Lessons learned in a decade: Medical-toxicological view of tattooing.

Tattooing has been part of the human culture for thousands of years, yet only in the past decades has it entered the mainstream of the society. With the rise in popularity, tattoos also gained attention among researchers, with the aim to better understand the health risks posed by their application. 'A medical-toxicological view of tattooing'-a work published in The Lancet almost a decade ago, resulted from the international collaboration of various experts in the field. Since then, much understanding has been achieved regarding adverse effects, treatment of complications, as well as their regulation for improving public health. Yet major knowledge gaps remain. This review article results from the Second International Conference on Tattoo Safety hosted by the German Federal Institute for Risk Assessment (BfR) and provides a glimpse from the medical-toxicological perspective, regulatory strategies and advances in the analysis of tattoo inks.

Tattoo-Associated Skin Reactions: A Danish Population-Based Survey in 5,914 Tattooed Individuals.

BACKGROUND: In Europe, Australia, and the USA, the estimated overall prevalence of tattooing is around 10-20%. Tattoo ink often comprises harmful chemicals and epidemiological studies on adverse effects of tattoos are lacking. OBJECTIVES: We aimed to estimate the prevalence of tattoo-associated skin reactions in the general Danish population and describe individuals with tattoo-associated skin reactions by socio-demographic factors and tattoo characteristics. METHODS: The study was based on respondents aged 16 years or older from a population-based 2021 survey entitled "How are you?" conducted in the Central Denmark Region (n = 33,925). Logistic regression was used to characterise individuals with tattoo-associated skin reactions by socio-demographic factors (gender, age, educational level, and ethnic background). Also, the relationship between size, age and colour of the tattoo, and tattoo-associated skin reactions was studied. Model 1 was adjusted for all socio-demographic variables (gender, age, educational level, and ethnic background); model 2, for all socio-demographic variables and tattoo characteristics (size, age, and colour). RESULTS: In total, 21.1% reported that they had at least one tattoo, 10.2% hereof reported that they had experienced tattoo-associated skin reactions (itching, pain, inflammation, and swelling) beyond the first 3 weeks after the tattoo was made. Lower age (16-44 years) (adjusted odds ratio (AOR) ≥1.75), larger tattoos (AOR ≥1.61) and having had tattoos for more than 10 years (AOR = 2.92, 95% confidence interval 1.45-5.88) increased the odds of tattoo-associated skin reactions. In general, tattooed individuals with colours other than black had higher odds of tattoo-associated skin reactions. CONCLUSION: Among participants with at least one tattoo, 10.2% had experienced tattoo-associated skin reactions beyond the first 3 weeks after their tattoo was made. This finding highlights the need for safer tattoo inks to prevent the adverse health problems experienced by many individuals with tattoos.

MRI-Induced Neurosensory Events in Decorative Black Tattoos: Study by Advanced Experimental Methods.

Adverse reactions in tattooed skin during magnetic resonance imaging (MRI) are rare but well known. Previous reports describe sudden burning pain in tattooed skin, sometimes accompanied by mild erythema and oedema when entering MRI scanners. The pathophysiology remains unclear, but simple direct thermal heating can be excluded. It has been hypothesized that MRI-triggered torque and traction create neural sensations from magnetic pigment particles. However, this case enlightens yet another possible mechanism. We present a 35-year-old woman experiencing reoccurring stinging sensations in three decorative black tattoos just seconds after the initiation of the MRI. Single-blind tests with handheld power magnets or a dummy could reproduce painful subjective feelings in her tattooed skin. Similar events were provoked during re-evaluation with MRI. Surprisingly, chemical analyses and electron microscopy of skin samples revealed carbon black as the colouring agent - no iron-based solids were detected. Our case demonstrates that MRI tattoo reactions are not limited to magnetic contaminants alone. More distinct subgroups of MRI-induced reactions may occur. We hypothesize that radiofrequency induction of surface currents in black carbon particles adjacent to sensory axons in the dermis may lead to neurosensations.

On the mechanism of painful burn sensation in tattoos on magnetic resonance imaging (MRI). Magnetic substances in tattoo inks used for permanent makeup (PMU) identified: Magnetite, goethite, and hematite.

