Earliest Tattoos Etymology: Tattoo
1. The word tattoo,ortattow in the 18th century, is a loanword from the Polynesian A tattoo on the word tatau, meaning “correct, right arm of a Scythian chieftain workmanlike” or “the results of tapping.” whose mummy 2. This is not to be confused with the origins of was discovered at Pazyryk, Siberia. thewordforthemilitarydrumbeator The tattoo was made more than performance see military tattoo.Inthis The tattooed right hand of a Chiribaya mummy is 2,500 years ago. displayedatElAlgarrobalMuseum,neartheportofIlo case, the English word tattoo is derived in southern Peru. The Chiribaya were farmers who lived from A.D. 900 to 1350. AMāori Chief with from the Dutch work taptoe. tattoos (moko) seen by Banks and his crew
http://www.smithsonianmag.com/history/tattoos-144038580/?no-ist https://en.wikipedia.org/wiki/Tattoo https://en.wikipedia.org/wiki/Tattoo
“Ötzi the Iceman” Etymology: Tattoo 5000 Year Old Tattooed Man
The word “tattoo” was brought to Europe by the naturalist Joseph Banks when he returned in 1769 Otzi the Iceman was from his first voyage to Tahiti found in 1991 in the and New Zealand. In his Italian/Austrian Alps. narrativeofthevoyage,herefers to an operation called “tattaw”.
Joseph Banks https://en.wikipedia.org/wiki/Tattoo http://www.crystalinks.com/otzi.html
Joseph Banks Tells of His First Encounter with Tattooing What Does the Bible Say about Tattoos?
Ye shall not make any cuttings in your flesh for the dead, nor imprint any marks upon you: I am the Lord.
Leviticus 19:28
(What is forbidden is the custom of tattooing some part of the body. Often this was a representation of the deity worshipped by the bearer of that mark.)
https://en.wikipedia.org/wiki/Joseph_Banks Tattooing: Christianity Materials and Equipment
Paul: “I bear on my body the marks of the Repeated injection of ink into the Lord Jesus” – Galatians 6:17 dermis Sterile needle that draws ink through 787 Edict distinguished between profane capillary action, an electric motor, and Christian tattoos and a foot pedal
Crusaders have crosses tattooed on their Aseptic techniques by professionals arms
Typical tattoo: gloves, disposable needles, and plastic sheath covering the parts of the tattoo machine likely to contact the client
Gilbert S. Tattoo History: A Source Book. New York: Juno Books, 2000. Simunovic C, Shinohara MM. Am J Clin Dermatol. 2014;15(6):525-36.
Famous People Known Regulation of Tattooing or Rumored to have Tattoos
King Harold the II Licensing of tattoo artists and facilities is left to the states Thomas Edison (?) Significant variability in scope and enforcement James Polk (?) July, 2014, FDA issued a voluntary recall of tattoo inks and needles due to confirmed bacterial King George V contamination
Theodore Roosevelt Rate of complication ~2%
Winston Churchill
Gilbert S. Tattoo History: A Source Book. New York: Juno Books, 2000. LeBlanc PM, et al. N Engl J Med. 2012;367(11):985-7.
Tattooing: Minimum Age (with Form of Notes parent/guardian Parent/Guardian & Intoxicated/Impaired Materials and Equipment State consent) Consent Exceptions Individuals Area of Law/Type of Penalty
Texas 18 (piercings excepted) For body piercings and for Ear piercing is exempt Cannot be tattooed or Misrepresenting one’s age to get covering existing tattoos from body piercing pierced. a tattoo, or to get a piercing (see Notes & Exceptions): statutes without parental consent, is a Parent/guardian must be class B misdemeanor. present during procedure, Minors may, with Samuel O’Reilly patented the sign an affidavit parent/guardian Violations of Texas tattooing & consent, be tattooed body piercing statute are a Class A to cover up an existing misdemeanor, with each day of first electric tattoo machine tattoo that has violation counting as a separate offensive, gang‐ offense. in 1891. [#5 Chatham Square related, or drug‐ related content, or Health Commissioner can impose “other words, symbols, a fine of up to $5000 on artists & – Bowery, NY] or marking, that the shops for each violation. person’s parent or guardian considers would be in the best Used Edison’s “Electric Pen interest of the person to cover.
(1876) Tongue splitting prohibited.
