"Tattoo Characteristics and Testing for Body Dysmorphic Disorder: An Internet-based Self-questionnaire Survey of 4,809 Individuals with Tattoos".

Tattoos have become very popular worldwide in recent years. The aim of this study was to analyse a group of people interested in having tattoos, and screen them for body image disturbances. This cross-sectional self-administered internet-based survey included 4,809 individuals interesting in having tattoos. The majority of the study population were female (79.1%). The survey was conducted using a self-created questionnaire and the Body Dysmorphic Disorder Questionnaire - Dermatology version. Most tattoos in the study group were located on the forearms and hands (28.1%). The most popular motifs were plants (17.5%) and animals (16.9%). Out of 4,809 individuals, 19.9% had problems with acceptance of some parts of their body and 9.8% were screened for body dysmorphic disorder with the Body Dysmorphic Disorder Questionnaire - Dermatology version. Four percent of individuals reported that tattoos helped to improve their own perception of the appearance of their body by distracting attention from the other problems. Limitations of this study include possible participant selection bias and the overrepresentation of women. In conclusion, clinicians may expect to see more patients with tattoos and, of these, approximately 10% may be screened for body dysmorphic disorder.

Retrospective clinical evaluation of Q-switched Nd:YAG laser safety and efficacy in tattoo removal: A new perspective on the Kirby-Desai scale.

BACKGROUND: With nearly 50% of the population in the United States, Italy, and Sweden tattooed with at least one tattoo, the demand for its removal has risen by 32% since 2011. Traditional removal methods, such as Q-switched (QS) laser-based tattoo removal, can be lengthy, requiring up to 20 sessions. AIM: This study presents a retrospective clinical evaluation of seven short-pulsed QS, dual-wavelength Nd:YAG laser, as an efficient alternative, that can potentially reduce the number of sessions needed as calculated by a founded scale. METHODS: The QS modality delivers high-intensity pulses in four wavelengths, ideal for removing multicolored tattoos, of which two were used. We studied 11 patients who underwent 3-8 treatments (average 5.09) every 2-3 months. Each tattoo was assessed using the Kirby-Desai scale, considering the following factors: location, Fitzpatrick skin type, ink amount, layering, scarring, tissue changes, and tattoo color. Follow-ups were conducted after 6 months and at 4-5 years following last session. RESULTS: The long-term follow-up presented a significantly higher tattoo removal efficiency than the short-term follow-up (p < 0.001), indicating a sustained process of ink breakdown and elimination. Notably, the actual number of treatments were significantly lower than that predicted by the Kirby-Desai scale (average 5.09 vs. 9.9, p < 0.001). No severe adverse events were reported. CONCLUSIONS: In conclusion, the QS Nd:YAG laser offers a safe and effective alternative for tattoo removal, requiring fewer treatments than initially expected.

Tattoo-induced allergic contact dermatitis presents diagnostic challenge as a cellulitis mimic.

Allergic contact dermatitis (ACD) is a prevalent condition associated with numerous potential allergen exposures. Tattoo ink is variable and may contain allergens that can be overlooked in patient education and diagnosis. We present a 27-year-old female with ACD following a new tattoo. The patient was repeatedly misdiagnosed with cellulitis by three different clinicians and treated with multiple antibiotics without improvement. The correct diagnosis was eventually made in the emergency department (ED). Although the patient was aware of her allergies to nickel and cobalt from patch testing, she was not aware of the potential for tattoo ink to contain these allergens because prior tattoos had not provoked an allergic reaction. Consequently, the appropriate care was delayed by a month, resulting in significant morbidity. This case demonstrates the potential for ACD to present similarly to cellulitis in an ED setting and the need for clinical vigilance in diagnosis of ACD. It also highlights the importance of detailed patient education on potential allergen sources particularly in the context of tattooing, which is performed with unregulated and variable ink products.

A Case of Persistent Macular Edema and a Disappearing Tattoo.

PURPOSE: To describe a case of macular edema (ME), uveitis, and a disappearing tattoo. METHODS: A single case report from a tertiary referral center. RESULTS: The patient described in the following case report developed ME 15 years after a recently acquired tattoo on his arm had developed an erythematous rash and subsequently spontaneously disappeared with pathology consistent with a granulomatous process. Chest imaging identified the development of hilar lymphadenopathy that had not been previously noted. CONCLUSIONS: This case represents a unique presentation of the delayed development of sarcoidosis many years after the patient had lost a tattoo to a dermal granulomatous reaction to the tattoo ink.

Lasers for the treatment of eyebrow microblading and cosmetic tattoo pigment: a review of the literature.

