Background

The tattoo is a part of every human society and culture for over 6000 years. Prevalence in the United States is probably about 3% to 5%. Many who get a tattoo will eventually want to get rid of it but unfortunately, tattoos are far more difficult to remove than they are to acquire. Tattoos are also not the benign cosmetic procedure that most parlors depict. There are a number of skin reactions including granulomas and infection that may result.

OUTLINE

Epidemiology
Disease Associations
Pathogenesis
Laboratory/Radiologic/Other Diagnostic Testing
Gross Appearance and Clinical Variants
Histopathological Features and Variants
Special Stains/ Immunohistochemistry/ Electron Microscopy
Differential Diagnosis
Prognosis
Treatment
Commonly Used Terms
Internet Links

EPIDEMIOLOGY	CHARACTERIZATION
BEHAVIOR-RISK
Tattoos and body piercings as indicators of adolescent risk-taking behaviors. Carroll ST, Riffenburgh RH, Roberts TA, Myhre EB. Adolescent Medicine Division, Department of Pediatrics, Naval Medical Center San Diego, San Diego, California 92134-5000, USA	Pediatrics 2002 Jun;109(6):1021-10217 Abstract quote PURPOSE: This study assessed tattoos and body piercings as markers of risk-taking behaviors in adolescents. METHODS: A 58-question survey, based on the 1997 Centers for Disease Control and Prevention Youth Risk Behavior Survey, was offered to all adolescent beneficiaries that came to the Adolescent Clinic. The survey contained standard Youth Risk Behavior Survey questions that inquire about eating behavior, violence, drug abuse, sexual behavior, and suicide. Questions about tattoos and body piercings were added for the purposes of this study. RESULTS: Participants with tattoos and/or body piercings were more likely to have engaged in risk-taking behaviors and at greater degrees of involvement than those without either. These included disordered eating behavior, gateway drug use, hard drug use, sexual activity, and suicide. Violence was associated with males having tattoos and with females having body piercings. Gateway drug use was associated with younger age of both tattooing and body piercing. Hard drug use was associated with number of body piercings. Suicide was associated with females having tattoos and younger age of both tattooing and body piercing. Tattoos and body piercings were found to be more common in females than males. CONCLUSIONS: Tattoos and/or body piercings can alert practitioners to the possibility of other risk-taking behaviors in adolescents, leading to preventive measures, including counseling. Tattoo and body piercing discovery should be an important part of a health maintenance visit to best direct adolescent medical care.
TRANSFUSION MEDICINE RISK
Tattooing and risk for transfusion-transmitted diseases: the role of the type, number and design of the tattoos, and the conditions in which they were performed. Nishioka Sde A, Gyorkos TW, Joseph L, Collet JP, Maclean JD. Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada.	Epidemiol Infect 2002 Feb;128(1):63-71 Abstract quote Tattoos have been shown to be associated with transfusion-transmitted diseases (TTDs), particularly hepatitis B virus (HBV) and hepatitis C virus (HCV) infections. Very little is known about the association between different categories of tattoos and TTDs. In a cross-sectional study in Brazil, we studied 182 individuals with tattoos and assessed the odds of testing positive for a TTD according to tattoo type, number, design and performance conditions. Major findings were significant associations between an increasing number of tattoos and HBV infection (odds ratio (OR) of 2.04 for two tattoos and 3.48 for > or = 3 tattoos), having a non-professional tattoo and testing positive for at least one TTD (OR = 3.25), and having > or = 3 tattoos and testing positive for at least one TTD (OR = 2.98). We suggest that non-professional tattoos and number of tattoos should be assessed as potential deferral criteria in screening blood donors.
Tattoos and transfusion-transmitted disease risk: implications for the screening of blood donors in Brazil. De A Nishioka S, Gyorkos TW, MacLean JD. Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada.	Braz J Infect Dis 2002 Aug;6(4):172-80 Abstract quote Having a tattoo has been associated with serological evidence of hepatitis B and C viruses, as well as human immunodeficiency virus infections and syphilis; all of these are known to be transmissible by blood transfusion. These associations are of higher magnitude for individuals with nonprofessionally-applied tattoos and with two or more tattoos. Tattoos are common among drug addicts and prisoners, conditions that are also associated with transfusion-transmitted diseases. We examined the implications of these associations for the screening of blood donors in Brazil. Numbers of individuals who would be correctly or unnecessarily deferred from blood donation on the basis of the presence of tattoos, and on their number and type, were calculated for different prevalence situations based on published odds ratios. If having a tattoo was made a deferral criterion, cost savings (due to a reduced need for laboratory testing and subsequent follow-up) would accrue at the expense of the deferral of appropriate donors. Restricting deferral to more at-risk sub-groups of tattooed individuals would correctly defer less individuals and would also reduce the numbers of potential donors unnecessarily deferred. Key factors in balancing cost savings and unnecessary deferrals include the magnitude of the pool of blood donors in the population, the prevalence of individuals with tattoos and the culture of tattoos in the population. Tattoos can therefore be an efficient criterion for the screening of blood donors in certain settings, a finding that requires corroboration from larger population-based studies.

