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Dermatologic Graffiti

What primary care providers need to know about tattooing

Tattooing has existed as a form of human expression for centuries, often used to commemorate religious ceremonies or to signify military experience.1 People use tattoos to express individual style or personality, convey a message, demonstrate membership in a particular group, or for a variety of other reasons. Tattooing is now omnipresent in U.S. society: 21% of adults have at least one tattoo.2 Given this high incidence, healthcare providers need to become more familiar with the process and associated risks of tattooing in order to properly counsel and educate patients.

Evaluating a patient's potential health risks with regard to tattoos requires the provider to stratify tattoos into two distinct groups: professional and nonprofessional tattoos. Professional tattoos placed by properly trained and licensed tattoo artists in an authorized, sanctioned tattoo parlor present significantly less risk than nonprofessional tattoos. Nonprofessional tattoos are affixed in various physical locations by virtually any person willing to perform the procedure. They may involve using many kinds of ink and sharp objects to place the ink under the skin. A quick search on eBay can bring up 9,000 listings for tattoo kits (machines and guns) for the amateur artist.3 Nonprofessional tattoos increase local and systemic complication and infection rates in tattoo recipients.

Scholarly articles on tattooing typically do not delineate between professional and nonprofessional tattoos. To be considered professionally done, tattoos must be applied in a tattooing establishment that has been licensed by state regulators and periodically inspected by the state or local health department.4 Tattoo artist training typically incorporates education in areas of anatomy and physiology, but its overall emphasis is on infection control and compliance with Occupational Safety and Health Administration (OSHA) standards.4 Training and certification of tattoo artists includes instruction on sterile techniques and blood and body secretion precautions.4

Tattoo studios are licensed and regulated by states, and most states have similar rules about cleanliness and adherence to OSHA guidelines.2 No federal laws govern tattoo salons, and each state, city and/or municipality can establish its own rules for licensure of tattoo artists, equipment and physical facilities.

In contrast, nonprofessional tattoos are not obtained at a licensed tattoo parlor staffed by a properly trained technician. Nonprofessional tattoos are often called "backyarders" or "scratchers," and they are frequently performed under nonsterile conditions with unclean needles.1 Many people receive tattoos while in prison. Prison tattoos are performed under unsanitary conditions with nonsterile inks. The prison population has a higher incidence of bloodborne illnesses than the unincarcerated population.1

Local, Systemic and Imaging Risks

The risk of localized infection or reaction from a tattoo is essentially the same as that associated with a breach of the skin using a needle or sharp object. The skin is pierced repeatedly during tattooing, resulting in numerous openings in the skin's defensive barrier and thus increasing the risk for developing infection-related complications. Sterile technique reduces the risk of infection, but it is not entirely obviated.5

Staphylococcus is commonly associated with tattoo-related infections; methicillin-resistant strains are an emerging are of concern.6,7 Other potential skin infections related to tattoos may be caused by fungal or viral pathogens. Proper skin care after the procedure helps reduce the risk of infection.6 Other risks with professional tattoos include localized skin infections stemming from contaminated ink, however, this much less common than the risks associated with nonprofessional tattoos.2

Ink used for professionally placed tattoos is approved by the FDA for use only as a cosmetic and color additive and not for subdermal placement.8 Acute inflammatory reactions are a typical consequence during tattooing. Inflammation results from the physical damage to the skin as well as the injection of a foreign material into the skin.5 Patients with localized lymphadenopathy and a normal white blood cell count, but no fever or chills, have a local inflammatory reaction rather than a skin infection.7

Allergy to tattoo ink can develop once it is placed in the epidermis. Localized allergic reactions can change the color and shape of the tattoo via scarring and dispersion of the dyes used, while systemic allergic reactions can include more serious hypersensitivity symptoms such as urticaria, shortness of breath and angioedema. Tattoo ink contains natural and synthetic compounds and other metallic substances known to induce local and possibly systemic hypersensitivity reactions (Table 1).6

Proper care of the skin after tattooing is crucial to reduce the risks associated with this procedure. Professional tattoo artists usually provide detailed aftercare instructions via verbal or printed form, similar to that provided for typical wound care. Patients should avoid ultraviolet (UV) exposure on tattooed area for at least 3 months after application, since sun exposure may cause the ink to appear altered (primarily faded).9 In addition, yellow and red dyes in particular have the potential to cause photosensitivity reactions in new tattoos exposed to sunlight. This is because cadmium sulfide is a light-sensitive material used in photoelectric cells; the reaction is believed to be phototoxic.5 Sunburns injure the epidermis and lower natural skin immunity, which may potentially render patients more susceptible to an infection in the tattooed area.