BACKGROUND: Persons with cosmetic tattoos occasionally experience severe pain and burning sensation on magnetic resonance imaging (MRI). OBJECTIVE: To explore the culprit magnetic substances in commonly used permanent makeup inks. MATERIAL AND METHODS: 20 inks used for cosmetic tattooing of eyebrows, eyeliners, and lips were selected. Ink bottles were tested for magnetic behavior with a neodymium magnet. Eight iron oxide inks qualified for the final study. Metals were analyzed by Inductively Coupled Plasma Mass Spectrometry (ICP-MS). The magnetic fraction of inks was isolated and analyzed by X-ray fluorescence (XRF). Magnetic iron compounds were characterized by Mössbauer spectroscopy and powder X-ray diffraction (XRD). RESULTS: ICP-MS showed iron in all magnetic samples, and some nickel and chromium. Mössbauer spectroscopy and XRD detected ferromagnetic minerals, particularly magnetite, followed by goethite and hematite. CONCLUSION: This original study of cosmetic ink stock products made with iron oxide pigments reports magnetic impurities in inks for cosmetic tattooing, e.g., magnetite, goethite, and hematite. These may be the main cause of MRI burn sensation in cosmetic tattoos. The mechanism behind sensations is hypothesized to be induction of electrical stimuli of axons from periaxonal pigment/impurity activated by magnetic force. Magnetite is considered the lead culprit.

Psoriasis and seasonal variation: A systematic review on reports from Northern and Central Europe-Little overall variation but distinctive subsets with improvement in summer or wintertime.

BACKGROUND: Positive influence of the sun on psoriasis is a common assumption in dermatology. Other season-related factors such as mental health may interfere. However, the role of seasonal effects on psoriasis needs to be clarified. This review aims to systematically analyze the literature on seasonal variation on psoriasis with emphasis on Northern and Central Europe representing temperate climate conditions. MATERIALS AND METHODS: Enrolled literature was identified through PubMed, EMBASE, and BIOSIS. An additional manual search of old reports before the introduction of efficient modern therapies, which can interfere with the spontaneous disease, was performed. RESULTS: Thirteen studies were enrolled. About 50% of psoriasis patients were stable and showed no seasonal difference between seasons. Approximately 30% improved in summer, and 20% performed better in winter, some with marked summer worsening. European results matched international reports from different continents and hemispheres with climate extremes. The psychological effects could not be ruled out. CONCLUSION: About 50% of psoriasis patients experience a season-independent disease, however, with a subset of patients who do better in summer. Others again do better in winter, with a few of these having marked worsening in warm periods. Individual season-related activity records should be paid proper attention to when considering light therapy or climatotherapy as a treatment.

Tatoo Ink, Magnetism and Sensation of Burn during Magnetic Resonance Imaging, and Introduction of Hand-Held Magnet Testing of Commercial Tattoo Ink Stock Products prior to Use.

Cosmetic tattoos may cause burning sensation during magnetic resonance imaging (MRI) and interrupt the procedure, and thereby any diagnostic workup. Tattoos also may cause disturbing artefacts in MRI images. The sensation, which can be painful, is due to magnetic elements in the tattoo ink deposited in the tattooed skin. It is not a thermal burn but a subjective sensation of burning. Tattoo ink bottles can be tested for magnetic properties by the artist in the studio, before cosmetic tattooing is performed, using a simple magnet test. This test and the pitfalls of the test are described. Hospital departments and clinics should be aware of the problem, and patients assessed prior to MRI regarding their tattoos, particularly eyebrows and eyeliners made in brown and dark colors. Red tattoos exemplified by tattooed lips are not prone to MRI-induced burning sensation. The problem is related to inorganic pigments with ferromagnetic properties.

A Practical Approach to Cosmetic Tattoo Removal with the Nd:YAG Laser.

The Q-switched neodymium-yttrium aluminium garnet (Nd:YAG) laser remains the gold standard method for tattoo removal including cosmetic tattoos. Modern picosecond lasers are referenced to the Nd:YAG laser and essentially do the same job. Persons with cosmetic tattoos in the face are especially eager to achieve perfect removal or correction and from start are critical to suboptimal results. Customers mostly request complete removal; sometimes the goal is fast treatment and bleaching to prepare for a cover up tattoo. Removal or correction of eyebrows is the largest group, followed by lip tattoos and eyeliners. The article gives a systematic and stepwise introduction to routine cosmetic tattoo removal by laser in an Austrian private medical practice. Rationales and selection of customers who can benefit from treatment, preparation, performance, and aftercare is reviewed. Emphasis is given to qualified power adjustment of the laser equipment and the treatment strategy, e.g. the delicate navigation between efficient removal and the risk of short-term and long-term adverse effects. Treatment relies on a partnership between provider and customer. Over the months of treatment, customers gain more insight into the possibilities of treatment, so that they get an understanding of the realistic results that can be achieved. Therefore, customers are also satisfied even with results that are not always optimal since best treatment was given a fair chance.

