepared for patients with tattoo complaints. Due to the extensive media attention, we will first briefly discuss the current legislation regarding the use of tattoo inks.

REACH regulation

The REACH regulation has caused a stir within the tattoo industry by banning some tattoo inks. ‘REACH’ stands for Registration, Evaluation, Authorization and Restriction of Chemicals and aims to ensure the safe use of chemicals within the European Union. Permissible limits have been set for 4,000 substances based on toxicological properties. Substances for which no limit has been set, but which are not by definition harmless, may therefore be used without limits, for example in cosmetic products or tattoo inks. Since January 2022, tattoo inks are also covered by the REACH regulation. The use of certain popular pigments, such as Pigment Green 7 and Pigment Blue 15:3, is therefore no longer permitted in the inks. [5] However, the usefulness of banning these specific colors is not (yet) supported by the medical literature. [1]

Types of tattoos

The type of tattoo is important for the approach to the patient. Tattoos can be divided into the following groups: professional, amateur, PMU and temporary. Tattoos done by amateurs are often less intense, shallower and therefore easier to remove with a laser than tattoos done by professional tattoo artists. [6]
PMU, often applied to the eyebrows or lips, often contains inorganic pigments such as iron oxide or titanium dioxide than regular tattoos and is therefore more difficult to remove. Laser removal can cause paradoxical hyperpigmentation due to oxidation of these inorganic pigments. [6]
Temporary tattoos, also called henna tattoos, get their color from the henna plant. Henna contains the pigment lawsone, which gives the skin a reddish-brown color by binding with keratin. Adding paraphenylenediamine (PPD) to henna turns the henna black. This black henna is popular in holiday areas, but also poses a risk of sensitization to PPD. Since PPD is the most commonly used dye in permanent hair dye, contact allergies to PPD are often seen. [7]

Tattoo complications

Acute mild reactions
Approximately 20% of all tattooed people report an acute mild reaction. These reactions lead to itching and erythema and in a smaller proportion of patients to purpura or edema. Long sessions in the lower legs or forearms are a risk factor. In unilateral edema, differentiation from a deep venous thrombosis can be difficult. The complaints usually disappear without medical treatment. [3-4]

Infectious complications are seen in 0.5-6% of people with a tattoo. Bacterial infections, especially impetigo or folliculitis, are the most common. Infections usually manifest within days to several weeks after tattooing. Streptococcus aureus and Streptococcus pyogenes are the most common pathogens. Pustules or papulopustules along tattooed lines are a typical presentation. If pus is present, a banal culture is recommended. Depending on the severity and location, treatment is indicated with fusidic acid or oral antibiotics targeted at the most likely causative agent. [3,4,8,9]
(Atypical) mycobacterial infections occur infrequently in the Netherlands, but can be caused by the use of contaminated water to dilute black ink in shadows or gray areas. If this type of infection is suspected, (culture) biopsies are indicated. [4,8] In addition to bacterial infections, dermatomycoses, parasitic infections and viral infections have also been described in tattoos. [3,4,10]

Allergic reactions
Allergic reactions can be caused by tattoo ink as well as by cosmetic products applied to tattoos, the so-called tattoo aftercare products. Reactions to tattoo aftercare products manifest as allergic contact dermatitis. Discontinuation of the causative product and treatment with topical corticosteroids is usually sufficient. [9,10] Chronic allergic reactions to tattoo ink are the most common chronic tattoo reaction. These reactions can even occur months to years after getting the tattoo. Intense itching is prominent in most patients. [4] Clinically, a distinction is made between 3 variants: plaque (most common), hyperkeratotic and ulceronecrotic pattern. [8,10] The hyperkeratotic variant can appear clinically as hypertrophic lichen planus and the ulceronecrotic type is sometimes difficult to distinguish from a skin malignancy. The most important clue for making the diagnosis is the fact that only 1 color of the tattoo is affected. Red tattoos are most commonly affected, but these reactions are also seen in pink, purple, yellow, green and blue tattoos (Figure 1).