The tattooed area should be washed daily with a mild soap and water. Soaking in baths, hot tubs and pools should be avoided for at least 2 weeks to decrease the risk of exposure of the injured skin to bacteria in these reservoirs.9 Dressings, particularly occlusive ones, are not recommended due to increased risk of infection.9 An ecchymotic lesion develops over the healing tattoo.

The patient should be instructed not to pick or scratch the area despite any itching or burning sensation. Doing so may result in spreading out the pigment, introducing infection or causing scarring.9 Tattoo artists may suggest application of a petrolatum-based ointment during the healing process; neomycin-bacitracin-polymyxin is contraindicated due to risk of contact dermatitis.9

Tattooing is similar to a minor surgical procedure, so patients with medical problems that inhibit or delay healing ability should carefully consider the risks. Patients with immunosuppression or other chronic illnesses (diabetes mellitus, peripheral vascular disease, bleeding disorders and HIV) may experience delayed wound healing and increased susceptibility to infection.6 Patients with bleeding or clotting disorders should avoid tattooing because the inability to clot properly could potentially cause changes in the appearance of the tattoo or excessive amounts of blood loss.10

Some absorption of tattoo dyes can occur within the vascular or lymphatic systems because ink is injected into the dermal layer of the skin. Nonsterile procedures and contaminated ink or instruments can introduce microorganisms and contaminants into the body. Professional tattoo parlors minimize this risk by using single-use sterile pigment containers and needles, frequent hand washing or autoclaving equipment. The most concerning systemic infections associated with tattooing are HIV, hepatitis B and hepatitis C transmitted via contaminated needles. The risk of acquiring these infections is greatest with amateur tattooists.7

HIV transmission has not been documented thus far in a professional tattoo studio, but HIV transmission has occurred via nonprofessional tattoo applications.7 In documented cases, inmates have infected other prisoners with infections such as tuberculosis and syphilis when they licked the tattoo needle to keep it moist during the application of the pigment.6 Diseases such as psoriasis, lupus erythematosus, lichen planus and sarcoidosis may occur in tattooed areas.6 The cause for these cutaneous manifestations is unknown, but they may be induced by specific ink (mainly red) color. Finally, there is the potential for metastatic change in tattooed skin. Cases of melanoma, keratoacanthoma and other skin cancers have been documented.11

The metallic dyes used in many tattoos react with magnetic resonance imaging (MRI) equipment and may cause warming or burning in the skin where the tattoo is located. In a few cases, patients have experienced second-degree burns over tattoos during MRI.12

Scarring may alter how structures beneath the tattoo are visualized with radiographic modalities. MRI machines may be unable to visualize tissue underneath a metallic-containing tattoo as well as normal, intact skin. This is particularly common in areas such as the face, where permanent makeup tattoo can distort the precise, small images gathered during head and face imaging. This could lead to an abnormality being missed.12 In addition, tattoos on breast tissue have led to difficulty interpreting mammogram results. Biopsy results have revealed abnormalities resulting from migration of pigments placed in a tattoo located close to the breast.13 There is also concern about the potential for malignant change related to pigmentation of the skin in proximity to the breasts.2 Other test modalities, such as computerized tomography studies or plain film x-rays, may be misinterpreted due to artifact related to metals in the tattoo.14


To provide the best possible care to patients, healthcare providers must be aware of problems associated with tattoos. NPs and PAs should be ready to counsel patients about how and where to safely get a tattoo. Patient education about licensure and regulation of tattoo facilities, tattoo care and how to manage potential complications is necessary.

If a patient already has a tattoo, providers should work to determine if it was professionally applied. Simply asking the patient where the tattoo was obtained is the best way to determine if it was professionally placed. Some patients may be confused about what constitutes a professional tattoo artist or shop. Ask how the patient selected the tattoo provider, the level of cleanliness of the facility, and whether state-issued licenses were displayed in the shop. Some patients admit to self-tattooing, allowing a friend to apply their skin pigments, or visiting an unlicensed artist practicing illegally for a lower cost.