 

DISEASE ASSOCIATIONS	CHARACTERIZATION
HEPATITIS C
Commercial tattooing as a potentially important source of hepatitis C infection. Clinical epidemiology of 626 consecutive patients unaware of their hepatitis C serologic status. Haley RW, Fischer RP. Division of Epidemiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8874, USA	Medicine (Baltimore) 2001 Mar;80(2):134-51 Abstract quote Tattooing in commercial tattoo parlors is known to transmit blood-borne viral infections, including hepatitis C virus (HCV), in other countries, but its contribution to the high population prevalence of HCV infection in the United States has been incompletely evaluated. Risk factors for blood-borne infection were assessed by physician's interview of 626 consecutive patients undergoing medical evaluation for spinal problems in 1991 and 1992 while unaware of their HCV status. Later all were screened for HCV infection with enzyme-linked immunosorbent assay (EIA-1 and EIA-2), and positives were confirmed with second-generation recombinant immunoblot assay (RIBA). Forty-three patients were seropositive for HCV (sample prevalence 6.9%, population-standardized prevalence 2.8%). Logistic regression analysis identified 4 independent risk factors for HCV infection: injection-drug use (adjusted prevalence odds ratio [OR] = 23.0; 95% confidence intervals [CI] = 7.5-70.6), ancillary hospital jobs held by men (OR = 9.6; 95% CI = 3.8-24.3), tattoos from commercial tattoo parlors (OR = 6.5; 95% CI = 2.9-14.8), and drinking > or = 3 6-packs of beer per month (OR = 4.0; 95% CI = 1.8-8.7). If causal, these 4 risk factors account for 91% of HCV infections, with tattooing explaining 41%, heavy beer drinking 23%, injection-drug use 17%, and ancillary health care jobs for men 8%. Transfusions, promiscuous sexual activity, bone grafts, acupuncture, perinatal or intimate transmission in families, and other modes were not independently associated with serologic evidence of HCV infection. Unlikely to be explained by confounding or incomplete disclosure of other risk factors, tattooing in commercial tattoo parlors may have been responsible for more HCV infections than injection-drug use.
KERATOACANTHOMAS
Tattoo-associated keratoacanthomas: a series of 8 patients with 11 keratoacanthomas. Fraga GR, Prossick TA. Kansas University Medial Center, Department of Pathology, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA.	J Cutan Pathol. 2009 Mar 19. Abstract quote Background: Keratoacanthoma is interpreted by many dermatopathologists in the United States as a form of squamous cell carcinoma that can spontaneously involute. Rare examples arising in tattoos have been reported in the literature. Materials and methods: We retrospectively reviewed all cases from our institution received between 2000 and 2008 for any that reported a tumor within a tattoo. Results: We identified eight patients with keratoacanthomas that arose within tattoos. One of the patients had four separate keratoacanthomas arising within two separate tattoos. Red tattoo ink was associated with 82% of the keratoacanthomas. Conclusions: Keratoacanthomas are more common than previously reported in tattoos and are easily misinterpreted. The association with red tattoo ink suggests a form of hypersensitivity-associated with adnexal hyperplasia. Tattoo-associated squamous tumors with innocuous nuclei, infundibulocystic structures, adnexal hyperplasia, and signs of regression should be reported as keratoacanthomas rather than as variants of squamous cell carcinoma.
SARCOIDOSIS
Development of Sarcoidosis in Cosmetic Tattoos Diana D. Antonovich, MD; Jeffrey P. Callen, MD	Arch Dermatol. 2005;141:869-872. Abstract quote Background  The development of granulomatous lesions within tattoos is a well-recognized occurrence in individuals with sarcoidosis. The characteristic histopathological finding of sarcoidosis is the presence of noncaseating granulomas; however, similar histopathogical findings may be seen in foreign body granulomas. Several reports have challenged the assertion that the presence of foreign material within sarcoidal granulomas is incompatible with a diagnosis of sarcoidosis. Observations  We describe a patient who had multiple linearly arranged papules along her eyebrows and the vermillion border of her upper lip. She had had cosmetic tattooing performed on these areas 3 year prior to presentation. Histopathologic examination revealed sarcoidal granulomas, polarizable foreign material, and pigment granules. Hilar adenopathy was noted on a chest radiograph. After 4 months of treatment with a midpotency topical steroid and doxycycline, she experienced complete clearance of her cutaneous lesions and normalization of chest x-ray film findings. Conclusions  This case demonstrates a unique adverse result after cosmetic tattooing and highlights the concept that granulomatous histopathologic findings containing foreign material should not be an exclusionary criterion for the diagnosis of sarcoidosis. In this setting, further investigation for the presence of systemic disease is indicated.
Systemic sarcoidosis presenting as a granulomatous tattoo reaction secondary to interferon-alpha treatment for chronic hepatitis C and review of the literature. Nawras A, Alsolaiman MM, Mehboob S, Bartholomew C, Maliakkal B. Department of Gastroenterology, Albany Medical College, New York 12208, USA.	Dig Dis Sci 2002 Jul;47(7):1627-31 Abstract quote Sarcoidosis is a multisystem granulomatous disease of unknown etiology. Immune alterations involving heightened T-helper-1 responses have been proposed to play a major role in the pathogenesis of sarcoidosis. Interferon-alpha therapy and hepatitis C infection have been implicated in the development of a variety of autoimmune diseases. However, despite the wide use of IFN-alpha therapy for hepatitis C, only a few cases of sarcoidosis have been reported in this context. We report the case of a 42-year-old white female with hepatitis C, who developed systemic sarcoidosis shortly after therapy with IFN-alpha2b. The disease was heralded by the appearance of a cutaneous sarcoid/ foreign body granulomatous reaction at the site of an old tattoo. The sarcoidosis responded to a short course of oral prednisone therapy. We also reviewed the other reported cases and discussed the possible immunological mechanisms involved.

