- Email: [email protected]
Complications of decorative tattoo
Complications of Decorative Tattoo Michi M. Shinohara MD PII: DOI: Reference:
S0738-081X(15)00136-4 doi: 10.1016/j.clindermatol.2015.07.003 CID 6966
To appear in:
Clinics in Dermatology
Please cite this article as: Shinohara Michi M., Complications of Decorative Tattoo, Clinics in Dermatology (2015), doi: 10.1016/j.clindermatol.2015.07.003
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Michi Shinohara, MD Clinics in Dermatology: Contemporary Dermatology DERMATOLOGIC DISQUISITIONS AND OTHER ESSAYS
T
Edited by Philip R. Cohen, M.D.*
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*Please submit contributions to the section to Philip R. Cohen, MD at
SC
[email protected] (email address)
NU
Complications of Decorative Tattoo Michi M Shinohara, MD
MA
From the Divisions of Dermatology and Dermatopathology
AC
Correspondence:
CE
PT
Conflicts of interest: none.
ED
University of Washington School of Medicine, Seattle, Washington
Michi M Shinohara, MD University of Washington Division of Dermatology 1959 NE Pacific Street BB-1353 Box 356524 Seattle, Washington 98195-6524 [email protected]
Shinohara Tattoo Clin Dermatol D&D Essay 4-10-15
1
ACCEPTED MANUSCRIPT Michi Shinohara, MD Abstract Decorative tattoo is a popular practice that is generally safe when performed in the
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professional setting, but can be associated with a variety of inflammatory, infectious, and
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neoplastic complications, risks which may be increased with current trends in home tattooing. Modern tattoo inks contain azo dyes, and are often of unknown composition
SC
and not currently regulated for content or purity. Biopsy of most (if not all) tattoo
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reactions presenting to the dermatologist is recommended, given recent clusters of nontuberculous mycobacterial infections occurring within tattoo as well as associations
MA
between tattoo reactions and systemic diseases such as sarcoidosis.
ED
Introduction
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Tattoo is an ancient practice, and has been performed for therapeutic purposes (such as the charcoal marks seen over degenerating joints on Otzi the iceman), cultural
CE
identification, decoration, and even punishment. Tattoos can be dehumanizing, as were
AC
those applied to Jewish prisoners in the Auschwitz Concentration Camp. Modern tattoos are placed to make people feel sexy, rebellious, attractive, and even spiritual, and are popular, with 21% of U.S. adults reporting at least one tattoo (Harris Interactive Poll, 2012).
Modern tattoo utilizes a variant of the electric pen originally designed by Thomas Edison, which punctures the skin with needles at a rate of 50-3,000 rpm, depositing ink into the dermis. Any pigmented substance can be used as tattoo ink, from soot to industrial grade pigments. Modern tattoo inks are suspensions of metal salts and/or organic pigments in
2
ACCEPTED MANUSCRIPT Michi Shinohara, MD water, alcohol, or glycerin. The most popular tattoo inks in the US contain variants of azo dyes, which are synthetic pigments generally used for industrial purposes (ie. automotive
T
paint), and are valued for their brilliant colors (Figure 1). The exact composition of tattoo
SC
unregulated, and there is no requirement for labeling.
RI P
inks can be nearly impossible to determine, as tattoo inks in the U.S. are largely
NU
In the U.S., professional tattoos are performed by licensed tattoo artists in a licensed tattoo parlor using aseptic or clean technique (Figure 2). Components that directly contact
MA
clients’ skin or body fluids are generally single use or sterilized by autoclave, tattoo artists wear gloves, and components that can’t be sterilized are covered or disinfected
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Tattoo Complications
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before the next client.
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The rate of complications from tattooing has been estimated as high as 2% (1), and the
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total number of is sure to increase as more of the population gets tattooed. After the tattoo artist who performed the tattoo, dermatologists are often called upon to diagnose and manage tattoo complications. A wide variety of inflammatory, infectious, and neoplastic complications can occur within tattoos (see Table 1). Skin biopsy of most, if not all, patients presenting with a tattoo reaction is recommended, as most entities occurring within tattoo cannot be reliably distinguished on clinical exam alone. Some tattoo reactions deserve particular attention because of their frequency or as possible indicators of systemic disease, and are discussed in more detail below.
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ACCEPTED MANUSCRIPT Michi Shinohara, MD Inflammatory Tattoo Reactions Although the incidence is unknown, inflammatory tattoo reactions are probably the most
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commonly encountered by the dermatologist. Inflammatory tattoo reactions begin
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anywhere from days to decades after tattooing, and can occur in any color tattoo ink. Patients who seek care for their tattoo reactions usually do so because of itch, and have
NU
SC
been shown to have reduced quality of life on par with psoriatic patients (2).
Most inflammatory tattoo reactions are likely delayed type hypersensitivity or allergic
MA
type reactions, though there are some examples of isomorphic response occurring after tattoo. What component of tattoo ink causing delayed type or allergic reactions has
ED
proven difficult to answer. When metal salts were the primary pigment in tattoo inks, red
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mercury/cinnabar containing salts were blamed, however, red tattoo reactions remain the most frequent despite a transition to azo dyes (Figure 3). Other metal salts may play a
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role; many tattoo inks contain allergenic levels of nickel, as well as chromium (3).