Samuel O’Reilly’s patent drawing for the first electric tattooing machine. Gilbert S. Tattoo History: A Source Book. New York: Juno Books, 2000. https://en.wikipedia.org/wiki/Legal_status_of_tattooing_in_the_United_States The Process of Tattooing: Materials and Equipment Applications of Tattoos in Medicine
Tattoo inks - suspensions of metal salts, In radiation oncology, utilized as a marker
alcohol or glycerin Endoscopic tattooing
The safety of pigments used today is largely Corneal tattooing unknown and unstudied Reconstructive breast surgery Azo pigment should be considered carcinogenic Medical alert purposes Human identification
Simunovic C, Shinohara MM. Am J Clin Dermatol. 2014;15(6):525-36. Vassileva S, Hristakieva E. Clin Dermatol. 2007;25(4):367-74.
Contents of Commonly Used Tattoo Inks/Pigments
Tattoo Ink or Pigment Ingredients Black Carbon, iron oxide, logwood extract, India ink, magnetite Cadmium red, iron oxide/common rust, ferric sulfate, hematite, cinnabar/mercury sulfide, cadmium selenide, sienna, naphthol, azo Red pigments (pigment red 210,170,112,122), quinacridones (Violet 19, red 122) Chromium oxide, lead chromate, ferrocyanide and ferro‐ferric cyanide, Green curcumin green, phthalocyanine dyes Azure blue, cobalt phthalocyanine, cobalt blue, cobalt aluminate, ferric Blue ferrocyanide, indigoid Manganese ammonium, pyrophosphate, various aluminum salts, pigment Violet Tattooed lip makeup Medical tattoo: blood type violet 19, indigoid Cadmium sulfide, ochre, curcumin yellow, azo dyes, limonite, Yellow anthraquinone Brown Ochre
Islam PS, Chang, C, Selmi C, et al. Clin Rev Allerg Immunol. 2016;50(2):273-86. https://en.wikipedia.org/wiki/Tattoo
Skin Responses to Who is Getting Tattoos? Uncomplicated Tattooing
Phagocytosis in the first two hours
Langerhans cells identify foreign antigens – cell mediated reaction
At one month, trans-epidermal elimination – draining lymph nodes
Simunovic C, Shinohara MM. Am J Clin Dermatol. 2014;15(6):525-36. https://en.wikipedia.org/wiki/Tattoo Tattooed Individuals’ Characteristics The Demographics and Rates of Tattoo Grouped into Four Types. Complications, Regret, and Unsafe Tattooing Practices: A Cross Sectional Study Liszewski W, Kream E, Helland S, et al. Dermatol Surg 2015 Nov; 41(11):1283-9.
Rates of Complications
Pain 3.8%
Infections 3.2%
Pruritus 21.2%
Regret 16.2%
Wish to have Tattoo Removed 21.2%
Received Tattoo while Intoxicated 21.2%
Kluger N. Curr Probl Dermatol. 2015;48:6-20.
Potential Complications of Tattoo Emotional profile and risk behaviours among tattooed and non‐tattooed students. Zrno M, et al. Med Glas (Zenica). 2015;12(1):93‐8. Complications following Clinical findings Symptom onset Color Students with bigger tattoos showed higher score on depression scale. tattoos Students in the tattooed group more frequently abused drugs and Bacterial infections Abscess Few days committed traffic offences compared to the students in non‐tattooed group. Erysipelas Few days Is tattooing a risk factor for adolescents’ criminal behavior? Local Gangrene Few days Empirical evidence from an administrative data set of juvenile detainees in Taiwan. Impetigo Few days Liao PA, et al. Cellulitis Few days Risk Anal. 2014;34(12):2080‐8. Systemic Sepsis Days to months A unique sample of 973 juvenile detainees drawn from the administrative profiles in Taiwan and the coarsened exact matching method were utilized. Results show that compared to their non‐tattooed counterparts, tattooed juvenile detainees were significantly more likely to commit fraud, assault, drug abuse, and homicide by 3%, 13%, 9%, and 9%, respectively. Islam PS, Chang, C, Selmi C, et al. Clin Rev Allerg Immunol. 2016;50(2):273-86.
