Tattooing: Medical Uses and Problems

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 Tattoos 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 considered 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 jewelry, 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. tattoo 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 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 79 • NUMBER 11 NOVEMBER 2012 761 Downloaded from www.ccjm.org on May 20, 2014. For personal use only. All other uses require permission. MEDICAL TATTOOING 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. 13 applied as a joke. 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), 762 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 79 • NUMBER 11 NOVEMBER 2012 Downloaded from www.ccjm.org on May 20, 2014. For personal use only. All other uses require permission. GLASSY AND COLLEAGUES 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 keratitis, and other Risks of tattooing in diabetic patients conditions can result in cosmetically disfigur- Diabetic patients who ask their physician ing discoloration of the cornea. 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- ‘Permanent makeup’ 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).

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