Tattoos are one of the most popular and prevalent forms of Body Art.  The practice of tattooing is centuries old, and is central to some cultures.  Much has been written about the hazards of tattooing if practiced under unsanitary conditions.  Little attention has been directed however to the potential latent health effects of tattoo inks. 

Tattooing has been practiced throughout most of the world, though it is rare among darkly pigmented peoples, and rare in China.  Evidence of tattoos has been found in Egyptian mummies over 4000 years old.  There is also evidence suggestive of the 5000+ year old Iceman having tattoos.  It is thought the word “tattoo” entered English and European languages in 1769, having been recorded by James Cook’s Tahiti expedition.  In 1891 the first electric tattoo device was patented in the US. 

Interest in tattoos has waxed and waned in US and European cultures.  Negative footnotes to tattoo history would be use with prisoners and Nazi concentration camp internees.  Religious objection to tattoos can be found in Leviticus 19:28:  “You shall not make any cuttings in your flesh on account of the dead or tattoo any marks upon you.” 

The practice of tattooing seems to have now become mainstream.  Young adults and teens worldwide are having dangerous compounds and chemicals injected under their skin for the sake of body art.  The trend started surging in the early 1990s.  By 2003 it was projected that 36% of 25- to 29-year olds in the US had at least one tattoo.  That makes tattoos a pretty big business. 

REGULATION

Did you know that there is no federal oversight of tattooing? Although tattoo businesses in the US fall under the purview of the Federal Drug Administration (FDA), the FDA has deferred. Their official position has been: “Because of other public health priorities and a previous lack of evidence of safety concerns, FDA has not traditionally regulated tattoo inks or the pigments used in them.” Therefore if an establishment claims that their tattoo business or tattoo inks are approved or certified by the FDA, it is simply not true.

The FDA acknowledges reports of immediate and delayed adverse reactions to tattoo ink. FDA also acknowledges occurrences of inflammation and itching of tattoos with summer sun exposure, and reports of adverse reactions to tattooed make-up, such as eyeliner.

RISKS ACKNOWLEDGED BY FDA

INFECTIONS such as HIV and hepatitis related to reused needles.

ALLERGIC reactions to temporary and permanent tattoo inks.

SCARRING may occur with getting a tattoo, or tattoo removal.

GRANULOMAS in the form of large or small bumps that form to encapsulate foreign substances, such as tattoo ink particles.

MRI studies may cause burning and swelling of tattoos due to metal components in tattoo inks.

FDA RESEARCH

FDA and medical providers have determined many tattoo inks contain “industrial strength” pigments suitable for automotive paint and printers’ ink. The following issues will be explored by the FDA’s National Center for Toxicological Research (NCTR):

Chemical make-up of tattoo inks and how the inks are broken down by the body

Short- and long-term impact of tattoo ink pigments

Body response to inks with sunlight and laser

STATE REGULATION

Is anyone watching the shop? Regulation of tattoo businesses and practices is established at the state level. Level of rules and oversight varies. California’s Proposition 65 requires tattoo businesses to warn customers that tattoo pigments contain heavy metals associated with birth defects, other reproductive injury and cancer. On the flip side, some states are unregulated.

OTHER TATTOO CONCERNS

The US Red Cross imposes a 12 month wait for potential donors who have had a tattoo in a facility that is not state regulated, or in a state that has no oversight of tattoo businesses. In the UK there is no regulation for tattooing, and a 6-month wait is imposed after tattoos, with no exceptions.

Canada introduced legal tattoo services in the prisons to give prisoners a skill, and to reduce health risks such as hepatitis.

The American Association of Nurse Anesthetists recommends no needle sticks through tattoo pigment for fear of deleterious effects of ink particles that may be carried into deeper tissues.

Plastic polymers are used in glow in the dark inks. Polymerization has occurred whereby particles mesh into a solid sheet of plastic under the skin.

Metal salts in tattoo pigment can cause burning and pain during MRI procedures. Some facilities are refusing to perform MRIs on clients with tattoos.

Some pigments, especially yellows, react to light and may break down into toxic components due to laser removal treatments. Toxins may put a burden on the liver and kidneys.

American Academy of Dermatology has voiced concern and identified an extensive list of potentially harmful ingredients and compounds in tattoo inks.

WHAT IS IN TATTOO INKS?

Central to the issue of the possible health hazards of tattoo inks, is that no one is sure what is in the inks. Manufacturers are not bound to divulge the ingredients of their pigments, and mixtures may be considered trade secrets. Professional tattoo ink pigments may be made from plants, plastics, iron oxides or metal salts. Homemade inks may be made from dirt, soot, plants, pen ink, blood or an unknown array of other possible ingredients.