Satisfaction with Life, Self – Esteem and Evaluation of Mental Health in People with Tattoos or Piercings Pajor AJ, Broniarczyk – Dyal G, Świtalska J Psychiatr Pol. 2015;49(3):559‐73. Bacterial Infections
• The study was conducted on a sample of 449 people aged 16-58 years (mean age 26.7 ± 6.35), of whom 308 had body modifications: tattoo (n = 90), body piercings in places Staphylococcus and Streptococcus other than the ear lobe (n = 53), or both tattoos and piercings (n = 165). • The control group consisted of 141 people without such modifications. The MRSA outbreak participants completed a questionnaire concerning their socio-demographic status, as in Kentucky, Ohio, Vermont was associated with well as the following psychological tests: unlicensed tattooist using unsterile techniques • The Satisfaction with Life Scale (SWLS), Multidimensional Self-Esteem Inventory Syphilis transmission has not been commonly (MSEI) and General Health Questionnaire (GHQ-28). reported in decades • Findings show no significant differences in terms of life satisfaction between the group with tattoos or piercings and the control group. People with body modifications were characterized by higher self-esteem, with regard to their competence and leadership abilities. • Tattoos and piercings should not be considered as indicators of psychopathology. Mycobacterial Infections in Tattoos Viral Infections in Tattoos
NTM: Mycobacterium Viral hepatitis/HIV chelonae and Mycobacterium abscessus Herpes simplex virus
Usually occur within first Human papilloma virus month No disseminated cases Molluscum contagiosum reported Typically confined to the area of tattoo ink Diluting ink with tap or distilled water has been Non‐tuberculous mycobacterium infection in a tattoo. implicated The patient had a tattoo placed 2 months prior to the development of pustules and itching within the tattoo. Culture of a skin biopsy grew Mycobacterium abscessus Molluscum contagiosum virus
Simunovic C, Shinohara MM. Am J Clin Dermatol. 2014;15(6):525-36. infection limited to tattooed skin Simunovic C, Shinohara MM. Am J Clin Dermatol. 2014;15(6):525-36.
Mycobacterium Potential Complications of Tattoo Infections in Tattoos
Complications Clinical findings Symptom onset Color Skin bx → tissue culture & PCR are used following tattoos Tinea Weeks to months Rxment: Dual Rx Macrolide and fluoroquinolone Fungal for months Zygomycoses Weeks to months
Spontaneous regression may occur
Cutaneous Mitbc or M. leprae can be transmitted rarely many years after inoculation
Reported in 19th and 20th century
43 cases of leprosy in women in India
Islam PS, Chang, C, Selmi C, et al. Clin Rev Allerg Immunol. 2016;50(2):273-86.
Potential Complications of Tattoo Potential Complications of Tattoo
Complications Clinical findings Symptom onset Color Complications following tattoos Clinical findings Symptom onset Color following tattoos Molluscum Weeks to months White to gray Allergic dermatitis Immediate to days contagiosum Immuno‐hypersensitivity Multicolored Immunologic Days to weeks to Multicolored, black or Delayed type IV Verruca vulgaris Months to years years Viral infections dark blue hypersensitivity
Hepatitis B,C Weeks to months Unknown HIV Weeks to months
Islam PS, Chang, C, Selmi C, et al. Clin Rev Allerg Immunol. 2016;50(2):273-86. Islam PS, Chang, C, Selmi C, et al. Clin Rev Allerg Immunol. 2016;50(2):273-86. Potential Complications of Tattoo
Complications Clinical findings Symptom onset Color following tattoos Psoriasis Weeks to years
Localized and Lichen planus Weeks to years Unknown systemic Pseudolymphoma Weeks to years inflammatory skin Pseudoepitheliomatous Multicolored Weeks to years reactions hyperplasia Systemic sarcoidosis Months to years Multicolored
Twenty years after placement of a tattoo, this patient developed small red‐brown nodules within the tattooed area. Histology revealed sarcoidal granulomas. Evaluation revealed that the patient had systemic sarcoidosis with pulmonary involvement.
Islam PS, Chang, C, Selmi C, et al. Clin Rev Allerg Immunol. 2016;50(2):273-86. Islam PS, et al. Clinic Rev Allerg Immunol. 2016;50:273-86.
Papulo – Nodular Reactions in Black Tattoos as Markers of Sarcoidosis: Study of 92 Tattoo Reactions from a Hospital Material Inflammatory Reactions in Tattoos Sepehri M, Carlsen KH, Serup J Dermatology. 2017 February 7. e‐Pub ahead of Print.