High-Frequency (20 MHz) Focused Ultrasound: A Novel Method for Noninvasive Tattoo Removal.

Alternatives or complements to laser tattoo removal are needed. Laser removal requires 8-12 sessions and can easily take longer than a year. Some colors cannot be removed, and scars may appear. Applied to allergic reactions in red tattoos, lasers can boost the allergy. A recently developed 20 MHz high-intensity focused ultrasound (HIFU) is introduced as a complementary method to lasers, but also as a stand-alone treatment for selected groups. 20 MHz HIFU allows for application of high-power ultrasound energy to very small focal targets in the dermis, and thereby precise confinement of thermal lesions in the outer layers of human skin, precisely where tattoo inks are deposited. HIFU treatment is "color blind" and can target any type of colored pigment in the dermis. It produces a controlled thermal lesion (up to 65°C) with superficial necrosis followed by an eschar with embedded tattoo pigment. This eschar, containing the tattoo pigment, is discharged over some weeks, and finally replaced by healed skin. HIFU can efficiently remove tattoos of any color in only 1-3 sessions. It can be applied to tattoos when lasers fail to produce efficient removal. The types of side effects are the same as with lasers. The operator shall be trained and knowledgeable. 20 MHz HIFU can furthermore be used in clinical and esthetic dermatology for various other applications, and a range of applications are open in clinical dermatology.

Tattooing of the Lips by Needle Technique: Artwork and Performance.

Lip tattooing for cosmetic or medical purposes is a difficult operation with indications and contraindications. Lips have a refined microanatomy and many functions ranging from aesthetics and mimics supporting facial expressions to entirely biological functions such as supporting oral functions and servicing sound expression as part of linguistic performance. The anatomy of the lip is explained and illustrated. In lip tattooing, the outlining and enhancement of contour particularly towards the philtrum is important along with keeping symmetry and shape right and as intended. The coloring of the vermilion and dosing of tattoo pigment is another challenge. The article reviews the technical and artistic aspects of lip tattooing down to detail and step by step procedures starting with client selection, strategy planning, and informed consent. Pitfalls and complications are described. When applied as a corrective operation as part of reconstructive plastic surgery, a close cooperation with medical specialists is needed. Lip tattooing appears underrated regarding medical usefulness. The review can be used as a tutorial in the training of newcomers in the field, having a cosmetic or a medical purpose, same technique.

The Sudden Rise of Cosmetic and Medical Tattoos on All Continents.

Cosmetic tattooing dedicated to beautifying the normal anatomy such as the eyebrows, the eyelines, or the lips is in a remarkable growth all over the world. Medical tattooing with reconstruction of the areola and the nipple after breast surgery, correction of the lost color of vitiligo and scars is a spin-off, which has made tattooing cross the barrier and become accepted and used in clinics and hospitals in service of the quality of life of patients. The last years have seen a major development of machinery, inks, techniques, experiences, and services. The overwhelming rise of the activity created by client pressure and business opportunity, however, also has its cons: amateur work and even malpractice. The development is driven by elite technicians, but competence is little transparent to clients, and there is no distinct authoritative recognition of practitioners based on a recognized educational curriculum. National regulations of the industry are highly variable and scattered. Some countries have no restriction and in others cosmetic tattoos shall be performed by medical doctors. The challenge of the coming decades is to parallel the success of the industry with quality assurance to better control practices and safeguard clients, and the patients.

Sarcoid Granulomas and Systemic Sarcoidosis Triggered by Cosmetic Tattoos.