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Introduction into the skin or exposure to UV light could alter the chemical component of tattoo inks, making them more allergenic; yellow azo dye, for example, has been shown to photodecompose (4). Other substances, including thimerosal and unknown propriety ingredients (Figure 4), are used in tattoo inks, and are potential sources of allergy. The role of patch testing in tattoo reactions was explored in a series of 90 patients; the authors found a generally low incidence of positive reactions even when a sample of the same ink presumed to cause the reaction was applied, and hypothesized that haptenization plays a role in tattoo reactions (5).
4
ACCEPTED MANUSCRIPT Michi Shinohara, MD Granulomatous tattoo reactions are among the most frequent inflammatory tattoo reactions, and can be foreign body-like, sarcoidal, and even granuloma-annulare or
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necrobiosis lipoidica-like. Sarcoidal tattoo reactions are worth particular mention because
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they may, in some cases, represent true scar sarcoid. Tattoo sarcoidosis can occur decades after tattooing (Figure 5). Sarcoidosis can be triggered by medications, particularly
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interferons, and in this setting, there is a high incidence (approximately 60%) of skin
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involvement (6). Given this, all patients presenting with suspected tattoo reactions, regardless of the duration of the tattoo, should reasonably undergo questioning about eye
MA
or pulmonary symptoms, a complete skin exam looking for other skin lesions, and skin
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biopsy to both confirm the diagnosis as well as exclude infection.
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In addition to reactions to permanent tattoos, reactions to temporary tattoos can occur, including allergic contact dermatitis to henna tattoo (Figure 6). Henna is a naturally
CE
occurring red-brown dye that is used in Indian, Asian, and African cultures, and is often
AC
mixed with paraphenylenediamine (PPD), a well-known contact allergen.
Infectious Tattoo Reactions Although often discussed, obtaining a tattoo in a professional tattoo parlor under aseptic conditions is no longer high risk for acquiring hepatitis C virus (7), and there have been no reported outbreaks of human immunodeficiency virus transmission from professional tattoo. Tattoos performed in jail or prison, however, remain risky (7), and those considering tattoo should be counseled to only visit a licensed, professional tattoo parlor.
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ACCEPTED MANUSCRIPT Michi Shinohara, MD Although the majority of infections occurring with in tattoo, such as acute pyogenic infections, are merely nuisances, some (reviewed by Kluger (8)) can be serious or even
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life threatening. Memorial tattoos are tattoos placed to commemorate a person or beloved
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pet; “cremains” (cremated remains) can be mixed with tattoo ink during this process,
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which has been associated with death from necrotizing myositis in at least one case (9).
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Among the numerous infections reported in tattoo (Table 1), non-tuberculous mycobacterial (NTM) infections deserve special mention because of several clusters of
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infection in the past decade. NTM infections in tattoo typically occur within 1 month of tattooing, presenting with erythematous papules, papulo-pustules, or even abscesses
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within the tattooed areas (Figure 7). Sources of NTM infection in tattoo include distilled
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or tap water, which is sometimes used to dilute tattoo ink for shading (10), as well as the ink itself. Mycobacterium chelonae and Mycobacterium abscessus have most frequently
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been implicated. M. abscessus, in particular, may show unusual resistance patterns,
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complicating therapy (11). Skin biopsy for culture should always be performed when pustules are present or NTM infection is otherwise suspected to confirm the diagnosis, speciate the organism, and, perhaps most importantly, identify antimicrobial sensitivities. Special stains on tissue sections can be performed, but lack the sensitivity of culture. Molecular techniques, such as polymerase chain reaction with universal bacterial primers, can be performed on formalin fixed tissue, and allow for identification of an organism but not antimicrobial sensitivity patterns. Although some patients with NTM tattoo infections may show spontaneous healing despite a lack of effective therapy, initial therapy with a
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ACCEPTED MANUSCRIPT Michi Shinohara, MD macrolide (such as clarithromycin) and/or quinolone (such as moxifloxacin), at a
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minimum, should be instituted until sensitivity data is available to tailor therapy (11).
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Neoplasms Occurring Within Tattoo
All manner of neoplasms have been reported in tattoos (Table 1), the vast majority of
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which likely represent coincident lesions (12). No data currently exists to answer whether
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people with tattoos have a higher incidence of skin cancer. Squamous lesions occur in tattoo on a spectrum from pseudocarcinomatous hyperplasia to keratoacanthoma to
MA
squamous cell carcinoma (Figure 8), and are frequently reported in tattoo, leading to conjecture that they may arise at least in part because of local trauma. The preponderance
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of squamous lesions occurring within tattoos containing red ink suggests that
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hypersensitivity plays a role as well (12).
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The collision between melanocytic lesions and tattoo can be very problematic, both in
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terms of detecting atypical nevi and melanoma, and interpreting biopsies. Some responsible tattoo artists will tattoo around existing melanocytic nevi, however, not all tattoo artists are educated as to this practice. Patients with atypical nevi or a history of melanoma should be counseled to ensure that they do not obtain tattoos that obscure melanocytic lesions. Dermatologists who biopsy a pigmented lesion within a tattoo should alert the dermatopathologist to the tattoo, so that pigmented macrophages do not get confused for melanocytes.