 

LABORATORY/ RADIOLOGIC	CHARACTERIZATION
MRI
Magnetic resonance imaging and permanent cosmetics (tattoos): survey of complications and adverse events. Tope WD, Shellock FG. Department of Dermatology, University of Minnesota Hospital and Clinic, Minneapolis, Minnesota, USA.	J Magn Reson Imaging 2002 Feb;15(2):180-4 Abstract quote PURPOSE: To use a survey to determine the incidence of complications and adverse events in individuals with permanent cosmetics (e.g., tattooed eyeliner, eyebrows, lips, cheeks, etc.) who underwent magnetic resonance (MR) imaging. MATERIALS and METHODS: A questionnaire was distributed to clients of cosmetic tattoo technicians. This survey asked study subjects for demographic data, information about their tattoos, and for their experiences during MR imaging procedures. RESULTS: Data obtained from 1032 surveys were tabulated. One hundred thirty-five (13.1%) study subjects underwent MR imaging after having permanent cosmetics applied. Of these, only two individuals (1.5%) experienced problems associated with MR imaging. One subject reported a sensation of "slight tingling" and the other subject reported a sensation of "burning"; both sensations were transient in nature. CONCLUSION: Based on these findings and information in the peer-reviewed literature, it appears that MR imaging may be performed in patients with permanent cosmetics without any serious soft tissue reactions or adverse events. Therefore, the presence of permanent cosmetics should not prevent a patient from undergoing MR imaging.

