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Title Tattooing: Medical uses and problems

Permalink https://escholarship.org/uc/item/72665746

Journal Cleveland Clinic Journal of Medicine, 79(11)

ISSN 0891-1150 1939-2869

Authors GLASSY, C. M GLASSY, M. S ALDASOUQI, S.

Publication Date 2012-11-02

DOI 10.3949/ccjm.79a.12016

License https://creativecommons.org/licenses/by/4.0/ 4.0

Peer reviewed

eScholarship.org Powered by the California Digital Library University of California REVIEW Crystal M. Glassy, DO, MPH Matthew S. Glassy, MD, MS Saleh Aldasouqi, MD, FACE, ECNU University of California, Irvine, University of California, Irvine, Michigan State University, Department of Family Medicine, Department of Internal Medicine Department of Medicine, Lansing, MI Irvine, CA Irvine, CA

Tattooing: Medical uses and problems

■■ Abstract eople have been marking the skin with P pigments for at least 4,000 years.1 Decorative tattooing is a custom thousands of years old have been found on Egyptian mummies, and and is growing in popularity today. Medical professionals Roman gladiators are known to have used tat- 2 may be less familiar with its medical applications—medi- toos for identification. Tattooing was consid- ered fashionable among royalty in the first half cal alert tattooing, reconstructive and cosmetic applica- 3 tions, endoscopic tattooing, corneal tattooing, tattooing of the 20th century. And today it is perhaps more popular than ever. in radiation oncology, and uses in forensic medicine. We But tattooing is not confined to popular cul- review current medically related tattooing applications ture and decoration. It has established uses in and discuss their potential risks and benefits. medicine, as well as other medically related uses ■■ that represent more recent trends. In this review, Key Points we explore the range of medical tattooing. Tattoos that state an advance directive for health care are not recognized as meeting the legal requirements for ■■ Medical alert tattooing advance directives. They should only be considered as a guide to treatment decisions. Medical alert tattooing is a form of medical identification similar to medical alert jew- elry, ie, bracelets and necklaces, to alert first- Tattooing for medical-alert purposes is part of current cul- responders to a medical condition or to spe- ture. People with diabetes should avoid tattooing of feet cific desires for care, such as do-not-resuscitate or lower legs in view of impaired healing. (DNR) directives. Some people choose to have their medi- Endoscopic tattooing is commonly used to aid visualiza- cal condition tattooed rather than wear medi- tion of diseased bowel segments during laparoscopic sur- cal alert jewelry, which can break or be mis- gical procedures. Complications are rare but include mild placed.4–6 chronic inflammation, abscesses, inflammatory pseudo- This practice is currently unregulated by tumors, focal peritonitis, and peritoneal staining. the medical community, and the few reports of its use published to date include two people with diabetes who had the word “diabetic” tat- Improper sterilization of tattooing needles can cause a tooed on their bodies,4,5 and a woman with a wide range of infectious diseases and skin reactions. warning of a past severe reaction to suc- cinylcholine during anesthesia.6 She had been advised to wear medical alert jewelry, but she instead chose a tattoo. Blood-type tattooing was briefly used in a few communities in the United States in the early 1950s as part of a program to provide a doi:10.3949/ccjm.79a.12016 “walking blood bank.”7 However, the practice

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FIGURE 1. Examples of tattoos patients have had done at tattoo parlors to alert emergency medical personnel to medical concerns. At left, a tattoo on the left wrist of a man, age 37, who had had type 1 diabetes since the age of 2. At right, tattooing on the left forearm of a woman, age 28, who had had type 1 diabetes since the age of 2.

The photograph at left is reprinted with the permission of the american academy of family physicians, from reference 5.

fell out of favor as physicians questioned the ments for advance directives, so they cannot reliability of tattoos for medical information.7 be considered as valid health directives, but This type of tattooing could also benefit only as a way to guide treatment decisions.14 patients with adrenal insufficiency, O-neg- The same is true for the other ways of noti- ative blood type, and allergies, and patients fying first-responders to one’s treatment wish- Some patients taking an anticoagulant drug (after discussing es, ie, wallet cards and medical alert bracelets may prefer the risks of bleeding with their primary physi- and necklaces. One manufacturer of medical cian). alert bracelets and necklaces offers to engrave tattooing Emergency medical technicians are trained that the wearer has a living will and to keep instead of a to search unresponsive patients for health- on file a copy of the document, which they medical alert related items, including medical alert neck- can fax or read out loud to paramedics if they laces and bracelets. Since tattooing for disease are contacted.11 bracelet identification purposes is not an officially rec- or necklace ognized procedure, these personnel need to be Organ donor tattoo aware that this practice is increasing among In the case of a man who had his consent to the general public. Identifying medical alert be an organ donor tattooed on his chest,15 the tattoos in emergency situations is much more tattoo was viewed as not equivalent to signed difficult in people with extensive decorative documentation; however, such tattoos can be tattooing. used to help guide management.15