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ACCEPTED MANUSCRIPT Michi Shinohara, MD The question of whether tattoo inks are potentially carcinogenic is not yet answered. Attempts have been made to address this question by focusing on would-be toxins or
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carcinogens in inks or by-products of inks. Tattoo pigments have been shown to contain
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aromatic amines, phthalates, polycyclic aromatic hydrocarbons, an even highly bioavailable nanoparticles (see Kluger (12) for review). The stability of tattoo inks have
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also been called into question, as some inks can photodecompose into secondary
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compounds with unknown biologic consequences. Although questions exist about the safety of tattoo inks, the fact remains that the incidence of malignancies occurring within
Treatment of tattoo reactions
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tattoos doesn’t appear to be more than one would expect for coincident lesions (12).
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The treatment of tattoo reactions should be individualized to the patient and type of tattoo reaction. For most inflammatory reactions, including lichenoid and granulomatous
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reactions, superpotent topical and/or intralesional steroids are reasonable first line
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therapies, assuming biopsy has been performed to exclude infection. Surgical excision may be needed for recalcitrant or recurrent reactions, though can be technically difficult and cosmetically deforming for large lesions.
The use of laser surgery to treat inflammatory tattoo reactions is controversial because of a theoretical risk of exposing potential allergen(s) to the systemic circulation and generating generalized reactions. The Q-switched lasers (neodymium:yttrium-aluminumgarnet (Nd:YAG), alexandrite, or ruby) and newer picosecond lasers are most frequently used for laser tattoo removal, and have largely replaced older, ablative lasers (13).
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ACCEPTED MANUSCRIPT Michi Shinohara, MD Published literature supporting the use of laser to treat tattoo reactions is scant, though there are reports of using the Erbium:YAG (14) and Nd:YAG (15) lasers successfully.
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Local and generalized reactions have been reported to occur as a consequence of laser
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treatment of previously uninvolved tattoos, suggesting that laser treatment can alter the
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antigenicity of tattoo pigment (16).
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Current trends in tattoo
Home or “DIY” tattoo. Non-professional or amateur tattoos are not limited to those who
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are incarcerated. Home tattooing, also known as “DIY tattoo” or “stick and poke” tattoo is enjoying popularity, and instructions can be readily found on the internet and even in
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pre-packaged kits (http://stickandpoketattookit.com/). Just as a market arises for home
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tattooing, a parallel market is arising for home tattoo removal. Kluger (17) reviewed the currently available, unregulated methods for amateur tattoo removal, which ranged from
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topical agents marketed as “tattoo removal creams”, many of which contain skin
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brightening agents, to destructive treatments with topical trichloroacetic acid.
Medical uses for tattoo. Historically, medical tattoos have been used mainly for localization, such as radiation fields and endoscopic marking of biopsy sites, and as cosmetic completion after reconstructive surgery, such as tattooing of the nipple after breast reconstructive surgery. Several novel medical uses of tattoo are under development. Nano tattoos are intradermally embedded biosensors that are engineered to change color based on detected changes, and are currently being developed to monitor glucose levels in diabetics (18). “DNA tattooing” is a novel technique in which a DNA-
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ACCEPTED MANUSCRIPT Michi Shinohara, MD based vaccine is delivered into the epidermis via multiple small perforations, inducing a robust local inflammatory response and increased immune response, leading to faster
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vaccine delivery and response (19).
Conclusions
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Although tattoos obtained at a professional tattoo parlor are generally safe based on the
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current evidence, unanticipated complications can arise, even decades after tattooing. Tattoo inks are currently minimally regulated for composition or purity in the U.S., and
MA
until they are, dermatologists should be vigilant in evaluating tattoo reactions, with skin biopsy of most (if not all) tattoo reactions. Biopsy for culture should be performed if
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there is any suspicion of infection, with caution against reliance on tissue special stains
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for microorganisms to rule out infection. Dermatologists should also counsel patients to only obtain tattoos in licensed tattoo parlors by licensed tattoo artists to minimize their
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risk of complications. Patients with pre-existing dermatoses that are susceptible to the
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isomorphic phenomenon or pathergy (ie. psoriasis, pyoderma gangrenosum) should be cautioned to avoid tattooing altogether.
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ACCEPTED MANUSCRIPT Michi Shinohara, MD References: 1.
8. 9. 10. 11.
12. 13. 14. 15. 16.
17. 18.
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5.
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4.
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3.
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2.