 

CLINICAL AND GROSS VARIANTS	CHARACTERIZATION
COLON
Tattoo of colonic neoplasms in 113 patients with a new sterile carbon compound. Askin MP, Waye JD, Fiedler L, Harpaz N. Division of Gastroenterology, Mount Sinai Medical Center, New York, New York.	Gastrointest Endosc 2002 Sep;56(3):339-42 Abstract quote BACKGROUND: Endoscopic marking of intestinal lesions is essential when difficulty is anticipated with subsequent localization during surgical resection or postpolypectomy surveillance. The most commonly used indelible marker has been India ink, which must be diluted and sterilized, a cumbersome process. SPOT, a prepackaged, sterile Food and Drug Administration-approved formulation of pure carbon particles in suspension, eliminates the need for preinjection preparation. METHODS: Ten patients with colonic polyps deemed endoscopically unresectable or malignant-appearing had the area surrounding the lesions injected with SPOT and subsequently underwent surgical resection. An additional 103 patients underwent colonoscopic injection with SPOT and were followed endoscopically or underwent surgery at another hospital. RESULTS: The SPOT injection sites were visible to the surgeons in all 10 cases. On histopathologic evaluation, none of the resection specimens exhibited necrosis or abscess formation. In total, there were 118 SPOT injections in 113 patients; none had fever, abdominal pain, or any other signs or symptoms of inflammation develop. In the nonoperated group, 42 patients subsequently underwent colonoscopies at our institution, and in all cases stains were readily identifiable at the injection sites. CONCLUSIONS: SPOT is a safe and effective marker for use at colonoscopy when surgical resection is anticipated. It is also useful for endoscopic follow-up of patients who have not undergone surgery.
CONTACT DERMATITIS
Allergic contact dermatitis to temporary tattoo by p-phenylenediamine. Pegas JR, Criad PR, Criado RF, Vasconcellos C, Pires MC. Dermatology Unit, Complexo Hospitalar Padre Bento de Guarulhos, Brazil.	J Investig Allergol Clin Immunol 2002;12(1):62-4 Abstract quote Temporary tattoos are widely applied today all over the world. The tattoo makers explain that they use "natural henna paint," although in fact they use "black henna," which includes a mixture of many substances, among them p-phenylenediamine (PPD). There have recently been many reports of allergic contact dermatitis because of temporary tattoo with PPD sensitization. We are adding a new case of temporary tattoo with black henna with an extensive reaction, in which a 12-year-old white boy showed contact dermatitis from PPD, followed by cutaneous eruption after corticosteroid topical treatment.
TEMPORARY TATTOOS
Clinicopathologic Features of Skin Reactions to Temporary Tattoos and Analysis of Possible Causes Wen-Hung Chung, MD; Ya-Ching Chang, MD; Lih-Jen Yang, MD; Shuen-Iu Hung, PhD; Wen-Rou Wong, MD; Jing-Yi Lin, MD; Heng-Leong Chan, MD	Arch Dermatol. 2002;138:88-92 Abstract quote Background Recently, temporary paint-on tattoos have become increasingly popular as a safe alternative to permanent tattoos in Asia and other regions. The most common dye for such temporary tattoos is henna, a vegetable dye. Henna is considered to possess low allergenicity because the incidence of allergic contact dermatitis to henna has rarely been reported. However, recently, allergic reactions to henna used in temporary tattoos have been reported frequently. Observations Ten patients developed inflamed skin eruptions after receiving temporary paint-on tattoos in either Thailand or Indonesia. The 6 patients who were patch tested all exhibited moderate to strong positive reactions to p-phenylenediamine (1% in petrolatum). Four of the 6 patients were then tested with commercial black henna obtained from Thailand, and all 4 had strong positive reactions. A skin biopsy specimen showed lichenoid dermatitis. Mass spectrometry analysis of commercial black henna for molecular weight revealed a major peak at the mass-charge ratio of 108.1, which corresponds to the molecular weight of p-phenylenediamine. Conclusions The most likely causative agent for the lichenoid reaction associated with use of commercial black henna for temporary tattooing, currently popular in Southeast Asia, is p-phenylenediamine. With the increased popularity of temporary paint-on tattoos, clinicians should be aware of the possible associated complications.
ZINC
Mucocutaneous pigmented macule as a result of zinc deposition. Greenberg JE, Lynn M, Kirsner RS, Elgart GW, Hanly AJ. Department of Dermatology and Cutaneous Surgery, Center for Advanced Microscopy, and Department of Pathology, University of Miami, and Global Pathology Laboratory Services, Miami Lakes, Miami, FL, USA.	J Cutan Pathol 2002 Nov;29(10):613-5 Abstract quote BACKGROUND: Mucocutaneous depositions of various metals such as silver, lead, gold, arsenic, mercury, iron, and bismuth have been previously published. Heavy metal deposition typically occurs in the setting of either prolonged topical application to intact skin, topical application to eroded or ulcerated skin, as a result of either parenteral administration, or due to penetrating traumatic exposure. METHOD: We report a unique case of mucocutaneous pigmentation occurring in a snow skier after topical application of a zinc-containing sunblock. Formalin-fixed paraffin-embedded tissue was utilized for electron microscopy. RESULT: Backscatter electron imaging and energy dispersive spectroscopy revealed that the dominant metal present was zinc. CONCLUSIONS: Mucocutaneous deposition of metals is enhanced by damage to the surface epithelium. Metal-containing topical agents, although commonly used, may rarely result in a permanent pigmentary alteration. We believe similar cases of mucocutaneous deposition of zinc exist; however, as these may be currently misdiagnosed as amalgam tattoos, the true incidence of this disorder is presently undefined.