We aim to discuss the use of laser for the treatment of eyebrow microblading and cosmetic tattoo complications through a review of the literature. Our research question is whether quality-switched or picosecond laser is superior for the removal of eyebrow tattoos. This structured review was conducted using a PubMed search using the search terms "laser tattoo removal" AND "cosmetic tattoo" AND "eyebrow" with the article type filtered to "case reports," "clinical trial," and "randomized controlled trial" ranging from dates 1994-2023. All case reports or series evaluating the effect of laser on eyebrow cosmetic tattooing pigment were included. We summarize the results of 11 studies evaluating the use of laser for cosmetic tattoo removal, with 129 patients treated specifically for eyebrow pigment. Most studies (8/11) report Fitzpatrick skin type or race. Seven studies utilize quality-switched (QS) neodymium-doped yttrium aluminum garnet (Nd:YAG), alexandrite or ruby, three used picosecond (PS) Nd:YAG or alexandrite, and three used carbon dioxide (CO2) laser. We report laser energy, spot size, and pulse duration, as well as treatment outcomes and adverse events. Historically, methods of pigment removal included dermabrasion, cryosurgery, electrosurgery, radiofrequency, infrared light, intense pulsed light, and surgical excision; however, these methods often led to poor cosmetic outcomes including scarring and further dyspigmentation. QS laser treatments provided superior cosmetic outcomes and thus were considered the gold standard treatment option for pigment removal. However, the advent of PS lasers has challenged this given their increased selectivity, lower fluence requirements, and reduction in surrounding thermal damage. Our review demonstrates that PS Nd:YAG is quicker and more effective that QS Nd:YAG in the treatment of eyebrow tattoos. Additionally, the paradoxical darkening seen with QS lasers is less common with PS lasers. We also demonstrate that CO2 laser may be a helpful adjunct to QS or PS laser. This review focuses on Fitzpatrick skin type and race, providing a unique perspective on the use of laser treatment in skin of color, which often poses an additional treatment challenge.

Flat Warts (Verrucae Planae) Confined to the Pigment of a Tattoo: A Rare Tattoo-associated Complication.

Tattoos are a form of decorative body art in which pigment dyes of different colors are inoculated into the skin. It is estimated that 15-25% of general population has one or more tattoos (1), and the reasons for the popularity of this procedure may include greater social acceptance, aesthetic appeal, or perhaps the option of using laser removal techniques to eliminate unwanted tattoos. Even though modern professional tattoos are usually performed in sterile conditions, complications still occur, and with increasing numbers of people getting tattoos, the incidence of tattoo-associated side-effects presenting to dermatologists, which may be as high as 2%, is likely to increase (2). Herein we present a case of a 43-year-old male patient with multiple HPV-associated flat warts (verrucae planae) confined to the black pigment of a tattoo done 15 years ago. A 43-year-old patient presented to our clinic due to eczema on the trunk. However, during skin examination, we observed asymptomatic verrucous papules confined to the black ink of a tattoo done 15 years ago on the lateral side of his right lower leg (Figure 1a). Clinical examination showed multiple, discrete, skin-colored, verrucous papules disseminated exclusively within the lines of the black-colored tattoo. Full skin examination did not reveal any similar lesions anywhere else on the body. Dermoscopically, papules showed a discretely papillomatous surface and sharp borders (Figure 1b). The patient had another black tattoo on his trunk, in which no similar lesions were found. All his tattoos had been done more than 15 years ago in a professional tattoo salon and with no previous history of cutaneous lesions within tattoos. The patient had no other medical conditions and was not taking any medications. Additionally, no history of warts or other HPV-related lesions of the skin or mucosal membranes could be established. A biopsy of an individual papule was taken and sent for a histopathological analysis, which subsequently showed hyperkeratotic, orthokeratotic, and parakeratotic acanthotic epidermis with hypergranulosis and rare cells with perinuclear halo indicative of koilocytes (Figure 3b). Immunohistochemical analysis showed negative reaction for p16 and p53, while Ki67 was positive only in rare basal and suprabasal cells. These findings were indicative of low-risk HPV, and the diagnosis of HPV-induced verruca plana was ultimately established. The patient was then successfully treated with cautious curettage of the lesions, leaving no scars. Due to the growing popularity of tattoos, especially among younger populations, it is necessary to emphasize the possibility of various tattoo-related side-effects that can still occur due to improper preparation of the tattoo location, contamination of ink products, improperly sterilized instruments, or due to insufficient personal hygiene following tattooing (3). In the past, tattoo-associated infections were significantly more frequent, with the highest prevalence of Staphylococcus and Streptococcus infections causing impetigo, folliculitis, cellulitis, erysipelas, or sepsis (2), but recent improvement and efforts in using sterile techniques in tattooing has led to a significant drop in the number of tattoo-related infections. In this short report, we present a case of a different and a relatively rare type of tattoo-associated infection - flat warts i.e., verrucae planae. Flat warts are usually caused by HPV-3, -6B, -10, -28, and -49. Typical predilection sites are the face, dorsal sides of the hands or feet, arms, and legs, and they usually appear as skin-colored, pink, or brown, flat-topped discrete papules. It is believed that HPV can be inoculated through contaminated ink, instruments, the artist's saliva, or that it may be a pre-existing unnoticed wart in the tattooed area (4-6). The latency period between tattooing and HPV infection can range from several months to 10 years, with a mean period of 5 years (3). This may suggest that the immune system can control the infection for some time, and that some form of immune suppression may result in the development of a clinical disease. In our case, the latency period could not be established due to the patient's unawareness of the lesions, and no potential trigger could be identified. The occurrence of lesions on only one of the patient's tattoos as well as their confinement to the black pigmented ink may indicate a correlation to this specific pigment. Ramey et al. (6) conducted a study in which they assessed the localization of warts in differently colored tattoos. The results showed that black ink tattoos had a seven times higher risk of developing warts when compared with colored ink. At first it was thought that this was due to HPV inoculation via contaminated instruments, ink, or autoinoculation of the patient's own warts, but some evidence indicates that it is unlikely for HPV to survive in ink and that if the warts were inoculated they would occur equally in all ink colors. A different theory by Ruocco et al. (7) explains this phenomenon through an "immunocompromised district" mechanism, in which polycyclic aromatic hydrocarbons found in black ink produce reactive oxygen species (ROS) that can damage cellular structures and consequently increase the risk of a variety of infections, including HPV. Moreover, black ink contains almost pure nanoparticles, which are associated with greater ROS production than the larger particles found in colored ink (7,8). There are several treatment options for verrucae planae, such as liquid nitrogen cryotherapy, topical 5% fluorouracil, topical 5% imiquimod, 0.025-0.050% tretinoin, 10% salicylic acid, or 10-30% glycolic acid. These treatments have differing success rates. Destructive modalities, such as surgical excision, curetting, or laser ablation may significantly damage the tattoo and cause scarring, and are thus not regularly performed. It's necessary to emphasize that despite today's sterile methods of tattooing, complications may still occur and medical professionals, namely dermatologists, should be aware of them. A person who wishes to get a tattoo should be advised to visit a licensed tattoo artist at a licensed tattoo parlour only. Patients with pre-existing dermatoses characterized by an isomorphic phenomenon, such as psoriasis or lichen planus, are particularly prone to developing a tattoo-associated adverse reaction, and those with severe dermatoses should be advised to avoid tattooing. Additionally, people with a previous history of warts should be aware of the possibility of warts occurrence, even years or decades after tattooing. Even though most of tattoo-related side effects are merely inconveniences, there is a potential for serious complications and patients should be advised as such.

