Page 61 - JSOM Fall 2024

an individual has more than one tattoo, allergic cross- usually occurs at the mid-dermis level but may occasionally
reactions have been observed. More specifically, a newer reach deeper levels. 21
tattoo that induces an allergic reaction can also trigger an
allergic reaction in one or more older tattoos, even if the “re- Over time, individuals may develop sensitivity to sunlight on
sponder” tattoos have previously been well-tolerated and are tattooed skin. Given that SOF personnel are frequently ex-
16
located in other parts of the body. Patients report symptoms posed to the sun more than the average U.S. citizen and that
common to allergies, particularly itching, swelling and sensi- ink particles degrade more readily under ultraviolet radiation,
tivity or pain to touch. 7,17 These symptoms may cause substan- servicemembers may be more prone to phototoxicity and
tial discomfort and affect the overall functionality of an SOF immunoactivation, leading to photoallergy. 6–8,13,14,25 Service-
servicemember. 17 members with black tattoos may be particularly susceptible to
photoallergy due to the high sunlight absorption of black ink
7
Diagnosing tattoo allergies can be challenging. For patients pigments. Sun-related responses can occur immediately upon
with amateur tattoos, skin prick and patch testing may not be exposure or have a delayed onset. Urticaria is a common pho-
7
feasible owing to the diverse particles in amateur inks, which toinduced adverse reaction that can last up to several days. 8,16
can include cotton, burned wood, vegetable matter, plastic, Beneficial behavioral changes include temporarily avoiding di-
shoe heels, styrofoam, paper, and molten rubber mixed with rect sunlight exposure. Tattoos may also form blisters during
13
2
other compounds. In patients with professional-grade tattoo low-light therapy for neuromuscular pain. 2
inks, skin prick and patch testing tend to be unreliable because
of the haptenization of the ink pigments during pathogene- Specific ink colors have been linked to distinct health com-
sis. 7,10,18,19 Additionally, intradermal testing may in itself lead plications. Black is the most prevalent color used in tattoos
to a prolonged skin reaction, as it mimics the tattooing pro- and is specifically associated with non-allergic papulo-nodular
cess, and is generally discouraged for diagnostic purposes. 6,10 reactions. 7,8,13,26 Papulo-nodules and granulomatous lesions in
Although skin biopsies are not considered definitive for diag- black-ink tattoos have been considered markers of sarcoid-
nosing tattoo allergies, they are recommended to exclude other osis, indicating a need for screening for sarcoidosis. 6,10,14,27
pathologies, such as infections with atypical microorganisms Although less commonly used in tattoos, red pigments have
and systemic diseases. 6,12 been implicated in most of the adverse tattoo-related health
responses, including chronic allergic reactions. 6,10,12,24,28 They
Diagnosing tattoo-based allergies relies heavily on visual have been linked with long-term reactions such as granulo-
symptoms. A central criterion is the localized nature of the matous and pseudolymphomatous phenomena, morphea-like
6,7
10
allergic reaction to a single ink color. An allergic reaction is lesions, and vasculitis. Both black and red inks generally con-
7,8
not suspected if, for example, thickening is observed in one tain carcinogenic agents; black ones may include high levels of
part of the tattoo but not in another area tattooed with the benzo(a)pyrene, while red colorants carry harmful com-
12
same ink color. A definitive criterion for allergy is the in- pounds, such as cadmium selenide. 2,8,10,25 Other colorants, such
duction of reactions in a previously tolerated tattoo of the as green and blue, may contain high levels of heavy metals
same color at a different anatomical site, indicating allergic but are less commonly implicated in adverse tattoo reactions,
cross-reactivity. Visible clinical manifestations of allergic re- potentially owing to their less frequent use in tattooing. 19,29
7
actions include plaque-like, hyperkeratotic, ulcero-necrotic,
and lymphopathic patterns. 7,8,13 In advanced stages, scarring Toxic effects may not be confined to the tattooed area; stud-
may develop, characterized by alterations in color or pigment ies suggest substance migration. 8,25,30 Researchers have shown
disappearance. 12 that ink particles are transported from the skin to other body
regions via blood vessels and the lymphatic system. 2,6,8,25,30 Tat-
Standard treatment options include topical, intralesional, and too ink pigments have been documented in the liver, lungs, and
oral steroids. 6,8,13,20 In cases of acute complications, oral anti- kidneys. 6,19 The long-term consequences of bioaccumulation
histamine therapy has been suggested. 6,13 Once triggered, the in internal organs and lymph nodes—including the potential
7
allergic response tends to be persistent and become chronic. conversion of ink particles into toxic substances—are unclear.
It may also become resistant to therapeutic approaches and The accumulated quantity may play a role. Individuals with
require the removal of the tattooed tissue. 7,21 Tattoos can be large-scale or multiple tattoos have several grams of tattoo
removed chemically (using imiquimod and ingenol mebutate), colorants injected into their skin and may therefore be more
mechanically (through abrasion or excision), and thermally prone to tattoo-induced pathological processes. 25
(with lasers). 2,8,13 Although laser ablation is the most widely
known form of tattoo removal and has been used with treat- Theorizing about potential migration processes, researchers
ment-resistant tattoo allergies, studies highlight potential have suggested a link between granulomatous tattoos and uve-
downsides and limitations. 8,21–23 Lasers can break down the itis. 8,31 They recommend asking patients with a granulomatous
pigments into smaller particles, potentially releasing more car- tattoo reaction about ocular symptoms such as blurred vision,
cinogens into the body. 6,24,25 Furthermore, laser treatment may photophobia, and eye pain. 6,31–33 The development of pigment
6
lead to additional allergic reactions. Dermatome shaving has migration and distribution models has been encouraged but is
emerged as a well-tolerated treatment alternative for chronic currently not feasible due to a poor understanding of biochem-
tattoo reactions. 7,8,15,21,24 Using instruments such as a Watson ical ink-body interactions. 8
knife supplemented with the Zimmer pneumatic instrument
for larger lesions and the Da Silva knife or a curved shave In addition to infectious and inflammatory responses, neoplas-
biopsy blade, the tattooed skin is shaved in slices ranging from tic reactions have drawn attention. 8,34,35 A case report describes
21
0.25mm to 1mm. The depth of shaving is determined by vi- a hemangioma that developed following the tattoo applica-
sual examination, and the procedure continues until the ap- tion. Another case report documents a dermatofibrosarcoma
36
pearance of collagen tissue that is free of ink pigments, which protuberans growing in a tattoo and highlights the difficulty
Tattoo Inks: Health Risks and Biokinetics Explored | 59