Cosmetic tattooing of eyebrow and lips has become very popular and is expected to be paralleled by more frequent complications. We present 4 cases of granulomas in cosmetic tattoos complicated by regional or systemic manifestations of sarcoidosis including affection of the lungs in 2 cases, the activity triggered by the tattoo. Three cases of traditional decorative tattoos on extremities serve as reference. It is noteworthy that cosmetic tattoos despite small size and thereby low relative dose of pigment injected in the skin can trigger fully developed systemic sarcoidosis. It is hypothesized that iron oxide pigments popular in cosmetic tattoo inks of red or brown color may be prone to elicit sarcoid reactions and thus carry a special risk of granuloma. In decorative tattoos, carbon black is the commonest trigger. It is emphasized that the finding of granulomas in tattoos shall be followed by search of other manifestations of sarcoidosis through patient history and diagnostic examinations to exclude pulmonary, ocular, and other organ manifestations. Patients with granulomas in tattoos shall be informed that active sarcoidosis, if not already present, can become manifest later with a latency of months or years and often with abrupt debut when the triggering tattoo may be overlooked by the doctor who is unfamiliar with this less common type of sarcoidosis.

Technical and Clinical Complications of Cosmetic Tattooing.

Cosmetic tattooing and medical tattooing of the face share basic principles and to some degree types and spectrum of technical and clinical complications known from decorative tattooing of other parts of the body. Cosmetic tattoos recently have grown exponentially in popularity in industrialized countries all over the world. The different complications and their clinical symptoms, pathophysiology, diagnosis, treatment, and prevention are analyzed versus culprit pigments and updated. Eyeliner tattooing is associated with special complications because of the subtle anatomy and the closeness to the eye, and the risk of meibomian gland damage. The spectrum of cosmetic tattoo complications includes early-onset complications (infections particularly with herpes simplex, healing issues, aesthetic and technical mistakes with regret), and late-onset complications (color fading and color shift, "blowout" pigment escape to surrounding skin, papules, nodules, granulomas associated with sarcoidosis, allergic reactions in lip tattoos with lichenoid dermatitis, eye irritation, and fibrosis and scaring especially after microblading); miscellaneous complications include severe burn sensation in tattoos during magnetic resonance imaging later in life. Corneal tattooing and subconjunctival/episcleral tattooing performed on medical indication by ophthalmologists, and for decoration by tattooists carry special risk of intraocular complications. It is recommended for the purpose of research harmonization that terms and diagnostic classification of tattoo adverse events follow the system introduced by the Tattoo Clinic of Copenhagen and already accepted in specialized tattoo clinics in other centers.

Color Biophysics and the Human Color Perception in Relation to Pigments and Tattooed Skin.

Perception of skin color in the natural state, or with tattoo pigment installed in the dermis is highly complex and includes both optical requisites and eye and brain functions connected to advanced cognitive and psychological functions. Permanent makeup (PMU) is miniaturized tattooing on critical anatomical location aiming at fulfilment of a person's esthetic ideal. It is a special challenge since a satisfactory outcome depends on perfectionated technique and very critical selection of pigments. The eye can be compared to a digital camera, and the center of central vision in the brain to a computer and color integrator. Color perception is the end product of a complicated brain function. The background theory of color physics and perception is reviewed with emphasis on aspects related to changed skin color created by pigment installed in the dermis with the purpose to tattoo eyebrows, eyeliners, lips, and other locations. The delicate dosing of pigment relative to the natural skin tone is highlighted. The review is relevant for all aspects of PMU including medical tattooing, e.g., areola tattooing after breast cancer surgery. A detailed guidance to PMU artists and medical tattooists on selection and use of tattoo inks and pigments is provided. The guidance is also relevant to laser surgeons and technicians performing tattoo removal.

Auxiliary Utensils in Cosmetic and Medical Tattoo Settings.

Cosmetic and medical tattooing is miniaturized tattooing of high precision and thus requires many dedicated utensils including advanced devices for marking and anatomical delineation. Symmetry is a special demand, as is aesthetic outcome, building on perfectionated detail. The artist shall master design and strategy along with advanced technical performance helped by having and using the right tools. This article reviews and illustrates the many special utensils involved in good-practice cosmetic and medical tattooing, exemplified by selected tools used for cleansing, disinfection, pre-operative measurement and marking, and special tattoo machines, cartridges, microblades and needles. Personal protective equipment used to prevent infections among technicians and customers are also illustrated. Educational tools, such as face phantoms and eyebrow mats, are displayed. Mastering cosmetic and medical tattooing is a challenge and involves mastering the many auxiliaries along with needle configurations, machines, inks and the whole setting of the activity. This review is an illustrated practical record and a guideline to good professional practice.