Granulomatous reactions Black tattoos with papulo‐nodular reactions should be seen as markers of Foreign – body sarcoidosis. Papulo‐nodularreactionsmay,astriggers,inducewidespread Sarcoidal reactions in other black tattoos ‐ a “rush phenomenon” ‐ depending on Pseudolymphoma individual predisposition. Sarcoidosis is estimated to be 500‐fold increased in Benign cutaneous lymphoid hyperplasia can mimic papulo‐nodular reactions compared to the prevalence in the general lymphomas population, and the association with black tattoos is strong. Lichenoid
Pruritic papular or plaques Red tattoos Connective Tissue Disease
Morphea – like reactions
Reactions/Exacerbations of Underlying Dermatosis
Psoriasis
Atopic dermatitis
Pyoderma gangrenosum
Lichen sclerosus
Sarcoidosis occurring in a tattoo. Tattoo reaction isolated Scaly, indurated papules limited to the to red‐inked areas tattooed skin. The patient also had sarcoidal lesions elsewhere on the skin
Simunovic C, Shinohara MM. Am J Clin Dermatol. 2014;15(6):525-36. Excessive hyperkeratotic pattern.
a Distinct and prominent thickening at all sites tattooed red, with excessive hyperkeratosis.
b Reaction entirely dominated by hyperkeratosis, with a sandpaper‐like appearance of the surface, which was flat and exhibits a loss of all skin markings. At a local site, poor nutrition, and ulceration appeared after the hyper Atopic dermatitis preferentially affecting a tattoo. The patient keratosis had loosened. had a long‐standing history of atopic dermatitis; during this flare, the tattoo developed discrete erythema and scale that improved with topical and systemic corticosteroids c Details of excessive hyperkeratotic lesions. Simunovic C, Shinohara MM. Am J Clin Dermatol. 2014;15(6):525-36. Serup J, et al. Curr Probl Dermatol. 2015;48:48-60.
Ulcero‐necrotic pattern
a. Ulceration and necrosis exclusively in the red part of a tattoo. The individual had similar necrotic elements in his normal, non‐tattooed skin that started as vasculitis‐like elements. Healing was spontaneous.
b. Aggressive ulceration and necrosis in a large tattoo on a leg, necessitating sequential amputations to the femur level. However, a reaction and recurrent Lymphomatoid papulosis within a tattoo. The patient Morphea‐like tattoo reaction occurring after a ulceration were still present. The non‐ had a crop of infiltrated papules and papulonodules red‐inked tattoo was placed. This patient tattooed skin was also affected. limited to the tattooed skin; biopsy showed a CD30+ subsequently developed linear morphea on lymphoproliferative disorder that was consistent with the contralateral leg lymphomatoid papulosis, and the lesions spontaneously resolved without treatment Simunovic C, Shinohara MM. Am J Clin Dermatol. 2014;15(6):525-36. Serup J, et al. Curr Probl Dermatol. 2015;48:48-60.
Plaque‐like pattern Neoplasms in Tattoos a. Flat elevation of the entire tattoo where lilac ink was instilled. Basal Cell Carcinoma Pseudoepitheliomatous hyperplasia (PEH) b. Flat elevation of a red tattoo. Keratoacanthoma and squamous cell carcinoma (SCC) c. Flat elevation and major thickening limitedtoaredtattooandsharply Melanocytic neoplasms and demarcated towards normal skin. malignant melanoma
a‐c.Allhavesomeadherentscalingand minor hyperkeratosis, which traditionally might be labelled ‘lichenoid’.
Kluger N, Koljonen V. Lancet Oncol. 2012;13(4):e161-8. Serup J, et al. Curr Probl Dermatol. 2015;48:48-60. Simunovic C, Shinohara MM. Am J Clin Dermatol. 2014;15(6):525-36. Keratoacanthoma in a tattoo Neoplasms in Tattoos Reactions in Patients Undergoing MRI
Melanocytic neoplasms and MRI
malignant melanoma Transient inflammation has been Use of immunohistochemical reported stains disguise melanoma from Large tattoos and those containing tattoo pigments darker pigments are at greater risk
Prophylactic cold compresses
Melanocytic nevus and tattoo. This responsible tattoo artist ensured that the melanocytic nevus was not affected by tattoo ink
Kluger N, Koljonen V. Lancet Oncol. 2012;13(4):e161-8. Simunovic C, Shinohara MM. Am J Clin Dermatol. 2014;15(6):525-36.