Tattoos indicating health directives ■■ Diabetic patients Reports of people with tattoos indicating and medical alert tattoos health directives (DNR, do-not-defibrillate) have prompted debate over the validity of tat- Medical alert tattooing is increasingly com- toos as a type of advance directive.8–13 These mon in people with diabetes. Discussions on types of tattoos pose practical and ethical social-networking sites on the Internet indi- problems: they may not reflect a person’s cur- cate that diabetic patients often do this on rent wishes, and they may have even been their own without consulting their physician. applied as a joke.13 Furthermore, they are not In our clinic, we have encountered pa- recognized as meeting any of the legal require- tients with tattoos on the wrist (Figure 1),

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similar to those seen on the Internet, typically stain and in cosmetic surgery of the scalp.20 displaying a six-pointed star of life, a caduceus Tattooing is used for micropigmentation (physician’s staff), and the word “diabetic.” of the lips and fingertips in patients who have Patients we have encountered in the past 3 vitiligo. However, this should be reserved to 4 years have cited the same rationale for for those with stable vitiligo, since tattooing resorting to medical tattooing—ie, the cost of may trigger another patch of vitiligo at tattoo repeatedly replacing broken and lost medical sites.21 alert jewelry. Although medical management exists for We believe there is a convincing rationale vitiligo, it is often ineffective for lip vitiligo for diabetic patients to undergo medical tat- since the success of medical therapy depends tooing, and we believe that diabetes organiza- on the pigment-cell reservoir at the site of de- tions need to evaluate this and provide educa- pigmentation. The lips lack such a reservoir of tion to patients and clinicians about it, so that melanocytes, so tattooing may be an option.22 patients can discuss it with their care provid- ers before taking action on their own. Corneal scarring Perforating injury, measles , and other Risks of tattooing in diabetic patients conditions can result in cosmetically disfigur- Diabetic patients who ask their physician ing discoloration of the . When micro- about getting a diabetes-alert tattoo should surgical reconstruction is ineffective or is not be informed about the dangers of tattooing an option, corneal tattooing has been re- in diabetes. The diabetes should be optimally ported to provide satisfactory results at up to 23 controlled, as gauged by both hemoglobin A1c 4 years. Reopacification, increased opacity, and mean blood glucose profile at the time of fading of the tattoo pigment, and epithelial tattooing, in order to promote healing of the growth have been reported, and in one series, tattooed area and to prevent wound infection. most patients required reoperation.24 Also helpful is to advise diabetic patients to avoid tattooing of the feet or lower legs in Tattooing to hide surgical scars view of the risk of diabetes-related neurovas- Spyropoulou and Fatah25 reported three pa- ‘Permanent cular disease that may impair healing or incite tients in a plastic surgery practice who un- makeup’ infection. derwent decorative tattooing to camouflage cosmetically undesirable scars. The authors tattooing may ■■ Reconstructive suggested this as a valid option, especially in be beneficial and cosmetic tattooing younger patients, among whom tattooing is to people with common and acceptable.25 Areolar reconstruction allergies to Breast reconstruction after mastectomy is fun- ‘’ conventional damental to the psychosocial health of the Tattooing is also used to simulate makeup patient and helps her regain a positive body (“permanent makeup”) and may be beneficial makeup or with image.16,17 Tattooing of the nipple-areola com- to people allergic to conventional makeup disabilities plex16 is usually the final step of the breast re- or people with disabilities that make apply- construction process. ing makeup difficult.26 Complications of this that make Complications of areolar tattooing are rare procedure include bleeding, crusting, swell- applying but can include local erythema and infec- ing, infection, allergic reactions, hypertrophic makeup tion.18 And patients should be informed that scars, keloid, loss of eyelashes, eyelid necrosis, the tattoos will likely fade over time and re- and ectropion, as well as complications relat- difficult quire re-tattooing.18 ed to magnetic resonance imaging (described further below). Tattooing as camouflage Most pigments used for this purpose do not Tattooing is used to repigment the skin in con- have an established history of safe use, and ditions that cause hypopigmentation or hyper- patients may experience severe allergic reac- pigmentation,2 including burns.19 It is also used tions. A recent report described severe aller- as an alternative to laser treatment in port-wine gic reactions resistant to topical or systemic

