Think B-4 you Ink!

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Acute complications include pain, blistering, crusting and pinpoint hemorrhage. Among the delayed complications pigmentary changes, hypopigmentation and hyperpigmentation, paradoxical darkening of cosmetic tattoos and allergic reactions can be seen. Another common complication is the presence of residual pigmentation or ghost images.

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Scarring and textural changes are potential irreversible complications. In addition, tattoo removal can be a prolonged tedious procedure, particularly with professional tattoos, which are difficult to erase as compared to amateur tattoos. Hence the adage, stop and think before you ink holds very much true in the present scenario. Although tattooing is an ancient practice, there has been a dramatic increase in recent times among teenagers and young adults, as a cosmetic and decorative body art form.

Medical therapeutic tattooing has been used as a camouflage technique in vitiligo, for breast areola reconstruction after cancer surgery, as camouflage for permanent hair loss after craniofacial surgery, and scars following plastic and reconstructive surgery. There are currently few requirements or regulations and no legislation for the safety of tattoos. Sterility of the pigments and equipment is an uncertainty as many are being performed on the roadside and in makeshift salons.

Consequently, the number of reported adverse reactions after tattooing has increased. These are often seen by physicians, but are generally unknown to the public. Dermatologic disorders and complications after tattooing[ 7 ]. In addition there has been an exponential increase in patients seeking removal of tattoos for various psychosocial reasons, especially when names are tattoed and patients have a change of heart or a change of faith in case of religious symbols.

Many occupations such as the armed forces prohibit the presence of tattoos and youngsters seek tattoo removal. It has been rightly sung by Jimmy Buffett, an American singer that a tattoo is a permanent reminder of a temporary feeling. Many people who get a tattoo will eventually want to get rid of it.

Tattoo removal can also be a tedious prolonged procedure, particularly professional tattoos, hence there is an urgent need to caution youngsters before they get themselves a tattoo. Tattoos by physicians are used in certain medical conditions for camouflage, like resistant vitiligo,[ 8 ] breast areola reconstruction following surgery, scar camouflage following burns or surgery and hair camouflage for permanent hair loss following radiation or craniofacial surgery.

In these settings infections are less common as compared to decorative tattoos as they are carried out in sterile environments, but general complications of tattoos can still occur. The commonest complications are changes in colour, leading to colour mismatch. In vitiligo it is essential to get a good cosmetic skin-coloured tattoo matching with the surrounding normal skin. This requires a great degree of skill and often a colour mismatch leads to worsening appearance of the patch and a dissatisfied patient [ Figure 1 ]. This is more common on the lips, exposed skin and the acral areas.

The colour can fade if the pigment is placed superficially or it can appear bluish due to the Tyndall effect if it is placed too deep [ Figure 2 ]. Tattooing should be avoided when the skin is tanned, as when the tan fades, the tattoo will appear darker than the surrounding skin. Management for a mismatched tattoo in vitiligo is skin grafting if the tattoo fades, though it is difficult to cover the tattoo adequately if it is deep in the dermis. Small patches can be excised, followed by suturing.

Colour mismatch of a skin-coloured tattoo on the exposed area used as a camouflage technique for vitiligo. Fading of the tattoo and bluish discolouration due to Tyndall effect on a patch of vitiligo. These occur mainly due to the unsterile pigments that are implanted and unsterile conditions in which they are carried out. Different reactions have different times of onset as few of them appear immediately after the procedure and some may take days to weeks to years to appear [ Table 1 ].

Tattooing involves physical injury to the skin that may promote the transdermal transmission of viral and bacterial infections, depending on the conditions of hygiene during tattooing.

There are three potential origins of infections after tattooing. Firstly, use of contaminated tattoo ink. Secondly, inadequate disinfection of the skin area to be tattooed because of which resident skin bacteria can enter the skin during the tattooing process. Thirdly, during the healing process of the injured tissue after tattooing, patients often develop pruritus and burning. Transmission of hepatitis B and C virus,[ 11 , 12 ] human immunodeficiency virus HIV ,[ 13 ] human papillomavirus HPV ,[ 14 ] molluscum contagiosum virus[ 15 ] and herpes simplex virus HSV [ 10 ] infection has been described.

In a meta-analysis it was reported that there is an increased risk of infectious complications like hepatitis C when tattooing was not done in professional parlors. Bacterial infections related to tattooing comprise infection by Streptococcus pyogenes leading to impetigo, erysipelas and even septicaemia, Staphylococcus aureus causing the rare toxic shock syndrome, skin and soft tissue infections caused by community-acquired methicillin-resistant S.

A study of 31 female patients with leprosy lesions starting over tattoo marks was reported from a leprosy endemic area from India. A case of zygomycosis was observed after tattooing. A case of Candida endophthalmitis in a year-old asplenic man after tattooing has been described. Classic pigments and their degradation products used in tattooing, such as dichromate green , cobalt blue , cadmium yellow and mercury salt red -based pigments are responsible for these kind of reactions with permanent tattoos.

In addition, contamination of pigments with nickel sulphate can cause marked allergic reactions. The introduction of foreign substances into the skin during tattooing can promote a toxic or an immunological response. The timing of these delayedtype hypersensitivity reactions may vary from shortly after the tattoo application up to several years later and may be triggered by retattooing.