Linearity and Surface Anatomy of the Face: From Embryo to Senescence.

Furrows, lines and wrinkles with distensibility and retractility are a biological need of skin in the service of skin integrity, plasticity and joint motion. The fundamental segmentation and linearity of skin is genetically coded, manifested early in embryonal life and remarkably constant throughout life. The basic pattern established early in embryonal life when facial segments expand and fuse is confounded by overlapping linearities of different backgrounds. Embryonal skin and skin in childhood, puberty, adult life and senescence undergo a general change in the direction of disturbed structure, nevertheless respecting the originally coded and segmented linearity. The fundamental linearity is expressed as the naso-frontal, maxillary and mandibular segments of the primitive face and the extremity buds forming extremities. The sensory nerves in this phase of morphogenesis follow and invade the segments of the face, trunk and extremities and form dermatomes,replicating the tissue segments. Early on, CREST cells migrate from behind, from the neural crest, and seed a normally hidden linearity in the tissues, which may appear as scleroderma lines, particularly the vertical "en coup de sabre" line(s) in the front. Later in pregnancy, during the phase of volume expansion, the resultant horizontal force applied to the outer skin results in gliding of epidermal structures relative to the underlying dermis, resulting in hair streams and whorls and bizarre V-shaped figures known as Blaschko's lines.Hairs in this process achieve their final distribution and inclination relative to the skin surface, known as Voigt's hairstreams and whorls. The dermatoglyphic lines and whorls of finger pulps share features with the two linearities explained by outer skin gliding. The fibre network of the dermis has uneven pretension, and circular wounds retract and become oval, systematically mapped as Langer's lines. Surgical incision lines influenced by static and dynamic forces to normal skin are described as Kraissl's linesand Borge's linesused to guide surgical incisions.Gravity acts as a constant vertical force on the face and entire body and results over years in gravitational lines, furrows and "hanging" skin. The sun creates its own pattern of disturbed linearity, photodamage lines and patterns that overrule the minute triangularlinearity, with accumulation of elastotic material in the dermis. Poor lifestyle and medical and psychiatric disease are associated with preterm skin ageing and increased furrowing. Skin linearity is complex with overlapping patterns. A broad insight into the essentials of skin linearity from the embryonal state to aged skin and senescence with an understanding and consideration of the ever-active influence of the genetic coding on skin linearities and ageing, including the forceful autoregulation aiming at the restauration of the natural state of the skin organ at any time and irrespective of interventions, is mandatory for professionals working on skin - plastic and aesthetic surgeons, dermatologists, cosmetologists, and cosmetic and decorative tattooists.

On the Use, Effectiveness, and Safety of Face Masks, Gloves, and Disinfectants to Prevent Transfer of Microbials between the Tattooist and the Customer: A Practical Review of Pros and Cons Including the Occupational Safety of the Tattooist.

Tattooists and their customers are under special risk of airborne infection because of the short distance during the procedure and the unavoidable exchange of expired and inhaled air potentially containing droplets holding pathogenic germs. Moreover, the manual procedure involves a significant risk of contamination through physical contact. A range of personal protective equipment (PPE) is available, including three-layered disposable surgical masks, cotton masks, respirators without or with expiration valve, visors and shields, goggles, medical gloves and aprons. Disinfectant fluids and wipes are used for skin and physical objects. Alcohol is used but may evaporate too fast and lose biocidal efficiency; it carries risk of fire. Alternatives such as chlorine and a range of new disinfectants listed in the EU biocide directive should be considered as alternatives. PPEs and disinfectants are subject to formal testing and classification. EU and US requirements are visited. No PPE and no disinfectant have 100% efficiency. Efficiency of masks is influenced negatively by the reduced breathability from masks and respirators with leakage of air between mask perimeter and the skin. Gloves have micro-porosity dependent on wear time and already after 30 min become less efficient. The humid microclimate under masks and gloves easily causes skin problems. Thus, there are many pros and cons to consider. Thoughts on ideal aim, sound sense and realistic application of PPE and disinfectants in daily routine in tattoo parlours are provided, the risk and health of the tattooist included.