Kazandjieva J, and Tsankov N. Tattoos: dermatological complications. Clin Dermatol. 2007;25:375-382 Bassi A, Campolmi P, Cannarozzo G, et al. Tattoo-associated skin reaction: the importance of an early diagnosis and proper treatment. Biomed Res Int. 2014;2014:354608 Forte G, Petrucci F, Cristaudo A, et al. Market survey on toxic metals contained in tattoo inks. Sci Total Environ. 2009;407:5997-6002 Cui Y, Spann AP, Couch LH, et al. Photodecomposition of Pigment Yellow 74, a pigment used in tattoo inks. Photochem Photobiol. 2004;80:175-184 Serup J, and Hutton Carlsen K. Patch test study of 90 patients with tattoo reactions: negative outcome of allergy patch test to baseline batteries and culprit inks suggests allergen(s) are generated in the skin through haptenization. Contact Dermatitis. 2014;71:255-263 Ramos-Casals M, Mana J, Nardi N, et al. Sarcoidosis in patients with chronic hepatitis C virus infection: analysis of 68 cases. Medicine (Baltimore). 2005;84:69-80 Tohme RA, and Holmberg SD. Transmission of hepatitis C virus infection through tattooing and piercing: a critical review. Clin Infect Dis. 2012;54:11671178 Kluger N. Acute complications of tattooing presenting in the ED. Am J Emerg Med. 2012;30:2055-2063 Hourmozdi JJ, Hawley DA, Hadi CM, et al. Streptococcal necrotizing myositis: a case report and clinical review. J Emerg Med. 2014;46:436-442 Binic I, Jankovic A, Ljubenovic M, et al. Mycobacterium chelonae infection due to black tattoo ink dilution. Am J Clin Dermatol. 2011;12:404-406 Falsey RR, Kinzer MH, Hurst S, et al. Cutaneous inoculation of nontuberculous mycobacteria during professional tattooing: a case series and epidemiologic study. Clin Infect Dis. 2013;57:e143-147 Kluger N, and Koljonen V. Tattoos, inks, and cancer. Lancet Oncol. 2012;13:e161-168 Luebberding S, and Alexiades-Armenakas M. New tattoo approaches in dermatology. Dermatol Clin. 2014;32:91-96 De Argila D, Chaves A, and Moreno JC. Erbium:Yag laser therapy of lichenoid red tattoo reaction. J Eur Acad Dermatol Venereol. 2004;18:332-333 Hindson C, Foulds I, and Cotterill J. Laser therapy of lichenoid red tattoo reaction. Br J Dermatol. 1995;133:665-666 Harper J, Losch AE, Otto SG, et al. New insight into the pathophysiology of tattoo reactions following laser tattoo removal. Plast Reconstr Surg. 2010;126:313e-314e Kluger N. The risks of do-it-yourself and over-the-counter devices for tattoo removal. Int J Dermatol. 2015;54:13-18 Rao PV, and Gan SH. Recent Advances in Nanotechnology-Based Diagnosis and Treatments of Diabetes. Curr Drug Metab. 2014
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20.
Pokorna D, Rubio I, and Muller M. DNA-vaccination via tattooing induces stronger humoral and cellular immune responses than intramuscular delivery supported by molecular adjuvants. Genet Vaccines Ther. 2008;6:4 Simunovic C, and Shinohara MM. Complications of decorative tattoos: recognition and management. Am J Clin Dermatol. 2014;15:525-536
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19.
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Table 1. Tattoo reactions ((8) and (20) for review). Psoriasis Lichen planus Lichen sclerosus SCLE-like Atopic dermatitis Contact dermatitis Foreign-body type Sarcoidal Granuloma annulare-like Necrobiosis lipoidica-like
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Inflammatory Isomorphic/koebner
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Lichenoid reactions Eczematous reactions
Bacterial infections
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Infectious
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Vasculitis Cutaneous lymphoid hyperplasia/pseudolymphoma Morphea Pseudocarcinomatous hyperplasia
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Granulomatous reactions
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Viral infections
Fungal infections Parasitic Infections Neoplasms
Impetigo Cellulitis, Abscess Bacteremia Streptococcal necrotizing myositis Necrotizing fasciitis Epidural abscess NTM M. Tuberculosis M. Leprae Syphilis Blood borne pathogens
HBV HCV HIV
Human papilloma virus Molluscum contagiosum Herpes simplex virus Dermatophytosis Zygomycosis Leischmaniasis
Keratoacanthoma Squamous cell carcinoma Basal cell carcinoma Melanocytic nevi Melanoma Leiomyosarcoma Primary cutaneous B-cell lymphoma
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ACCEPTED MANUSCRIPT Michi Shinohara, MD
Legends
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Figure 1. Examples of commercially available tattoo inks containing azo dyes.
Figure 2. Tattoo technique. Components of the tattoo machine are either single use,
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SC
sterilized, or cleaned and covered for use.
Figure 3. Red tattoo reaction showing indurated papules and plaques involving only the
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red-inked areas.
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Figure 4. Tattoo ink ingredients.
Figure 5. Sarcoidal tattoo reaction involving only the black ink; the patient’s tattoo had
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been placed 20 years prior.
Figure 6. Bullous contact dermatitis to a henna temporary tattoo.
Figure 7. Squamous proliferation consistent with keratoacanthoma occurring within a tattoo.
Figure 8. Non-tuberculous mycobacterial infection occurring within tattoo, with pustules and erythematous papules appearing approximately 2 weeks after tattoo placement.
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ACCEPTED MANUSCRIPT Michi Shinohara, MD Autobiographic Sketch Dr. Shinohara was born and raised in Anchorage, Alaska, the first-born to a latte-loving
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journalist born in Nome, Alaska, and a first generation Japanese novice sports fisherman
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who taught English as a second language. She attended Reed College in Portland, Oregon, starting as an art major, but falling victim to the geeky-cool lure of the sciences
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and graduating majoring in Chemistry. She attended the University of Washington
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School of Medicine in Seattle. Her broad interests led her first to internal medicine residency at the University of Washington, however, exposure to dermatology clinics
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during her medicine residency led to a second residency in dermatology. After a dermatopathology fellowship at the University of Pennsylvania, she returned to the
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Seattle area to join the faculty at University of Washington, where she has dual
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appointments within Dermatology and Dermatopathology. She specializes in the care of complex medical dermatology patients, and maintains a multidisciplinary Cutaneous
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Lymphoma Clinic in addition to holding the title of Director of Inpatient Consultative
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Dermatology at the University of Washington Medical Center. Her interest in tattoo relates back to her long-standing love of art, and merges this with medicine.
