Tattooed skin: how to manage them?

Tattoos are increasingly popular in today’s society, especially with the advent of laser tattoo removal.

Millions of people in the Western world supposedly have transient or persisting health problems after tattooing:

• 67,5%: Skin problems
• 6,6%: Systemic reactions
• 9%: Health problems, four weeks after tattooing, especially with colored tattoos.¹

Tattooing of skin via deposition of pigment particles and ink ingredients in the dermis changes normal skin into abnormal skin. The tattoo ink products of today remain composite, with unknown ingredients and a range of chemical contaminants. Pigments in the skin slowly vanish over time, along with a slow release of minute amounts of chemicals and metabolites, which may actually cause harm, such as allergy. They also instilled into the tattoo partly escape via the lymph and become deposited in the regional lymph nodes. The nodes are invisibly dyed along with the skin. However, unknown amounts of pigment nanoparticles might reach the blood stream and theoretically cause harm somewhere in the body.²

Tattoo complications are serious adverse reactions or events after tattooing that manifest as objective abnormalities or pathologies associated with clinical and subjective symptoms of a severity that is considered as a disease or disablement. The dominating groups are allergic reactions in red tattoos and papulonodular reactions in black tattoos.^3,4

How to recognize allergy due to tattoos?

The introduction of foreign substances into the skin during tattooing can promote:

• A toxic response
• An immunological response

The timing of these delayed type hypersensitivity reactions may vary from shortly after the tattoo application up to several years later and may be triggered by retattooing.

Rarely generalized reactions may occur due to autosensitisation that can explain why the tattoo reactions become generalized, a localized hypersensitivity reaction stimulates the immune system causing distant skin eruptions.⁵

Clinical picture is quite variable and includes eczematous, lichenoid, pseudolymphomatous lesions, and contact urticaria like reactions or photoallergic reactions.

Patch tests unfortunately often show negative results, maybe because suitable patch test solutions are difficult to obtain owing to the low dispersing capacities of most pigments.

To increase patch test reactions
Recommendations:

• Tape stripping
• Late readings
• Photopatch testing particularly for red pigments

The immunologic mechanisms involved are still a subject of speculation.

A specific allergic pathway with a dermal-immunologic pattern is assumed, which probably bypasses the mechanisms in place in transepidermal allergen penetration. Therefore, additional intracutaneous testing, obviously including late readings, are required.⁵

The diagnosis of allergy due to tattoos is performed in the absence of a valid test reference and based on the following clinical criteria:

• Allergic reactions are monomorphic, i.e. uniformly manifested in one particular color and at all sites where that particular color is applied in the tattoo;
• There is latency of primary sensitisation lasting weeks, months, or years since the tattoo was made until the reaction appears;
• Once elicited and full blown, the reaction is constant, chronic, cumbersome and refractory to topical corticoid therapy;
• A definite criterion for allergy is induction of alike reaction(s) in a hitherto-tolerated tattoo of the same color located in another anatomical region, i.e. a manifestation of allergic cross-reactivity.²

Table : Local allergic reaction patterns.²

Chronic allergic reactions of red tattoos respond little to local corticoids and are best treated with dermatome shaving. Laser removal is contraindicated due to the risk of photochemical activation of the allergy with anaphylaxis or worsening. Chronic reactions in black tattoos can be treated with local corticoids, dermatome shaving, and lasers as well.⁶

What's to be done in practice currently?

With the increasing incidence of tattooing as a fashion trend in society, clinicians should be able to recognize and treat those complications at the earliest and appropriately counsel their patients on risks of tattoo placement.
Thorough clinical history and examination are essential to make a diagnosis. To confirm the diagnosis, skin biopsy is mandatory, especially with a papulonodular growth within the tattoo pigment, since neoplastic conditions are not immediately recognized with clinical examination only.⁵

Tattooists routinely treat the tattooed skin and advice the customer on how to treat the wound during uncomplicated tattoo healing, which takes a few weeks. Tattooists practice many different treatments, and there is no consensus. It is common to perform “moist wound healing” for a couple of days by covering the tattooed skin with a wrap of transparent foil, followed by moisturizing ointments or creams.⁷

Tattoos are sensitive to light, which may induce the photochemical breakdown of pigment associated with complaints, especially swelling and itching of the tattoo. Thus, regular use of sun protection in the summertime, at the beach, and on special exposure to sun is rational. If sensitivity to light is advanced and a medical complication, of course, treatment with sun protection is mandatory, with detailed instructions on the correct application and use.⁶