Tattooist-Associated Tattoo Complications: "Overworked Tattoo," "Pigment Overload" and Infections Producing Early and Late Adverse Events.

BACKGROUND: Tattooist-related technical failures of tattooing were hitherto unstudied and related to clinical complications. Tattooing requires talent, training and experience. Amateurism is a challenge in popular tattoo industry with no formal education and certification of the tattooists. OBJECTIVE: To study technical tattoo failures causing disease in a consecutive hospital material of tattoo complications. MATERIAL: 574 patients with 702 tattoo complications referred to the "Tattoo Clinic" (a subspecialised dermatological clinic) were enrolled. Patients were examined clinically and classified with respect to the cause of complication. RESULTS: 147 (21%) tattooist and tattoo studio-related complications were recorded, i.e. excessive pigment installed in the dermis with "pigment overload" in 64 (9%), tattoo "needle trauma" with "overworked tattoos" in 43 (6%), contaminated ink causing infection in 20 (3%), and other sources of infections related to tattooing in 20 (3%). Pain and discomfort were particularly common as well as long-term complications including scarring induced by "needle trauma." "Pigment overload" with black pigment carried a special risk of granulomatous inflammation and sarcoid granuloma and was observed in 12/35 (34%) of punch biopsies taken from tattoos with "pigment overload." Keratoacanthoma associated with trauma was observed in 1 case. 82% of complications were related to professional tattooists working in a tattoo studio and 18% to amateurs. CONCLUSION: Technical failures of tattooing are associated with medical tattoo complications. "Needle trauma" with major skin damage, e.g. "overworked tattoo," and installation of excessive pigment, e.g. "pigment overload," and (re)use of contaminated tattoo ink bottles are identified failures calling for preventive intervention.

Cutaneous Mycobacterium massiliense infection from tattooing: a common yet under-reported and persistent epidemic hazard for dermatologists.

Tattoo popularity continues to rise, with 3 in 10 Americans bearing at least one. Among tattoo complications, non-tuberculous mycobacteria (NTM) has emerged as a global public health concern. NTM infections associated with tattooing of immunocompetent individuals have occurred as sporadic cases and community outbreaks. Water sources are considered the major pathogenic reservoirs. Tattoo-related inoculation has been linked to contamination of ink, either during the manufacturing process or during dilution of black ink using non-sterile water. NTM infections have also been documented in a number of cosmetic and surgical procedures, including cutaneous surgery, Mohs micrographic surgery, mesotherapy, liposuction and laser resurfacing. NTM inoculation through exposure to contaminated water or non-sterile instruments remains a challenge for dermatologists and risk to patients. We reported a case of cutaneous Mycobacterium massiliense infection following tattoo placement. This report underscores the importance of clinicians to consider NTM infections in the differential diagnosis of procedure-related reactions.

A Practical Guide About Tattooing in Patients with Chronic Skin Disorders and Other Medical Conditions.

With tattoos becoming increasingly mainstream, dermatologists are more and more often consulted by patients who are considering getting an ornamental, cosmetic, or even a medical tattoo, and who subsequently ask for advice. This includes not only patients with chronic skin diseases such as psoriasis or atopic dermatitis but also patients with other medical conditions. This review first explores the reasons why patients may want to get a tattoo and aims to offer some key information to dermatologists on what they should know about tattooing and the main risks associated with this procedure. Second, the risks and recommendations of tattooing in patients with specific skin diseases are described more in detail, and the relative and strict contraindications discussed, including the necessity to discontinue certain treatments that could influence the outcome of the procedure and the final result. Our aim was to provide dermatologists with the current knowledge they need to help their patients make adequate and informed choices on skin art, focusing specifically on considerations in patients with chronic skin conditions. Finally, other aspects regarding some general systemic conditions and concomitant diseases that the patient could present are also addressed. In particular, the risks of tattooing in patients with diabetes, coagulation disorders, heart conditions, immunosuppressive treatments, and pregnancy are discussed.

Centro de tatuajes y perforaciones corporales: norma técnica No. 25-2018 / Tattoo and Body Piercing Center: Technical Standard No. 25-2018

"El objeto de la presente Norma Técnica es regir las condiciones y requisitos mínimos que deben cumplir los establecimientos donde se realicen Tatuajes y Perforaciones por medio de procedimientos invasivos y/o perforaciones corporales, incluyendo los delineados en forma permanente que se realizan en las salas de estética, con el objetivo de lograr un servicio seguro y de calidad." Es de carácter obligatorio, por lo que se aplica en todo el territorio nacional. Contiene además, las definiciones de los conceptos relacionados al tema principal, además de la infraestructura que deberá tener cada clínica, incluidos el equipo y recurso humano y técnico.

Tattoo Infections, Personal Resistance, and Contagious Exposure through Tattooing.