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S0738-081X(15)00136-4 doi: 10.1016/j.clindermatol.2015.07.003 CID 6966
To appear in:
Clinics in Dermatology
Please cite this article as: Shinohara Michi M., Complications of Decorative Tattoo, Clinics in Dermatology (2015), doi: 10.1016/j.clindermatol.2015.07.003
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Michi Shinohara, MD Clinics in Dermatology: Contemporary Dermatology DERMATOLOGIC DISQUISITIONS AND OTHER ESSAYS
T
Edited by Philip R. Cohen, M.D.*
RI P
*Please submit contributions to the section to Philip R. Cohen, MD at
SC
[email protected] (email address)
NU
Complications of Decorative Tattoo Michi M Shinohara, MD
MA
From the Divisions of Dermatology and Dermatopathology
AC
Correspondence:
CE
PT
Conflicts of interest: none.
ED
University of Washington School of Medicine, Seattle, Washington
Michi M Shinohara, MD University of Washington Division of Dermatology 1959 NE Pacific Street BB-1353 Box 356524 Seattle, Washington 98195-6524 [email protected]
Shinohara Tattoo Clin Dermatol D&D Essay 4-10-15
1
ACCEPTED MANUSCRIPT Michi Shinohara, MD Abstract Decorative tattoo is a popular practice that is generally safe when performed in the
T
professional setting, but can be associated with a variety of inflammatory, infectious, and
RI P
neoplastic complications, risks which may be increased with current trends in home tattooing. Modern tattoo inks contain azo dyes, and are often of unknown composition
SC
and not currently regulated for content or purity. Biopsy of most (if not all) tattoo
NU
reactions presenting to the dermatologist is recommended, given recent clusters of nontuberculous mycobacterial infections occurring within tattoo as well as associations
MA
between tattoo reactions and systemic diseases such as sarcoidosis.
ED
Introduction
PT
Tattoo is an ancient practice, and has been performed for therapeutic purposes (such as the charcoal marks seen over degenerating joints on Otzi the iceman), cultural
CE
identification, decoration, and even punishment. Tattoos can be dehumanizing, as were
AC
those applied to Jewish prisoners in the Auschwitz Concentration Camp. Modern tattoos are placed to make people feel sexy, rebellious, attractive, and even spiritual, and are popular, with 21% of U.S. adults reporting at least one tattoo (Harris Interactive Poll, 2012).
Modern tattoo utilizes a variant of the electric pen originally designed by Thomas Edison, which punctures the skin with needles at a rate of 50-3,000 rpm, depositing ink into the dermis. Any pigmented substance can be used as tattoo ink, from soot to industrial grade pigments. Modern tattoo inks are suspensions of metal salts and/or organic pigments in
2
ACCEPTED MANUSCRIPT Michi Shinohara, MD water, alcohol, or glycerin. The most popular tattoo inks in the US contain variants of azo dyes, which are synthetic pigments generally used for industrial purposes (ie. automotive
T
paint), and are valued for their brilliant colors (Figure 1). The exact composition of tattoo
SC
unregulated, and there is no requirement for labeling.
RI P
inks can be nearly impossible to determine, as tattoo inks in the U.S. are largely
NU
In the U.S., professional tattoos are performed by licensed tattoo artists in a licensed tattoo parlor using aseptic or clean technique (Figure 2). Components that directly contact
MA
clients’ skin or body fluids are generally single use or sterilized by autoclave, tattoo artists wear gloves, and components that can’t be sterilized are covered or disinfected
PT
Tattoo Complications
ED
before the next client.
CE
The rate of complications from tattooing has been estimated as high as 2% (1), and the
AC
total number of is sure to increase as more of the population gets tattooed. After the tattoo artist who performed the tattoo, dermatologists are often called upon to diagnose and manage tattoo complications. A wide variety of inflammatory, infectious, and neoplastic complications can occur within tattoos (see Table 1). Skin biopsy of most, if not all, patients presenting with a tattoo reaction is recommended, as most entities occurring within tattoo cannot be reliably distinguished on clinical exam alone. Some tattoo reactions deserve particular attention because of their frequency or as possible indicators of systemic disease, and are discussed in more detail below.
3
ACCEPTED MANUSCRIPT Michi Shinohara, MD Inflammatory Tattoo Reactions Although the incidence is unknown, inflammatory tattoo reactions are probably the most
T
commonly encountered by the dermatologist. Inflammatory tattoo reactions begin
RI P
anywhere from days to decades after tattooing, and can occur in any color tattoo ink. Patients who seek care for their tattoo reactions usually do so because of itch, and have
NU
SC
been shown to have reduced quality of life on par with psoriatic patients (2).
Most inflammatory tattoo reactions are likely delayed type hypersensitivity or allergic
MA
type reactions, though there are some examples of isomorphic response occurring after tattoo. What component of tattoo ink causing delayed type or allergic reactions has
ED
proven difficult to answer. When metal salts were the primary pigment in tattoo inks, red
PT
mercury/cinnabar containing salts were blamed, however, red tattoo reactions remain the most frequent despite a transition to azo dyes (Figure 3). Other metal salts may play a
CE
role; many tattoo inks contain allergenic levels of nickel, as well as chromium (3).