Providers can obtain objective information about a tattoo by studying its characteristics. A tattoo with more basic design or letters without a specific font type is more likely to have been applied by an amateur. The placement of the tattoo could give another clue to its origins, since professional tattoo artists are prohibited from placing a tattoo within 1 inch of the eye.15

Nonprofessional tattoos usually use dark green or black ink (Figure 1) that is easily obtained. Generally, licensed tattoo artists use multiple colored inks and more complex designs in their work (Figure 2). Licensed tattoo artists have more training and apprenticeship; their workmanship showcases their talent and serves as an advertisement.

If a patient has obtained a tattoo in any location other than a licensed tattoo parlor, even if it was placed with a traditional tattoo gun, he or she should be evaluated for local complications such as infections and scarring, and screened for possible exposure to HIV, hepatitis B and hepatitis C. Careful examination of the wound area and lymph nodes should be performed, and appropriate wound care techniques should be discussed and initiated. If an oral antibiotic is indicated, select one that covers normal skin flora including methicillin-resistant Staphylococcus aureus. A tetanus toxoid booster should be administered if the patient's vaccination status is not current or cannot be determined.

The authors are members of the physician assistant program faculty at Mercer University in Atlanta. Philip Tobin is the department chairman and program director, and Heather L. Schmidt and Martha L. Sikes are clinical assistant professors.


1. Hellard ME, et al. Tattooing in prisons-not such a pretty picture. Am J Infect Control. 2007;35(7):477-480.

2. LeBlanc PM, et al. Tattoo ink-related infections. Awareness, diagnosis, reporting, and prevention. N Engl J Med. 2012;367(11):985-987.

3. Ebay. March 12, 2013. Search results for "Tattoo Kits: machines and guns."

4. Maddox N. Tattoo rules and regulations.

5. Wenzel SM, et al. Adverse reactions after tattooing: Review of the literature and comparison to results of a survey. Dermatology. 2013;226(2):138-147.

6. Kazandjieva J, Tsankov N. Tattoos: dermatological complications. Clin Dermatol. 2007;25(4):375-382.

7. Kluger N. Acute complications of tattooing presenting in the ED. Am J Emerg Med. 2012;30(9):2055-2063.

8. Ortiz AE, Alster TS. Rising concern over cosmetic tattoos. Dermatol Surg. 2012;38(3):424-429.

9. Hudson KL. Tattoo aftercare. How to take care of your new tattoo.

10. Steps for living: Education for all life stages.

11. Kluger N, Kolijonen V. Tattoos, inks, and cancer. Lancet Oncology. 2012;13(4):e161-168.

12. Tope WD, Shellock FD. Magnetic resonance imaging and permanent cosmetic (tattoos): Survey of complications and adverse events. J Magn Reson Imaging. 2002;15(2):180-184.

13. Honegger MM, et al. Tattoo pigments mimicking axillary lymph node calcifications on mammography. Am J Roentgenol. 2004;183(3):831-832.

14. NetForum community.

15. National Conference of State Legislatures. Tattoos and body piercing for minors.


This was a very informative article. I have a 40's female with nearly full body tattoos. She is showing signs of RA. Not sure how safe proceeding with methotrexate will be?

Sue Meiner,  EdD, APRN,  consultantAugust 16, 2014
Princeton, TX

I would encourage anyone with a pt with tattoos also ask about military service. Multiple locations, all over the world (Korea, SE Asia, Philippines, Middle East, Eastern or Northern coasts of Africa) have "professional" tattoo parlors that may appear clean, but are not. When I did a clinic at the local Vet Center, I found perfectly healthy appearing & asymptomatic young prior service members, with a hx of tattoos outside of the US who had elevated LFT's. When screened for Hepatitis, I found that several dozen turned out to be Hep C +, understandably a huge shock, and very much in need of f/u care.
As always & as my favorite attending used to say, "if all else fails, take a history."

Donell Kelly,  Retired ,  VA & US ArmyAugust 14, 2014
Tucson, AZ


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