Tattoo Infections

Tattoos are not as much of a taboo topic in many countries as they use to be. In the United States alone estimated percentages of people with tattoos increased from 14% to 21% in only four years. ⁽²⁾ With it being more common and at times more accessible there has been an increased in the amounts of infections being reported.

This is not to say that tattooing is never safe but there is a need for precaution. The increase in acceptance of tattooing there has also been an increase in regulations for tattoo artist and studios.

The FDA has had some success in reaching out to those involved in tattooing. This outreach is to increase knowledge about treatment of infected tattoos and to increase reports in order to further prevention success. ⁽²⁾

It is important to understand what a tattoo is and the effects it can have on the body. In this article, you will read about various infections or side effects that could happen after receiving a tattoo. Also, causes, treatments, and possible precautions will be outlined.

What is a Tattoo?

• Permanent markings in the dermis or skin made by piercing the skin with a needle and inserting ink.
• An aseptic procedure which is done without anesthetics. ^(5,6)

Possible Infections and Complications

1. Cutaneous (skin diseases)

can show immediately or can be delayed.

• Allergic contact dermatitis – usually red, yellow, green and blue dyes are those that can cause these reactions.
• These may appear many years after the tattoo. Reactions to red dye are the most common.
• Granulomatous dermatitis– granulomas look like small bumps that may show up around the tattoo. Keloids can also form which is scar tissue which appears as a raised area.
• Lichenoid dermatitis– Mainly due to blue pigment
• Pseudolymphomatous reactions– Mainly due to red pigment.
• Photo-aggravated reaction- Yellow dye at times can react to sunlight causing skin irritation.^(5,6,7,8)

2. Systemic

• Viral infections such as Hepatitis B and Hepatitis C ^(7,8)
• Bacterial infections such as:

1. Streptococcus pyogenes – can cause impetigo, septicemia, erysipelas
2. Staphylococcus aureus – can cause toxic shock as well as simple skin infections.
3. Teponema pallidum – can cause syphilis
4. Mycobacterium leprae – causes leprosy.
5. Tetanus

• Fungal infections – Zygomycosis or Candida endophthalmitis.(as noted in the following image) ⁽⁸⁾

Image Source: ncbi.nlm.nih.gov

3. MRI complications

This is very rare, but swelling and burning around a tattoo site have been noted during MRI. There have also been cases noted that a tattoo causes problems with the image.

4. Inflammation at the site

This is a normal self-limiting reaction. ⁽⁵⁾

The Table below shows some of the above-mentioned skin reactions and their histology or cellular structure:

Table adapted from http://www.ncbi.nlm.nih.gov

The second table expresses some of the above-mentioned complications alongside their symptoms and onset.

Image Source: ncbi.nlm.nih.gov

What does an infected Tattoo look like

Causes of Tattoo infections

The artist or their studio

• Tattooing is an aseptic procedure which uses only sterile material. An artist should be properly educated on how to properly sterilize their equipment and work area. ⁽¹⁾
• Anyone can now buy inks and kits online which increases the risk that those who are tattooing have not been properly trained. ⁽³⁾
• Although it is no longer common, reuse of material can cause transmission of systemic diseases.
• Infections due to artist misuse or lack of precautions are unusual. ⁽⁶⁾

Infected Ink

• Tattoo ink is considered a cosmetic product; therefore the FDA does not monitor or regulate it. FDA can only respond to adverse effects reported. The FDA alerts companies when their ink has been found to cause health concerns. ^(1,3)
• Originally infections were thought to be introduced into the ink due to artist diluting with infected water. But further investigation shows that most ink was infected at some point during manufacturing. Therefore even sealed bottles of ink could contain the infection. ⁽²⁾
• Studies were done to prove that certain at home kits had unopened ink bottles showing bacterial contamination.
• Allergic reactions are also the cause of dye ingredients, these allergic reactions can result in infection. ⁽⁶⁾

Symptoms and Signs of Tattoo infection

• In nontuberculous mycobacteria – red papules show where ink has been placed, this can look very similar to allergic reactions and must be diagnosed through a culture. ⁽²⁾
• Sometimes there is only a red rash or bumps that appear on or around the tattooed area.
• If the infection has gone systemic you may present with fever, shaking, chills, and sweat. In this case, seek medical attention immediately. ⁽³⁾

In this image, you can see what various types of cutaneous reactions look like. In the case that any of these types of reactions appear you should seek medical attention.

Picture of an infected tattoo
Image Source: img.medscapestatic.com

How to Treat an Infected Tattoo

What should I do if I notice the above symptoms and how can it be treated?

The FDA suggests three direct actions which are noted below:

• Contact a doctor to discuss your symptoms.

• Notify the tattoo artist so all precautions can be taken to prevent that someone else will be infected. Also get any possible information available about the ink used in your tattoo.

• Report the problem to the FDA so that other users of the same ink can be advised to take precautions. ⁽³⁾

In the case of allergic reaction, steroid ointments can help to treat the reaction. In stronger allergic cases tattoo removal may be necessary to remove the permanent ink. ⁽⁶⁾

Prevention

For the tattoo artist:

1. Buy ink made by the sterile procedure.
2. Use only products made specifically for tattooing.
3. Do not dilute ink, and if necessary dilute with sterile water.
4. Use only sterile water to rinse any equipment used.
5. Use aseptic techniques when doing the tattoo. This includes disposable gloves and proper hand hygiene. ⁽⁴⁾

For those getting the tattoo:

1. Check with local jurisdictions or the health department in order to check for registered tattoo artists.
2. Ask your artist about their training and background with tattooing.
3. Ask your artists about the ink used. Be sure it is ink specifically made for tattooing.
4. Ask your artist about their hygienic and sterilization practices.
5. Ask about after tattoo care. ^(1,4,5)

Care for your tattoo properly:

1. With clean hands remove the bandages after 3-5 hours.
2. With clean hands wash the tattoo with soap and warm water, and then pat dry.
3. After the area is dry you can apply a cream given you by your artist, Vaseline, or Aquaphor.
4. Repeat this process at least 3-4 times a day for at least four days.
5. Be sure not to pick any scabs or peel away any dead skin from your tattoo. This can open an area for infection.
6. Use lotion or moisturizer when the area gets dry.
7. Notify your doctor if you notice any of the signs and symptoms noted above.
8. Be sure to avoid sun exposure, tight clothing, swimming in water that has chlorine ^(1,5)

References:

1. http://www.health.harvard.edu/blog/tattoos-and-infection-think-before-you-ink-201210125405
2. http://www.nejm.org/doi/full/10.1056/NEJMp1206063
3. http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm316357.htm
4. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6133a3.htm
5. http://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/tattoos-and-piercings/art-20045067
6. http://emedicine.medscape.com/article/1124433-overview
7. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4799043/
8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4411590/
9. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4494346/
10. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921756/