Page 113 - Journal of Special Operations Medicine - Summer 2016

ingredients are not standardized. In a study of 30 pig- career limitation should be emphasized to active duty
ment samples, the most commonly identified elements patients considering a tattoo. Additionally, should a
19
were aluminum, oxygen, carbon, and titanium. Some Servicemember voice intent of obtaining a tattoo, pro-
16
pigments are industrial grade, used for printer ink or au- viders should stress only visiting licensed tattoo parlors.
tomobile paint. Hypersensitivity reactions are typically While tattoo parlors are required to be licensed, it is
16
secondary to metallic salts, mercury, chromium and cad- prudent to note that freelance or individual tattoo art-
mium (red), cobalt (cobalt blue, cobalt aluminate, azure ists may not be required to have a license, depending on
blue), and nickel. Red pigment most commonly causes the state. In fact, not having an individual tattoo art-
hypersensitivity reactions, and such reactions would have ist license is a misdemeanor in certain states. Businesses
a positive patch test demonstrating IgE-mediated sensi- that hire tattoo artists are more closely regulated than
tivity. The specific ingredients of red ink known to incite are individual artists because the business must pass an-
reactions include cinnabar/mercuric sulfide, cadmium nual inspections by local county health departments.
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red, iron oxide/common rust, and naphthol-AS pigment. Amateur tattoo artists are more likely to use elemental
3
Both cinnabar and cadmium are also important to note carbon particles complied from cigarette ash, pencil par-
as they are the most common ingredients of red tattoo ticles, graphite, or India ink, increasing the risk of a skin
pigment. One case report details an anaphylactic reac- reaction. Although regulations vary state to state, only
3
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tion secondary to tattoo ink in which the patient had no California requires an itemization of ink ingredients.
symptoms at time of injection 12 hours earlier. When For the health and safety of the Servicemember, obtain-
17
ink allergies occur, the patient will typically present with ing tattoos while outside the contiguous United States
pruritus, local edema, eczematous eruption with serous should be strongly discouraged due to unclear or lack of
drainage, or, rarely, exfoliative dermatitis. 3 regulations. Moreover, repercussions of acquiring body
art should be highlighted to active duty personnel in ad-
Granulomatous reactions and lichenoid hypersensitivi- dition to counseling regarding potential medical compli-
ties are less frequent than eczematous reactions, and cations and the need to seek medical evaluation should
are most frequently associated with red pigment (mer- these complications occur. Ultimately, in the setting of a
cury). This reaction pattern would have a negative cutaneous complication, a broad differential is prudent
3,7
patch test, unlike a hypersensitivity reaction. Red ink is to rule out unusual etiologies due to the unique environ-
also associated with pseudolymphomatosis reaction, of mental exposures faced by Servicemembers.
which the mechanism is unknown. Typically, the red-
3
to-violet indurated nodules and plaques are clinically Disclosures
similar to cutaneous B-cell lymphoma; therefore, histol-
ogy is required to differentiate. The authors have indicated they have no financial rela-
tionships to disclose.
The final most common skin reaction to tattoos is tattoo
sarcoidosis. This condition occurs when sarcoidal gran- Disclaimers
3
ulomas develop within the cutaneous surface of tattoos. The views expressed in this article are those of the au-
In some patients, this can be the initial presentation of thor and do not necessarily reflect the official policy or
sarcoidosis. The timeline to first cutaneous symptoms position of the Department of Defense, or the United
may vary from within 1 year of obtaining the tattoo to States Government. The authors are military service
decades after the tattoo was obtained. As with other members or employees of the US Government. Title 17,
18
skin reactions, red ink (cinnabar) is the most common USC, § 105 provides that “Copyright protection under
pigment in which a sarcoidal infiltration occurs. Clini- this title is not available for any work of the United
3
cal characteristics would include edematous, firm pap- States Government.” Title 17, USC, § 101 defines a U.S.
ules or plaque at the tattoo site in addition to pain or Government work as a work prepared by a military Ser-
pruritus. Histopathology is required for definitive diag- vicemember or employee of the US Government as part
nosis. Because a sarcoidal tattoo reaction can be the pre- of that person’s official duties.
senting sign of sarcoid, a patient with these confirmed
lesions should be evaluated for systemic disease. 18
References
Conclusion 1. Taylor P, Keeter S, eds. Millennials: a portrait of Generation
Next. Confident. Connected. Open to change. Philadelphia,
From honoring a lost friend to commemorating a vic- PA: Pew Research Center, Pew Charitable Trusts; 2010.
tory, tattoos are avenues of expression that are ubiq- 2. CDC. Methicillin-resistant Staphylococcus aureus skin infec-
uitous in military culture. However, along with the tions among tattoo recipients—Ohio, Kentucky, and Ver mont,
2004–2005. MMWR Morb Mortal Wkly Rep. 2006;55:677–
aforementioned risks associated with tattooing, body 679. Retrieved April 12, 2015, from http://www.cdc.gov/mm
art can hinder progression to officer candidacy and this wr/preview/mmwrhtml/mm5524a3.htm.

Lesions Arising in a Tattoo 99