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To increase positive patch test reactions, tape stripping, late readings, and photopatch testing particularly for red pigments are recommended. The immunologic mechanisms involved are still a subject of speculation. A specific allergic pathway with a dermal-immunologic pattern is assumed, which probably bypasses the mechanisms in place in transepidermal allergen penetration. Therefore, additional intracutaneous testing, obviously including late readings, are required. On biopsy, various types of histopathologic patterns have been reported in tattoo reactions.

These include lichenoid, eczematous, granulomatous and pseudolymphomatous reactions, most of which are confined to the areas of the tattoo. Granulomatous reactions after tattooing can be subdivided into two main categories: Sarcoidal granulomas and other granulomatous reactions, e.

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  5. Besides the classic patterns of reactions in tattoo intolerance or allergy, cases of morphea-like lesions and marked pseudoepitheliomatous hyperplastic lesions have been described. Henna tattoos mixed with p-phenylenediamine PPD to produce black colour can produce acute allergic contact dermatitis which may be accompanied by systemic reactions, for example, generalised lymphadenopathy and fever.

    Tattoos: Understand risks and precautions

    Benign lesions such as seborrheic keratosis, histiocytofibroma, epidermal cysts and milia are well known after tattooing but are rarely published. Numerous factors could be involved, including intradermal injection of potentially carcinogenic substances benzapyrene in black tattoo ink , exposure to UV radiation and genetic factors. True association is difficult to study and detect.

    Dark black tattoos may impede a correct clinical and dermatoscopic evaluation, and can mask the development of new melanocytic lesions or the change of existing nevi. Another problem arises when tattoos are removed by laser therapy. Tattoo pigments are phagocytosed by macrophages and are transferred to regional lymph nodes.

    Therefore, tattoo pigments in draining lymph nodes can be confused with metastatic changes. In case of a concurrently evident malignant melanoma, a histologic pigment analysis is recommended. Moreover, tattoos may be used to cover up suspect lesions which can cause delay in diagnosis. Tattooing can lead to koebnerisation in patients with active psoriasis,[ 29 , 30 ] lichen planus and vitiligo. Tattooing can lead to reactivation of infections such as herpes simplex and herpes zoster, subacute cutaneous and discoid lupus erythematosus[ 31 , 32 ] and pyoderma gangrenosum.

    Most tattoos are a result of peer pressure and following media personalities such as actors, sportspersons, etc. Teenagers get themselves tattooed without thinking of the consequences. Getting tattoos of the names of the current love interest leads to a lot of psychological distress if there is a change of heart.

    Social complications arise when religious symbols are tattooed and if patients desire a change. Dissatisfaction or boredom with an existing tattoo also leads to patients seeking tattoo removal. Feelings of low self esteem, stigmatisation and anxiety are common in patients seeking tattoo removal.

    With the increasing incidence of tattooing as a fashion trend in society, clinicians should be able to recognise and treat those complications at the earliest and also appropriately counsel their patients on risks of tattoo placement. Thorough clinical history and examination are essential to make a diagnosis. To confirm the diagnosis, skin biopsy is mandatory, especially with a papulonodular growth within the tattoo pigment, since neoplastic conditions are not immediately recognised with clinical examination only. Diagnostic procedures to prove allergic reactions to tattoo colours remain challenging due to the numerous and usually unknown substances in the tattoo inks.

    So patch testing, as performed in several studies to confirm the diagnosis of allergic reactions, might not be the appropriate approach in tattoos. Topical tacrolimus is useful for lichenoid reactions.

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    Viral and fungal infections can be treated by appropriate antivirals and antifungals, respectively. Surgical removal of tumours is done depending on the site and size of the lesion with or without lymph node removal in case of metastases. Active disease needs to be treated in case of koebnerisation with appropriate therapy. A majority of the complications of tattooing can be prevented by following proper guidelines. Strict aseptic precautions are important to prevent bacterial, viral and fungal infections. The instruments should be sterile and preferably all disposables should be used to prevent transmissible infections such as Hepatitis B, C and HIV infection and leprosy.

    For many people a tattoo may seem like a good idea at the time but with over a third of the population now sporting one or more, some people come to regret the decision later in life and find that they are judged differently because of it. Main triggers for tattoo regret can be a prominent placed tattoo that can be hard to hide for employment reasons, or a name of a partner that is no longer in their life.

    Leading plastic surgeons and dermatologists now regard laser as the superior gold standard method for removal of tattoos. The tattoo removal industry is on the rise, however it is very important that you choose a removal clinic carefully as there are many people out there using inferior laser machines and these can result in undesired effects and lengthy treatment courses before they take any effect. To find some inspiration, looking online at Pinterest, Instagram, Tumblr, etc. Here are some links below:.

    Tattoos of Instagram. Tiny Tattoo Inspiration. Safety should be a top concern of anyone getting a new tattoo.

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    Look for reviews on Yelp or a tattoo shop's website, or ask friends about recommendations. Once you find a tattoo artist, ask to see a portfolio of their work to see what they're capable of and if the price you pay matches up to their artistry. Ask the artist what type of ink they use. You may be aware that some tattoos cause pain and discomfort for people when getting an MRI.