AC
Introduction into the skin or exposure to UV light could alter the chemical component of tattoo inks, making them more allergenic; yellow azo dye, for example, has been shown to photodecompose (4). Other substances, including thimerosal and unknown propriety ingredients (Figure 4), are used in tattoo inks, and are potential sources of allergy. The role of patch testing in tattoo reactions was explored in a series of 90 patients; the authors found a generally low incidence of positive reactions even when a sample of the same ink presumed to cause the reaction was applied, and hypothesized that haptenization plays a role in tattoo reactions (5).
4
ACCEPTED MANUSCRIPT Michi Shinohara, MD Granulomatous tattoo reactions are among the most frequent inflammatory tattoo reactions, and can be foreign body-like, sarcoidal, and even granuloma-annulare or
T
necrobiosis lipoidica-like. Sarcoidal tattoo reactions are worth particular mention because
RI P
they may, in some cases, represent true scar sarcoid. Tattoo sarcoidosis can occur decades after tattooing (Figure 5). Sarcoidosis can be triggered by medications, particularly
SC
interferons, and in this setting, there is a high incidence (approximately 60%) of skin
NU
involvement (6). Given this, all patients presenting with suspected tattoo reactions, regardless of the duration of the tattoo, should reasonably undergo questioning about eye
MA
or pulmonary symptoms, a complete skin exam looking for other skin lesions, and skin
ED
biopsy to both confirm the diagnosis as well as exclude infection.
PT
In addition to reactions to permanent tattoos, reactions to temporary tattoos can occur, including allergic contact dermatitis to henna tattoo (Figure 6). Henna is a naturally
CE
occurring red-brown dye that is used in Indian, Asian, and African cultures, and is often
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mixed with paraphenylenediamine (PPD), a well-known contact allergen.
Infectious Tattoo Reactions Although often discussed, obtaining a tattoo in a professional tattoo parlor under aseptic conditions is no longer high risk for acquiring hepatitis C virus (7), and there have been no reported outbreaks of human immunodeficiency virus transmission from professional tattoo. Tattoos performed in jail or prison, however, remain risky (7), and those considering tattoo should be counseled to only visit a licensed, professional tattoo parlor.
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ACCEPTED MANUSCRIPT Michi Shinohara, MD Although the majority of infections occurring with in tattoo, such as acute pyogenic infections, are merely nuisances, some (reviewed by Kluger (8)) can be serious or even
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life threatening. Memorial tattoos are tattoos placed to commemorate a person or beloved
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pet; “cremains” (cremated remains) can be mixed with tattoo ink during this process,
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which has been associated with death from necrotizing myositis in at least one case (9).
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Among the numerous infections reported in tattoo (Table 1), non-tuberculous mycobacterial (NTM) infections deserve special mention because of several clusters of
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infection in the past decade. NTM infections in tattoo typically occur within 1 month of tattooing, presenting with erythematous papules, papulo-pustules, or even abscesses
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within the tattooed areas (Figure 7). Sources of NTM infection in tattoo include distilled
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or tap water, which is sometimes used to dilute tattoo ink for shading (10), as well as the ink itself. Mycobacterium chelonae and Mycobacterium abscessus have most frequently
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been implicated. M. abscessus, in particular, may show unusual resistance patterns,
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complicating therapy (11). Skin biopsy for culture should always be performed when pustules are present or NTM infection is otherwise suspected to confirm the diagnosis, speciate the organism, and, perhaps most importantly, identify antimicrobial sensitivities. Special stains on tissue sections can be performed, but lack the sensitivity of culture. Molecular techniques, such as polymerase chain reaction with universal bacterial primers, can be performed on formalin fixed tissue, and allow for identification of an organism but not antimicrobial sensitivity patterns. Although some patients with NTM tattoo infections may show spontaneous healing despite a lack of effective therapy, initial therapy with a
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ACCEPTED MANUSCRIPT Michi Shinohara, MD macrolide (such as clarithromycin) and/or quinolone (such as moxifloxacin), at a
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minimum, should be instituted until sensitivity data is available to tailor therapy (11).
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Neoplasms Occurring Within Tattoo
All manner of neoplasms have been reported in tattoos (Table 1), the vast majority of
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which likely represent coincident lesions (12). No data currently exists to answer whether
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people with tattoos have a higher incidence of skin cancer. Squamous lesions occur in tattoo on a spectrum from pseudocarcinomatous hyperplasia to keratoacanthoma to
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squamous cell carcinoma (Figure 8), and are frequently reported in tattoo, leading to conjecture that they may arise at least in part because of local trauma. The preponderance
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of squamous lesions occurring within tattoos containing red ink suggests that
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hypersensitivity plays a role as well (12).
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The collision between melanocytic lesions and tattoo can be very problematic, both in
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terms of detecting atypical nevi and melanoma, and interpreting biopsies. Some responsible tattoo artists will tattoo around existing melanocytic nevi, however, not all tattoo artists are educated as to this practice. Patients with atypical nevi or a history of melanoma should be counseled to ensure that they do not obtain tattoos that obscure melanocytic lesions. Dermatologists who biopsy a pigmented lesion within a tattoo should alert the dermatopathologist to the tattoo, so that pigmented macrophages do not get confused for melanocytes.