Bacterial infection of tattoos remains a common complication. Pyogenic bacteria can cause infections shortly after the tattoo is made. Severity of infection varies from minor to major, ultimately with life-threatening septicemia. Viral infections may be introduced, i.e. HVB, HVC, and HIV. The risk of infection depends on the following triad: microbial pathogen and its aggressiveness, individual resistance of the tattooed, and inoculation and exposures by the tattoo needle and in the tattoo parlor. Some infectious risks can be controlled. Persons with weaknesses can refrain from tattooing. Tattoo parlors and tattooing can be hygienic and clean albeit not sterile; much has improved helped by hygiene guidelines of professional tattooists' organizations and through control instituted by local and national authorities. Tattoo inks remain a potential source of infection difficult to control in a low-priced competitive market operating over the Internet and across national borders. Ten percent of new inks are contaminated with bacteria pathogenic to humans, independent of a claim of 'sterility'. Known brands and established manufacturers are considered safer. Work is in progress aiming at common European standards for tattoo hygiene. Doctors have a role not only in treating tattoo infections but also in reporting cases to the competent authority in their country to support the monitoring of tattoo infections at any time, as an instrument for the authority to detect local outbreaks of tattoo infections early and prevent that new tattoo customers become infected. It is a potential risk of the future that new and very aggressive bacteria not seen in the past may unexpectedly show up in the tattoo scene.

Endoscopic tattooing to aid tumour localisation in colon cancer: the need for standardisation.

BACKGROUND/AIMS: An increasing number of colon and rectal tumours are being resected using laparoscopic techniques. Identifying these tumours intraoperatively can be difficult. The use of tattooing can facilitate an easier resection; however, the lack of standardised guidelines can potentially lead to errors intraoperatively and potentially result in worse outcomes for patients. The aim of this study was to identify the most reliable method of preoperative tumour localisation from the available literature to date. METHODS: A literature review was undertaken to identify any articles related to endoscopic tattooing and tumour localisation during colorectal surgery. RESULTS: To date there is still mixed evidence regarding tattooing techniques and the choice of ink that should be used. There are numerous studies demonstrating safe tattooing techniques and highlighting the risks and benefits of different types of ink available. CONCLUSION: Based on the available studies we have recommended a standardised approach to endoscopic tattooing of colorectal tumours prior to laparoscopic resection.

The Demographics and Rates of Tattoo Complications, Regret, and Unsafe Tattooing Practices: A Cross-Sectional Study.

BACKGROUND: Tattoos have become increasingly common in the United States; however, there are limited data on the rates of tattoo complications and tattoo regret. OBJECTIVE: To determine the rates of infectious and allergic complications after tattooing, rates of tattoo regret, the perception of dermatologists among people with tattoos, and the demographics of people with tattoos. MATERIALS AND METHODS: An 18-question cross-sectional survey was fielded in New Orleans in January 2015. Participants had to be at least 18 years old, have at least 1 tattoo, and reside within the United States. RESULTS: In total, 501 participants from 38 American states were enrolled. Of all participants, 3.2% had a history of an infected tattoo, 3.8% had a history of a painful tattoo, and 21.2% had a history of a pruritic tattoo; 16.2% of participants regret a current tattoo and 21.2% are interested in having 1 or more tattoos removed; 21.2% received a tattoo while intoxicated and 17.6% had a tattoo placed somewhere other than at a tattoo parlor; and 78.9% believe dermatologists are knowledgeable about the infectious and allergic complications of tattoos. CONCLUSION: Given the rates of pruritic tattoos and tattoo regret, there is an opportunity, and trust among people with tattoos, for dermatologists to manage these complications.

[Colonoscopic Tattooing of Colonic Lesions].

With the development of minimal invasive surgery including laparoscopic and robot surgery, colonoscopic tattooing of colonic lesions is becoming more important to ensure easy localization of the lesion during surgery. Lack of accurate lesion identification during minimal invasive surgery may lead to resection of wrong segment of the bowel. In this article, some topics including proper materials, injection technique, and safety of colonoscopic tattooing are reviewed.

Non-tuberculous mycobacterium skin infections after tattooing in healthy individuals: A systematic review of case reports.

In recent years, several case reports and outbreaks reported occurrence of non-tuberculous mycobacteria (NTM) infections within 6 months after receiving a tattoo in healthy individuals. NTM species (e.g., Chelonae, Fortuitum, Hemophillum, and Abscessus) are widespread in the environment and it is often suspected that contamination may occur through unsterile instrumentation or unsterile water used for diluting tattoo ink to dilute color. In reported cases, lesions were mainly restricted to a single color 'gray' part of the tattoo. Mycobacterium Chelonae was the most common cause of tattoo associated NTM infections. Less than 50% of the case reports tested tattoo ink for acid fast bacilli stains and cultures. Subjects required treatment with either clarithromycin alone or in combination with quinolones for 6 to 9 months. An increase in NTM skin infections in healthy individuals after tattooing indicates the need for sterile standards during tattooing and improved local and regional regulatory oversight.

Preoperative endoscopic tattooing to mark the tumour site does not improve lymph node retrieval in colorectal cancer: a retrospective cohort study.