Monkeypox virus transmission in tattoo parlor.

In monkeypox virus (MPXV) transmission caused by contaminated material, we have to consider that recently the outbreak of several MPXV cases was linked to tattoo parlors in Cadiz, Spain. These tattoo parlors did not cause a single outbreak, but instead are an established transmission route for MPXV, underscoring the need for increased awareness. We recommend increasing awareness among tattooists and piercers not only to protect their own safety and health, but also to prevent spreading the virus to their customers. Personal protective equipment such as gloves should be utilized and vaccination can be considered for those at risk of occupational exposure.

PRESUMED PANUVEITIS FOLLOWING COVID-19 VACCINATION IN A PATIENT WITH GRANULOMATOUS TATTOO INFLAMMATION.

PURPOSE: To report a case of panuveitis that developed following COVID-19 vaccination in a patient with a recent history of granulomatous tattoo inflammation. METHODS: Case report. RESULTS: A 25-year-old woman with a recent history of biopsy-proven granulomatous tattoo inflammation developed bilateral eye pain and blurred vision 1 week following her second mRNA-1273 COVID-19 vaccination (Moderna, Inc, Cambridge, MA). Examination revealed bilateral panuveitis. Workup for infectious etiologies and sarcoidosis was negative. The intraocular inflammation initially resolved with systemic prednisone therapy but then recurred following tapering, requiring the initiation of mycophenolate mofetil. CONCLUSION: A case of panuveitis that developed following a COVID-19 vaccination in a patient with a recent history of tattoo inflammation is reported. The temporal relationship between the vaccine and the development of uveitis in this patient may be coincidental and should be interpreted with caution, but multiple vaccines have been associated with uveitis, presumably as a result of their generalized stimulation of the immune system. It is believed that this case of tattoo-associated uveitis may have been exacerbated by the generalized inflammatory effect of COVID-19 vaccination.

Tattoo-associated sarcoidosis from a nuclear medicine perspective.

Tattoo-associated sarcoidosis is characterized by granulomas in tattoos with or without the involvement of other organ systems such as the lungs and eyes. 18F-fluorodeoxyglucose (18F-FDG PET is a nuclear medicine imaging study that can differentiate between metabolically over-active areas and normal tissue. Thus, this review finds that 18F-FDG-PET/CT imaging can be used to image inflammatory activity in tattoos and in case of papulonodular tattoo reaction be used to investigate possible systemic sarcoidosis.