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ACCEPTED MANUSCRIPT Michi Shinohara, MD The question of whether tattoo inks are potentially carcinogenic is not yet answered. Attempts have been made to address this question by focusing on would-be toxins or
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carcinogens in inks or by-products of inks. Tattoo pigments have been shown to contain
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aromatic amines, phthalates, polycyclic aromatic hydrocarbons, an even highly bioavailable nanoparticles (see Kluger (12) for review). The stability of tattoo inks have
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also been called into question, as some inks can photodecompose into secondary
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compounds with unknown biologic consequences. Although questions exist about the safety of tattoo inks, the fact remains that the incidence of malignancies occurring within
Treatment of tattoo reactions
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tattoos doesn’t appear to be more than one would expect for coincident lesions (12).
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The treatment of tattoo reactions should be individualized to the patient and type of tattoo reaction. For most inflammatory reactions, including lichenoid and granulomatous
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reactions, superpotent topical and/or intralesional steroids are reasonable first line
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therapies, assuming biopsy has been performed to exclude infection. Surgical excision may be needed for recalcitrant or recurrent reactions, though can be technically difficult and cosmetically deforming for large lesions.
The use of laser surgery to treat inflammatory tattoo reactions is controversial because of a theoretical risk of exposing potential allergen(s) to the systemic circulation and generating generalized reactions. The Q-switched lasers (neodymium:yttrium-aluminumgarnet (Nd:YAG), alexandrite, or ruby) and newer picosecond lasers are most frequently used for laser tattoo removal, and have largely replaced older, ablative lasers (13).
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Local and generalized reactions have been reported to occur as a consequence of laser
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antigenicity of tattoo pigment (16).
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Current trends in tattoo
Home or “DIY” tattoo. Non-professional or amateur tattoos are not limited to those who
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are incarcerated. Home tattooing, also known as “DIY tattoo” or “stick and poke” tattoo is enjoying popularity, and instructions can be readily found on the internet and even in
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pre-packaged kits (http://stickandpoketattookit.com/). Just as a market arises for home
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tattooing, a parallel market is arising for home tattoo removal. Kluger (17) reviewed the currently available, unregulated methods for amateur tattoo removal, which ranged from
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topical agents marketed as “tattoo removal creams”, many of which contain skin
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brightening agents, to destructive treatments with topical trichloroacetic acid.
Medical uses for tattoo. Historically, medical tattoos have been used mainly for localization, such as radiation fields and endoscopic marking of biopsy sites, and as cosmetic completion after reconstructive surgery, such as tattooing of the nipple after breast reconstructive surgery. Several novel medical uses of tattoo are under development. Nano tattoos are intradermally embedded biosensors that are engineered to change color based on detected changes, and are currently being developed to monitor glucose levels in diabetics (18). “DNA tattooing” is a novel technique in which a DNA-
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ACCEPTED MANUSCRIPT Michi Shinohara, MD based vaccine is delivered into the epidermis via multiple small perforations, inducing a robust local inflammatory response and increased immune response, leading to faster
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vaccine delivery and response (19).
Conclusions
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Although tattoos obtained at a professional tattoo parlor are generally safe based on the
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current evidence, unanticipated complications can arise, even decades after tattooing. Tattoo inks are currently minimally regulated for composition or purity in the U.S., and
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until they are, dermatologists should be vigilant in evaluating tattoo reactions, with skin biopsy of most (if not all) tattoo reactions. Biopsy for culture should be performed if
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there is any suspicion of infection, with caution against reliance on tissue special stains
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for microorganisms to rule out infection. Dermatologists should also counsel patients to only obtain tattoos in licensed tattoo parlors by licensed tattoo artists to minimize their
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risk of complications. Patients with pre-existing dermatoses that are susceptible to the
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isomorphic phenomenon or pathergy (ie. psoriasis, pyoderma gangrenosum) should be cautioned to avoid tattooing altogether.
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8. 9. 10. 11.
12. 13. 14. 15. 16.
17. 18.