BACKGROUND: A direct correlation between number of lymph nodes retrieved and evaluated after a colectomy for colorectal cancer and survival of the patient has been reported, and consensus guidelines recommend to assess at least 12 lymph nodes for adequate staging. Many factors (i.e., patients' and tumour characteristics, surgeon, and pathologist) may influence the evaluation of the presence of neoplastic disease in lymph nodes as well as the total number of lymph nodes examined. Preoperative endoscopic tattooing to mark the site of the tumour has recently been suggested to facilitate the retrieval of lymph nodes in colorectal specimens. The aim of this study was to investigate its association with adequate lymphadenectomy (≥12 nodes) after colorectal resection for cancer. RESULTS: All patients undergoing elective colorectal resection for cancer between 2009 and 2011 at the S. Anna University Hospital in Ferrara, Italy (N = 250) were retrospectively divided into two cohorts according to whether ink tattooing to mark the tumour site was performed during preoperative colonoscopy. The two cohorts were comparable regarding age, gender, body mass index, tumour location and size, TNM staging, and DNA microsatellite instability-high status. No difference between the tattoo (N = 107) and control (N = 143) groups could be detected in the rate of adequate lymphadenectomies performed (78% vs. 79%, p = 0.40). All factors known to influence lymph nodes retrieval from colorectal specimen were specifically evaluated. Rectal and colonic cancers were analysed together and separately. Full adjusted logistic regression analysis in patients who underwent colonic resection showed that right hemicolectomy (OR 4.72; CI95% 1.09-20.36) was the only factor associated to adequate lymphadenectomy. No association between ink tattooing performed preoperatively to mark the site of the tumour and adequate lymphadenectomy after colorectal resection was found with logistic regression analysis. CONCLUSION: This study shows that preoperative ink tattooing utilized to mark the site of the tumour does not improve adequate lymphadenectomy and lymph nodes yield from colorectal cancer specimens. Further studies are therefore needed to determine if preoperative colonoscopic tattooing to mark the tumour site can refine staging.

Survey of studies on microbial contamination of marketed tattoo inks.

Tattooing became a popular phenomenon during the late twentieth century. Because the act of tattooing involves repeated injection of ink through the skin, a risk of contracting infections from contaminated tattooing equipment and ink and the surrounding environment exists. Progress has been made in infection control strategies; however, contraction of bacterial and viral infections from tattooing continues to occur. The risk of acquiring a tattoo-related infection largely depends on the hygiene conditions under which the tattoo is applied. Nevertheless, even when adequate hygiene and sanitation measures are taken, the inks themselves may contain infectious microorganisms that are able to survive under hostile conditions, such as in inks. The results of the few studies on the microbiological quality of unopened and opened tattoo inks are reported. Some authors' conclusions demonstrated that the current ink sterilisation systems show a low capability to inactivate microbial contamination in tattoo inks. At the moment, European Resolution ResAP2008-1 recommends that the ink be sterile and supplied in containers that maintain the sterility of the product until application. In light of the outcomes of published studies, at the moment, preservation of the microbial quality and safety of ink seems challenging and still difficult to reach.

Implementation of European Council resolution ResAP(2008)1 in Italy. National and regional regulation of tattoo practices: diversity and challenges.

In Italy, tattoos and permanent make-up have become increasingly popular in recent years. The number of tattoo parlours has increased from 257 in 2009 to 2,055 in 2014, wich is a eight-fold increase over the last 6 years. Although there is no specific legislation, the Italian Ministry of Health issued a document containing the 'Guidelines for the implementation of procedures for tattooing and piercing in safe conditions'. This document has not been adopted by all Italian regions, principally regarding training course requirements for tattoo professionals, creating a highly fragmented situation that resembles the European scene in miniature. ResAP(2008)1, which is not mandatory in Italy but was made binding by Italian Decree n. 206/2005, has been applied uniformly throughout the country. Thus, as far as the safety of inks is concerned, the surveillance system appears to be working well. However, surveillance has highlighted the presence of non-compliant inks and potentially unsafe preparations for tattoo removal in the market. Updating and rebalancing the situation will be the goal in order to face the challenge of combining well-being with the on-going social demand of looking after and beautifying the body. This would include the growing fashion of tattoos, provided that the products that are used are safe and that tattooing is performed in controlled hygienic conditions that fully guarantee the health of consumers.

The Amsterdam model for control of tattoo parlours and businesses.

In the early 1980s, an outbreak of hepatitis B in Amsterdam stood at the start of the development of the first hygiene guidelines for tattooists in The Netherlands. Ever since, infection control in tattoo practice has continued to prove its importance as tattoo-related outbreaks of infectious diseases have continued to be reported in Europe. Furthermore, the act of tattooing includes breaking the skin barrier but is performed by professionals who are not medically trained. The Ministry of Health has now implemented uniform regulations that apply to professionals who perform tattooing and apply permanent make-up. These regulations include hygiene guidelines that were developed by the National Institute for Public Health and the Environment in cooperation with representatives of the tattooing associations. The guidelines contain a list of requirements, including for the studio interior, the cleanness of the studio, the safe use of permitted equipment and products, sterilization methods, and the information provided to the customer. A permit may be granted after an inspection by the local health service, during which the act of tattooing has to be performed. It is now estimated that over 95% of all tattoos in The Netherlands were obtained at one of the almost 900 licensed studios. Reports of complications are generally low in number. We suggest that uniform European hygiene guidelines would further contribute to the safety of tattooing.