Figure 1: Allergic reaction to plaque-type blue-green ink.

Black tattoos seem to be exempt from this complication. This may be because black ink consists of amorphous carbon. [11] Various patterns can be seen on histopathological examination, including an interface dermatitis. The presence of eosinophilic granulocytes is usually not prominent. [8] Routinely performing epicutaneous allergological examination using the European standard series has no added value. [12] In collaboration with various European tattoo clinics, the Amsterdam UMC offers the possibility to test patients with a specific tattoo series consisting of pigments, solvents, preservatives and degradation products, among other things. The exact value of this still needs to be demonstrated.
In the treatment of chronic allergic tattoo reactions, potent topical corticosteroids, possibly under occlusion, are usually the first step. Unfortunately, the complaints regularly recur after stopping therapy. Intralesional corticosteroids and topical calcineurin inhibitors also have a place in treatment. If these treatments have insufficient effect, ablative CO2 laser treatment or ‘dermatome shaving’ can be considered. Non-ablative lasers such as Q-switched pigment lasers are contraindicated, because with this type of lasers the released ink particles redistribute throughout the body and may therefore induce a systemic allergic reaction. [4,13]


Figure 2: Sarcoidosis in tattoo. The involvement of multiple colors is suggestive of the diagnosis.

Non-allergic inflammatory reactions
Inflammatory conditions such as psoriasis, lichen planus, cutaneous lupus erythematosus and vitiligo can spread or be provoked by tattooing. This so-called Köbner phenomenon is also seen in sarcoidosis (Figure 2). [4,8,13] Papulonodular reactions in black tattoos are often the reason for consultation with a specialized tattoo clinic. These patients present with papules, plaques, nodules and/or nodules in black tattoos. The complaints can occur soon after getting a tattoo, but they can also only become manifest years later. Sometimes the ‘rush’ phenomenon is seen. This phenomenon is strongly associated with sarcoidosis and is characterized by the simultaneous development of papulonodular reactions in multiple black tattoos. [14] Pigment overload, where the tattoo artist has applied too much (often black) ink to the skin, appears to be associated with the formation of granulomas and the provocation of a local sarcoidal reaction or even systemic sarcoidosis. [15]
To distinguish a foreign body reaction to black ink from sarcoidosis, a skin biopsy is necessary. Naked, non-necrotizing granulomas are seen in sarcoidosis. However, these sarcoid granulomas are not pathognomonic (characteristic) of sarcoidosis. [14] Chest x-ray and additional laboratory tests (including CRP, complete blood count, renal function, liver enzymes, calcium and the marker angiotensin-converting enzyme and/or serum interleukin-2 receptor) should be considered. Depending on additional extracutaneous complaints, referral to other medical specialists is indicated. In practice, this usually concerns the pulmonologist and ophthalmologist. In the absence of eye complaints, consultation with the ophthalmologist should be accessible. Cases of patients with granulomatous reactions to tattoos and uveitis without other manifestations of systemic sarcoidosis have been described in the literature. [13] Papulonodular reactions to black ink can be treated with topical corticosteroids and, if the effect is insufficient, with hydroxycloroquinine, methotrexate or minocycline. Sarcoidosis in tattoos is treated the same as cutaneous sarcoidosis on untattooed skin. [4,9,10,13]


The popularity of tattoos and permanent make-up is increasing worldwide. Unfortunately, 6 to 8% of tattooed people experience chronic tattoo complications. These complications range from infections and allergic reactions to autoimmune diseases such as sarcoidosis. The Köbner phenomenon plays a role in the development of some of the complaints. The frequent occurrence of tattoos means that every dermatologist can see patients with tattoo-related complaints. This article provides guidelines for the recognition and treatment of the most common tattoo complications.


Tattoo – sarcoidosis – allergy – infection – complications


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Source: Nederlands tijdschrift voor Dermatologie & Venereologie – N.A. Ipenburg