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therapy with steroids in combination with and secondary markers such as birthmarks, topical tacrolimus (Prograf), especially after scarring, and tattoos to identify victims.32 Tat- exposure to red dye 181.27 Researchers have toos are useful for identification when finger- recommended the regulation and control of prints or dental records are unavailable,33 as in colorants in permanent makeup.27 the tsunami of December 2004 in Southeast Asia34 and the London Paddington train crash ■■ Radiation oncology of October 1999.35 However, as the body de- composes, tattoos can discolor and fade, mak- Tattooing is used in radiation oncology to en- ing them hard to identify. Application of 3% sure accurate targeting of radiation therapy. hydrogen peroxide to the tattoo site has been Typically, several small, black marks 1 to 2 mm reported to aid in identification, and infrared in size are applied by a medical professional us- imaging has shown promise.32 ing an 18- or 19-gauge hypodermic needle and india ink.2 The marks are permanent. ■■ General Risks and complications Although these markings are clearly help- of tattooing ful during radiation treatment, they can be psychologically upsetting to patients, as they Improper sterilization of tattooing needles and are a constant reminder of the disease and the in public tattoo parlors can cause a treatment, both during the treatment course wide range of diseases and skin reactions.36–44 and long after it is finished. An alternative is to use temporary marks Infection for the 6 to 7 weeks that patients typically Pyodermal infections can include temporary need them. However, temporary tattooing is inflammation at the sites of needle punctures, prone to fading, and this is a key limitation. superficial infections such as impetigo and ec- thyma, and deeper infections such as cellulitis, ■■ Endoscopic tattooing erysipelas, and furunculosis. Other transmissible infections include The metallic In laparoscopic gastrointestinal surgery, le- hepatitis, syphilis, leprosy, tuberculosis cutis, pigments sions are often difficult to visualize and local- rubella, chancroid, tetanus, and molluscum ize since the surgeon is unable to palpate the contagiosum. An outbreak of infection with in tattoos bowel directly to identify the diseased seg- Mycobacterium chelonae from premixed tattoo can conduct ment; this increases the risk of resecting the ink has also been reported.44 wrong segment of bowel.28 Endoscopic tat- Hepatitis C has been shown in epidemio- heat and cause tooing of the segment to be resected greatly logic studies to be transmissible via nonsterile burns during improves the accuracy of laparoscopic pro- needles. Human immunodeficiency virus is magnetic cedures. Endoscopic tattooing is also used to also theoretically transmissible this way, but facilitate identification of subtle mucosal le- this is difficult to confirm because the virus has resonance sions or endoscopic resection sites at the time a long incubation period.36 imaging of subsequent endoscopy.29,30 India ink or a similar presterilized commer- Cutaneous reactions cial preparation is commonly used.31 Com- Skin reactions to tattooing include aseptic plications are rare but include mild chronic inflammation and acquired sensitivity to tat- inflammation, hyperplastic changes, inflam- too dyes, especially red dyes, but also to chro- matory bowel disease, abdominal abscess, mium in green dyes, cadmium in yellow dyes, inflammatory pseudotumor, focal peritonitis, and cobalt in blue dyes.38 The reaction can peritoneal staining, and, very rarely, seeding manifest as either allergic contact dermatitis of tumor via the tattooing needle.30 or photoallergic dermatitis. Cutaneous conditions that localize in tat- ■■ Forensic medicine tooed areas include vaccinia, verruca vulgaris, herpes simplex, herpes zoster, psoriasis, lichen Specialists in forensic medicine use primary planus, keratosis follicularis (Darier disease), markers such as fingerprints and dental records chronic discoid lupus erythematosus, and ker-

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atoacanthoma. ments.41 Patients should be asked before this Other possible conditions include keloid, sar- procedure if they have tattooing so that this coidal granuloma, erythema multiforme, local- complication can be avoided. ized scleroderma, and lymphadenopathy.36,37 Two other complications Malignancy Two interesting complications of tattooing Malignancies reported to arise within tattoos have been described. First, tattoo pigments include squamous cell carcinoma, basal cell have been noted within lymph nodes in pa- carcinoma, malignant melanoma, leiomyosar- tients with melanoma.42 This finding during coma, primary non-Hodgkin lymphoma, and surgery could cause the surgeon to mistake dermatofibrosarcoma protuberans.39 These tattoo pigment for disease and to complete a malignancies may be considered coincidental, regional lymph node dissection if biopsy of the but carcinogenicity of the tattooing colorants sentinel node is not performed. is a concern to be addressed. Nevertheless, a The other involved disseminated hyperal- malignancy within a tattoo is more difficult to gesia after volar wrist tattooing. The authors identify on skin examination. speculated that the pain associated with volar tattooing may have been related to the prox- Burns during magnetic resonance imaging imity of the tattoo to the palmar cutaneous The metallic ferric acid pigments used in branch of the median nerve.43 ■ tattoos can conduct heat on the skin during 40 ACKNOWLEDGMENT: The authors would like to acknowl- magnetic resonance imaging, resulting in edge the patients in Figure 1 for their permission to use their traumatic burns. This has also been reported photos and Nicolas Kluger, MD, Departments of Dermatology, Allergology, and Venereology, University of Helsinki, Finland, to occur with tattoos with nonferrous pig- for his input into an early draft of this manuscript.

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