Patient Presentation
A 15-year-old male came to clinic with his mother after she had noticed some redness and swelling around his ankle the previous day. He had been experimenting with giving himself a tattoo using pins and pen ink 3 days previously. He said that he had done this alone and had not shared any pins or needles with anyone. He said he had taken new pins from a container from his mother’s sewing basket, and had cleaned them by a match flame and then by sitting in alcohol. He had cleaned his skin with an iodine solution. He stated that, “It didn’t hurt too much and I think I did a good job with the small design. I’m not sure how much I like it though now.” He had re-cleaned the site afterwards and a few times a day since. The next day though it was redder but hadn’t really spread. His mother noticed the redness the night before. He denied wanting to hurt himself in any way including having no history of substance abuse, mental health issues or self-harm. He was doing well in school with the same social group. “I’m a pretty good artist and just wanted to see if I could give myself a small tattoo,” he stated.
The social history showed that his mother was a nurse and had been very upset when she found out about it. The past medical history showed that he was fully immunized.
The pertinent physical exam showed a healthy male with normal vital signs. There was a 2 cm black geometric drawing just about the lateral malleolus on the right ankle. There was a surrounding 3-4 cm ring of erythema but no significant swelling or induration. There was no streaking up the leg. There was full range of motion in the ankle and knee.
The diagnosis of a mild allergic local reaction vs mild cellulitis was made. Oral antibiotics were started. This incident was felt to be a very low risk of bloodborne pathogen exposure and so testing was not done at that time. He was also felt to not have significant psychosocial risk factors for self-harm or other high-risk behaviors. During confidential questioning the pediatrician confirmed the adolescent’s story The pediatrician discussed body art and the potential risks of tattoos. “Amateur tattoos have the highest risks of problems. Please don’t do that again or in the future. If you are going to get one in the future, please use a licensed business. They are professionals and can do it right if that is what you want to do. Remember tattoos are permanent and can be beautiful if done right. But there are real risks too. Please use your artistic talents in a different medium than tattoos for right now.” Three months later the adolescent had not done further tattooing but was doing ink drawings inspired by graphic artists.
Discussion
“Tattooing of skin via deposition of pigment particles and ink ingredients in the dermis changes normal skin into abnormal skin. Fortunately, this often causes no harm and no disease, although with important exceptions.” Tattoos can be inadvertent from road dirt, gunpowder, pencil graphite etc., but most are desired. Tattoos are common in many cultures and over time..They have been increasing in popularity in the United States over the past few years particularly with a younger, wider and more diverse population.
Newsweek reported an 18-country study in 2018 which showed 46% of Americans have a tattoo and the US and Sweden tied for the highest median number of tattoos at 4. Of those 14-29, 36% had a tattoo. Unfortunately many adolescents and young adults are not aware of the potential complications.
“If tattoos are placed in licensed parlors, infections are less likely to occur after tattooing than if they are placed by unlicensed individuals.” “Unfortunately, many tattoos are placed by amateurs, which makes the process much riskier. In these cases, antiseptic process may not be followed, leading to potential skin infections and transmission of bloodborne illnesses, such as hepatitis C or HIV.” Common sense recommendations if someone wishes to have a tattoo placed are to use a licensed business, and follow all appropriate after-care instructions scrupulously.
Tattoos sometimes can be removed but should be considered permanent before placement. Removal can be attempted including ablative, chemical, and mechanical, removal. Laser treatment is often used currently but has its own set of potential complications including burns. Removal can also be expensive. One study cited $49/square inch of tattoo/laser session. Multiple sessions are usually needed.
Learning Point
Tattoo complaints are not uncommon and occur around the time of tattoo placement or later. These include reactions such as inflammation, irritation, pruritis, or swelling. These can be worse with worse with sun exposure for people.
Tattoo complications include:
- Infection
- Potentially the most serious complication
- Caused because contaminated equipment or ink, inadequate disinfection and secondary during healing due to irritation, pruritis etc.
- Superficial problems are more common (e.g. impetigo, pustules), but can be worse with cellulitis or abscess problems. Bacteremia, sepsis or complications related to them such as endocarditis, erysipelas, and gangrene.
- Common skin flora is the most common include Staphylococcus aureus and Streptococcus pyogenes. Other bacterial infections also include Clostridium species, E. coli, Pseudomonas species. Tuberculosis, non-tuberculosis mycobacterium and leprosy have been reported. Tetanus is not common because of vaccination but can occur. Fungus, parasites and spirochetes can also be inoculated.
- Viral infections are probably of the most concern including bloodborne pathogens of Hepatitis B, Hepatitis C, and HIV. Other viruses causing local disease include Herpes, molluscum, warts and condyloma.
- Allergic reaction
- These are frequent and can be caused by inks, chemicals used, equipment or personal protective equipment
- Long term inflammation, elevation, thickening, scaling, hyperkeratosis and even ulceration, necrosis and scarring.
Can be more papular, nodular or more plaque-like - Latex allergy can be an early or late complication as particles from the tattooists’ latex gloves are introduced into the skin. These can cause problems later when latex is encountered including in foods that can cross-react
- Neoplasms
- Described in areas of tattoos and not know if this is causal or coincidence.
- Tattoos over dermal lesions can make it difficult to monitor for malignant transformation
- Provoked illness
- Eczema
- Psoriasis
- Sarcoid
- Other
- Psychosocial problems
- Ink problems – photosensitivity, migration, or metabolic conversion
- Acute vasculitis
- MRI burn
- Syncope and falls around the procedure
Questions for Further Discussion
1. How does the American Academy of Dermatology recommend to care for tattoos? See To Learn More below.
2. How should new body piercings be cared for? A review can be found here
3. How old does someone need to be in your location to get a tattoo legally?
Related Cases
- Disease: Piercing and Tattoos
- Symptom/Presentation: Pigmentary Lesions
- Specialty: Adolescent Medicine | Dermatology | Infectious Diseases
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Piercing and Tattoos
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Which country has the most people with tattoos? It’s not the U.S. Newsweek. https://www.newsweek.com/which-country-most-people-tattoos-943104. Published May 24, 2018. Accessed March 3, 2020.
Serup J, Carlsen KH, Sepehri M. Tattoo Complaints and Complications: Diagnosis and Clinical Spectrum. Tattooed Skin Health. 2015;48:48-60. doi:10.1159/000369645.
Breuner CC, Levine DA, COMMITTEE ON ADOLESCENCE. Adolescent and Young Adult Tattooing, Piercing, and Scarification. Pediatrics. 2017;140(4). doi:10.1542/peds.2017-1962.
Caring for tattooed skin. https://www.aad.org/public/everyday-care/skin-care-basics/tattoos/caring-for-tattooed-skin. Accessed March 3, 2020.
Tattoos: 7 unexpected skin reactions and what to do about them. https://www.aad.org/public/everyday-care/skin-care-basics/tattoos/tattoo-skin-reactions. Accessed March 3, 2020.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
Pediatric Education 