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Kazandjieva J, and Tsankov N. Tattoos: dermatological complications. Clin Dermatol. 2007;25:375-382 Bassi A, Campolmi P, Cannarozzo G, et al. Tattoo-associated skin reaction: the importance of an early diagnosis and proper treatment. Biomed Res Int. 2014;2014:354608 Forte G, Petrucci F, Cristaudo A, et al. Market survey on toxic metals contained in tattoo inks. Sci Total Environ. 2009;407:5997-6002 Cui Y, Spann AP, Couch LH, et al. Photodecomposition of Pigment Yellow 74, a pigment used in tattoo inks. Photochem Photobiol. 2004;80:175-184 Serup J, and Hutton Carlsen K. Patch test study of 90 patients with tattoo reactions: negative outcome of allergy patch test to baseline batteries and culprit inks suggests allergen(s) are generated in the skin through haptenization. Contact Dermatitis. 2014;71:255-263 Ramos-Casals M, Mana J, Nardi N, et al. Sarcoidosis in patients with chronic hepatitis C virus infection: analysis of 68 cases. Medicine (Baltimore). 2005;84:69-80 Tohme RA, and Holmberg SD. Transmission of hepatitis C virus infection through tattooing and piercing: a critical review. Clin Infect Dis. 2012;54:11671178 Kluger N. Acute complications of tattooing presenting in the ED. Am J Emerg Med. 2012;30:2055-2063 Hourmozdi JJ, Hawley DA, Hadi CM, et al. Streptococcal necrotizing myositis: a case report and clinical review. J Emerg Med. 2014;46:436-442 Binic I, Jankovic A, Ljubenovic M, et al. Mycobacterium chelonae infection due to black tattoo ink dilution. Am J Clin Dermatol. 2011;12:404-406 Falsey RR, Kinzer MH, Hurst S, et al. Cutaneous inoculation of nontuberculous mycobacteria during professional tattooing: a case series and epidemiologic study. Clin Infect Dis. 2013;57:e143-147 Kluger N, and Koljonen V. Tattoos, inks, and cancer. Lancet Oncol. 2012;13:e161-168 Luebberding S, and Alexiades-Armenakas M. New tattoo approaches in dermatology. Dermatol Clin. 2014;32:91-96 De Argila D, Chaves A, and Moreno JC. Erbium:Yag laser therapy of lichenoid red tattoo reaction. J Eur Acad Dermatol Venereol. 2004;18:332-333 Hindson C, Foulds I, and Cotterill J. Laser therapy of lichenoid red tattoo reaction. Br J Dermatol. 1995;133:665-666 Harper J, Losch AE, Otto SG, et al. New insight into the pathophysiology of tattoo reactions following laser tattoo removal. Plast Reconstr Surg. 2010;126:313e-314e Kluger N. The risks of do-it-yourself and over-the-counter devices for tattoo removal. Int J Dermatol. 2015;54:13-18 Rao PV, and Gan SH. Recent Advances in Nanotechnology-Based Diagnosis and Treatments of Diabetes. Curr Drug Metab. 2014
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Pokorna D, Rubio I, and Muller M. DNA-vaccination via tattooing induces stronger humoral and cellular immune responses than intramuscular delivery supported by molecular adjuvants. Genet Vaccines Ther. 2008;6:4 Simunovic C, and Shinohara MM. Complications of decorative tattoos: recognition and management. Am J Clin Dermatol. 2014;15:525-536
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Table 1. Tattoo reactions ((8) and (20) for review). Psoriasis Lichen planus Lichen sclerosus SCLE-like Atopic dermatitis Contact dermatitis Foreign-body type Sarcoidal Granuloma annulare-like Necrobiosis lipoidica-like
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Inflammatory Isomorphic/koebner
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Lichenoid reactions Eczematous reactions
Bacterial infections
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Vasculitis Cutaneous lymphoid hyperplasia/pseudolymphoma Morphea Pseudocarcinomatous hyperplasia
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Granulomatous reactions
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Viral infections
Fungal infections Parasitic Infections Neoplasms
Impetigo Cellulitis, Abscess Bacteremia Streptococcal necrotizing myositis Necrotizing fasciitis Epidural abscess NTM M. Tuberculosis M. Leprae Syphilis Blood borne pathogens
HBV HCV HIV
Human papilloma virus Molluscum contagiosum Herpes simplex virus Dermatophytosis Zygomycosis Leischmaniasis
Keratoacanthoma Squamous cell carcinoma Basal cell carcinoma Melanocytic nevi Melanoma Leiomyosarcoma Primary cutaneous B-cell lymphoma
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Figure 1. Examples of commercially available tattoo inks containing azo dyes.
Figure 2. Tattoo technique. Components of the tattoo machine are either single use,
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sterilized, or cleaned and covered for use.
Figure 3. Red tattoo reaction showing indurated papules and plaques involving only the
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red-inked areas.
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Figure 4. Tattoo ink ingredients.
Figure 5. Sarcoidal tattoo reaction involving only the black ink; the patient’s tattoo had
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been placed 20 years prior.
Figure 6. Bullous contact dermatitis to a henna temporary tattoo.
Figure 7. Squamous proliferation consistent with keratoacanthoma occurring within a tattoo.
Figure 8. Non-tuberculous mycobacterial infection occurring within tattoo, with pustules and erythematous papules appearing approximately 2 weeks after tattoo placement.
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ACCEPTED MANUSCRIPT Michi Shinohara, MD Autobiographic Sketch Dr. Shinohara was born and raised in Anchorage, Alaska, the first-born to a latte-loving
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journalist born in Nome, Alaska, and a first generation Japanese novice sports fisherman
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who taught English as a second language. She attended Reed College in Portland, Oregon, starting as an art major, but falling victim to the geeky-cool lure of the sciences
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and graduating majoring in Chemistry. She attended the University of Washington
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School of Medicine in Seattle. Her broad interests led her first to internal medicine residency at the University of Washington, however, exposure to dermatology clinics
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during her medicine residency led to a second residency in dermatology. After a dermatopathology fellowship at the University of Pennsylvania, she returned to the
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Seattle area to join the faculty at University of Washington, where she has dual
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appointments within Dermatology and Dermatopathology. She specializes in the care of complex medical dermatology patients, and maintains a multidisciplinary Cutaneous
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Lymphoma Clinic in addition to holding the title of Director of Inpatient Consultative
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Dermatology at the University of Washington Medical Center. Her interest in tattoo relates back to her long-standing love of art, and merges this with medicine.
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