 

HISTOPATHOLOGICAL VARIANTS	CHARACTERIZATION
LICHENOID
Lichenoid delayed hypersensitivity reactions in tattoos. Winkelmann RK, Harris RB.	J Cutan Pathol 1979 Feb;6(1):59-65 Abstract quote Two patients with an inflammatory reaction in a red tattoo had histopathologic changes of lichen planus. The lesions demonstrated a lymphocytic bandlike infiltrate, liquefaction degeneration, acanthosis, hypergranulosis, and orthokeratosis and many hyaline bodies. Metal particles were observed in the region of the dermal-epidermal reaction. This probably is another example of the lichenoid reaction produced by delayed cellular hypersensitivity.
MORPHEA REACTION
Morphea-like tattoo reaction. Mahalingam M, Kim E, Bhawan J.	Am J Dermatopathol 2002 Oct;24(5):392-5 Abstract quote Tattoo reactions are histologically diverse. In general, dermal changes predominate, although epidermal changes such as acanthosis or spongiosis can also be seen. The chronic inflammatory cell infiltrate can be nodular, lichenoid, or granulomatous. Occasionally, the dermal infiltrate may be so dense as to suggest a diagnosis of cutaneous lymphoma. We report an unusual tattoo reaction that mimicked morphea histologically.
PSEUDO-EPITHELIOMATOUS HYPERPLASIA
Massive pseudoepitheliomatous hyperplasia: an unusual reaction to a tattoo. Balfour E, Olhoffer I, Leffell D, Handerson T.	Am J Dermatopathol. 2003 Aug;25(4):338-40 Abstract quote We document an unusual tattoo reaction presenting as verrucous plaques, which on histopathologic examination showed marked pseudoepitheliomatous epidermal hyperplasia. The patient is a 27-year-old female who presented to her dermatologist complaining of itchy overgrowth of her tattoo. Her symptoms began 2 months after tattoo placement approximately 1 year ago. Physical examination revealed verrucous plaques in the purple areas of the tattoo, suggesting a clinical diagnosis of a granulomatous tattoo reaction. A superficial biopsy showed epidermal hyperplasia somewhat reminiscent of a regressing keratoacanthoma. No tattoo was identified. A repeat shave biopsy demonstrated marked epidermal hyperplasia with focal keratin filled cystic dilatations, and local mild reactive keratinocytic atypia. In the surrounding dermis, there was dense chronic inflammation, fibrosis, and granules of dark red pigment. These findings suggest marked pseudoepitheliomatous hyperplasia secondary to the tattoo.Different reaction patterns have been described in association with tattoos, such as granulomatous and/or perivascular lymphocytic inflammation. However, there have been few cases reported of pseudoepitheliomatous hyperplasia arising at a tattoo site. Therefore, we encourage physicians to consider massive epidermal hyperplasia in the differential diagnosis of a verrucous tattoo reaction.