SOME KNOWN INGREDIENTS OF TATTOO INKS:

HEAVY METALS

Aluminum

Barium

Cadmium

Chromium

Cobalt

Copper

Iron

Lead

Mercury

Nickel

Titanium

Zinc

METAL OXIDES

Ferrocyanide

Ferricyanide

ORGANIC CHEMICALS

Azo chemicals

Naptha derivative chemicals

Carbon

Polycyclic compounds

OTHER COMPOUNDS

Antimony

Arsenic

Beryllium

Calcium

Lithium

Phosphorus

Selenium

Silica

Sulfur

Titanium dioxide

Polymethylmethacrylate (PMMA)

COMMON INGREDIENTS OF INKS BY COLOR

RED: mercury, cadmium, iron, ferrocyanide, ferricyanide, naptha derived chemicals

ORANGE: cadmium, azo chemicals

YELLOW: lead, cadmium, zinc, ferrocyanide, ferricyanide, azo chemicals

GREEN: lead, chromium, aluminum, copper, ferrocyanide, ferricyanide, azo chemicals

BLUE: cobalt, copper, ferrocyanide, ferricyanide

VIOLET: aluminum, azo chemicals

BROWN: iron, azo chemicals

BLACK: nickel, iron, carbon as soot or ash, black henna

WHITE: lead, zinc, titanium, barium

COMMON INK REACTIONS

Although data is not collected on allergic reactions to tattoo ink, some sources state reactions are more common to latex than to tattoo inks, and recommend clients ask tattoo artists to use non-latex gloves.

Reports indicate allergic reactions to tattoo inks are most common with red and yellow inks, and occasionally white ink.

Of reactions after laser removal treatments, red ink is the most commonly implicated, and is associated with mercury and azo chemicals.

The European Commission report from 2003 describes

• A case of allergic skin reaction to cobalt blue, and many cases of reactions of red tattoo ink, of both azo compounds and inks of heavy metal composition.
• Nodular granulomateous reactions, mostly related to azo or heavy metal red inks. One case developed in the red pigmented areas of a 37 year old tattoo.
• Sarcoidosis cases traced to red ink, black ink, and multiple colors of ink.

PIGMENT CARRIERS

Pigments are dissolved in a solvent to help “carry” the color from the needle to the skin.  Carriers make ink application easier and help keep the ink mixed with the pigment and evenly distributed.  Typical carriers are some form of alcohol or aldehyde.  Alcohol derivatives as carriers are known to increase the permeability of the skin which results in more chemicals absorbed into the bloodstream.  Alcohol carriers are also known to amplify the cancer causing potential of ingredients of inks. 

COMMON CARRIERS

Water

Ethyl alcohol

Denatured alcohol

Methanol

Rubbing alcohol

Propylene glycol

Glycerine

Formaldehyde

Other aldehydes

The European Commission published Risks and Health Effects from Tattoos, Body Piercing and Related Practices in May of 2003. The team had identified concerns regarding health risks from tattooing and piercing, and a lack of regulation of these industries. The specific composition of tattoo ink was generally unknown. It was known however that organic industrial pigments and heavy metals were used, which had impurities and microbiological components.

Part of the problem identified was that there have been few defined, targeted studies to examine risks for immediate or latent effects of tattoo inks. In examining many studies, including casual report of adverse effects related to tattooing, they developed a list of health risks that were “potentially associated with tattooing and piercing”. Examination of the full report however reveals some findings to have been well substantiated as a direct result of tattooing.

EUROPEAN COMMISSION FINDINGS OF POSSIBLE HEALTH EFFECTS:

The commission findings can be categorized into 5 areas: infections, allergic reactions, cancer, behavioral changes, and skin diseases. Many of the effects are delayed, sometimes up to 20 years or longer, and auto-immune in nature. In my view, this is similar to delayed problem development associated with silicone breast implants, agent orange exposure and Gulf War Syndrome.

INFECTIONS

Infections are associated with poor hygienic conditions and more overtly risky practices such as reuse of tattoo needles. Infections are understandably noted with surreptitious prison tattooing, but have also been commonly found with unlicensed tattoo facilities and artists. Known infections include:

VIRAL INFECTIONS: HIV/AIDS, hepatitis, skin infections

BACTERIAL INFECTIONS: toxic shock syndrome, impetigo, chancroid, tetanus, leprosy, tuberculosis

FUNGAL INFECTIONS: zygomycosis, sporotrichosis

ALLERGIC REACTIONS

Allergic reactions associated with tattoos are almost exclusively related to tattoo inks and pigment carriers. Case reports state that allergic skin reactions are “not infrequent”. Allergic reactions include:

Skin irritation and uticaria

Lichenoid and granulomateus reactions

Lymphadenopathy

Pseudo lymphomas

Sarcoidosis

CANCER

Skin cancers have occurred within the boundaries of tattoos, and gone unnoticed until they began to extend beyond the boundaries of the tattoo. Included:

Malignant melanoma

Squamous cell carcinoma

Basal cell carcinoma

BEHAVIORAL FACTORS

Correlation of other risk taking behaviors

SKIN DISEASES

Psoriasis

Photosensitization

Photogenotoxicity

Phototoxicity

EUROPEAN COMMISSION RECOMMENDATIONS

Systematic study of adverse health impacts

Regulation of facilities, materials/inks, workers

List of prohibited and permitted ingredients

Education and certification of tattoo artists

OTHER FINDINGS

Nearly 40% of organic pigments used in tattoos are not approved even for cosmetic topical use.  Almost 20% of pigments were cancer causing aromatic amines. 

Tattoo inks travel in the body.  Black tattoo pigments have been found in lymph nodes.  Further, these pigments look like metastases in the nodes, complicating the evaluation of cancer status. 

Laser removal of tattoos has been shown to generate new chemical compounds which travel through the blood and lymph vessels.  Cancer causing compounds have also been generated. 

FINAL THOUGHTS

There is no such thing as a safe tattoo.  There are a reasonable number of studies and case reports as to the adverse health effects of tattoos.  The lack of extensive definitive studies proving adverse effects is just that, a lack of studies.  It is not proof that tattoo inks are safe.