 

PROGNOSIS/TREATMENT	CHARACTERIZATION
TREATMENT
LASER
Cosmetic tattoo refractive to Q-switched alexandrite laser. Moreno-Arias GA, Camps-Fresneda A. Department of Dermatology, General Hospital of Catalonia, 08190 Sant Cugat del Valles, Spain	J Cutan Laser Ther 1999 Apr;1(2):117-9 Abstract quote BACKGROUND: Lip tattooing is a common cosmetic technique not exempt from certain risks and which may lead an unsatisfied customer to seek tattoo elimination. OBJECTIVE: To assess the clinical outcome of a patient with a brownish-colored cosmetic lip tattoo after treatment with the Q-switched alexandrite laser (QSAL). METHODS: Two sites were tested using the pigment lesion dye laser (PLDL) and QSAL. The patient received 10 monthly sessions with QSAL, with an average fluence of 6.925 J/cm2. The double and triple shot technique was applied. RESULTS: The brownish pigmentation turned black after the PLDL and QSAL tests. Epidermal splattering and bleeding made a fluence increase with QSAL inadvisable. Treatment was unsuccessful. CONCLUSIONS: PLDL and QSAL may induce a photochemical alteration in brownish pigment. Factors that may contribute to the poor response of a cosmetic lip tattoo to QSAL treatment are related to pigment characteristics and laser parameters.
Use of the Q-switched alexandrite laser (755 nm, 100 nsec) for eyebrow tattoo removal. Moreno-Arias GA, Camps-Fresneda A. Department of Dermatology, General Hospital of Catalonia, Sant Cugat del Valles, Barcelona, Spain.	Lasers Surg Med 1999;25(2):123-5 Abstract quote BACKGROUND AND OBJECTIVE: Permanent tattooing for cosmetic reasons has increased in recent years; as a consequence, there has been an increase of requests for pigment removal due to complications or undesired results. The Q-switched alexandrite laser has been found useful in removing black exogenous pigment, which is the most popular color in eyebrow enhancement. We report the case of a patient with black-pigment eyebrow cosmetic tattoo after treatment with the Q-switched alexandrite laser. STUDY DESIGN/MATERIALS AND METHODS: Treatment conditions included 755-nm wavelength, 100 +/- 10-nsec pulse width, and 3-mm spot size. Fluence threshold was determined, and a spot test was made at the first visit. Single impact technique with 10% overlapping was applied to the whole tattoo. Five treatments were performed with a mean fluence of 7 J/cm(2). RESULTS: Complete pigment removal was achieved after five sessions. Superficial bleeding and vesicle formation was observed. CONCLUSIONS: Eyebrow tattooing can be treated efficiently with the use of the Q-switched alexandrite laser when black pigment has been used for cosmetic reasons.
Laser tattoo removal. Adrian RM, Griffin L. Georgetown University Medical School, Washington, DC, USA.	Clin Plast Surg 2000 Apr;27(2):181-92 Abstract quote The availability of Q-switched ruby Nd:YAG and alexandrite lasers has revolutionized the treatment of tattoos. These modalities offer significant advantages over all previously available treatments and are currently the standard of care for the cosmetic removal of unwanted tattoos.
SURGERY
Treating traumatic tattoo by micro-incision. Sun B, Guan W. Department of Plastic Surgery, Shanghai Ninth People's Hospital, Shanghai Second Medical University, Shanghai 200011, China.	in Med J (Engl) 2000 Jul;113(7):670-1 Abstract quote OBJECTIVE: To design a micro-incision operation for treating traumatic tattoo. METHODS: With an 11-gauge blade, a micro-incision was made on each side of the small tattoo spot and the tattoo skin was removed. For a longer tattoo particle, a longer incision was needed. The skin incision was sutured with 6-0 silk. For a complex tattoo, dermabrasion could be used first to remove the superficial one so as to expose the deep one which was removed in the same way as mentioned above. When there was a large number of tattoo particles, many operations were needed. RESULTS: Fourteen patients were treated by this method with good to excellent result. CONCLUSION: Micro-incision for treating traumatic tattoo is an effective method.

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