Neoplasms in Tattoos Reaction According to Color of Ink
Basal Cell Carcinoma and Malignant Red – most commonly associated with adverse Melanoma reaction
Black, dark blue or dark colored tattoos Cinnabar (mercuric sulfide) is a skin sensitizer
Squamous Cell Carcinoma, Now uses cadmium selenide, sienna, ferric hydrate keratoacanthromas, pseudopitheliomatous hyperplasia Black – delayed reactions. Generalized lichenoid reactions Red tattoos Green – worsening skin reactions during patch testing to green chromium tattoos
Blue – sarcoid – like granulomatous reactions
Potential Surgical and Oncological Consequences Related Side – Effects of Henna and Semi – Permanent to Skin Tattoos in the Treatment of Cervical Cancer ‘Black Henna’ Tattoos: A Full Review Kohler C, Foiato T, Marnitz S, et al de Groot AC J Minim Invasive Gynecol. 2016 July 28. e‐Pub ahead of Print. Contact Dermatitis. 2013 July;69(1):1‐25.
• Between January 2014 and May 2016, 267 laparoscopic oncologic • Black henna is the combination of red henna and the dye PPD operations including at least a pelvic sentinel or a complete • They are usually applied in holiday resort areas, in attraction parks, at lymphadenectomy have been performed in the Department of festivals and at fairs by street artisan tattoo artists, but black henna Advanced Surgical and Oncologic Gynecology-Asklepios Hospital, preparations for tattooing are also available as do‐it‐yourself kits and Hamburg, Germany. ready‐to‐use henna paste, or are made by patients themselves • 191 patients were affected by cervical cancer. • In nine patients, skin tattoos localized in the lower extremities caused discoloration of at least one pelvic lymph node. • This effect was observed in 40% (9/23) of the women with tattoos in this area of the body. Side – Effects of Henna and Semi – Permanent ‘Black Henna’ Tattoos: A Full Review Tattoo Removal de Groot AC Contact Dermatitis. 2013 July;69(1):1‐25. 1. Motives - A poll conducted in January 2012 by Harris Interactive reported that 1 in 7 • Allergic• reactionsfrequently are. usually limited to the tattoo site, but generalization (14%) of the 21% of American adults who may occur. It often takes several weeks for the dermatitis to subside, have a tattoo regret getting one. despite topical and sometimes oral corticosteroid therapy. Long‐lasting pigment alterations are observed frequently observed. 2. Removal by replacement • Once sensitized, the patients may experience allergic contact dermatitis from the use of hair dyes containing PPD or related chemicals. Such reactions are often fierce, especially in children, and many of them need to 3. Laser removal be hospitalized. Laser tattoo removal using Q‐Switch laser
https://en.wikipedia.org/wiki/Tattoo_removal
Side – Effects of Henna and Semi – Permanent ‘Black Henna’ Tattoos: A Full Review de Groot AC Contact Dermatitis. 2013 July;69(1):1‐25.
• Red henna is the dried and powdered leaf of L. inermis. Henna has been used as a dye for the skin, hair and nails for over 4000 years, and as an expression of body art, especially in Islamic and Hindu cultures in the Arab, African and Indian world. Body painting with red henna is generally safe, with few reports of allergic contact dermatitis caused by it and/or its active ingredient lawsone (2‐hydroxy‐1,4‐naphthoquinone) • Mainly an occupational hazard in hairdressers, in whom it may cause symptoms such as sneezing, conjunctivitis, running nose, dry cough, dyspnoea, swelling of the face, or generalized urticaria Complications from cosmetic tattoo of the eyebrows. This is a common • Topical application of henna maythereforecauselife‐threatening practice in Iran, often found to be a granulomatous reaction. In this example, the biopsy revealed sarcoidal granulomas. Acid fast stains were haemolysis in children with G6PD deficiency negative. In this patient, there was no evidence of systemic sarcoidosis.
Islam PS, et al. Clinic Rev Allerg Immunol. 2016;50:273-86.
Complications of cosmetic tattoo of the lips. This patient experienced swelling and induration of the lips for following cosmetic tattoo. This reaction did not respond to topical or intralesional corticosteroids, but gradually resolved over a 5‐year span. http://thenextweb.com/insider/2016/06/04/fbi-is-developing-software-to-sort-track-and-profile-citizens-by-their-tattoos/ Islam PS, et al. Clinic Rev Allerg Immunol. 2016;50:273-86. Tattoos: The Good, The Bad and the Ugly Photothermolysis Key Points
Tattoos can be complicated by a variety of inflammatory, Creates acoustic pressure leading to infectious, or neoplastic conditions; despite the increasing use pigment fragmentation into the of azo dyes in tattoo inks, reactions continue to occur. surrounding tissues enabling it to be A skin biopsy of all suspected tattoo reactions is engulfed by macrophage leading to the recommended as these can be a harbinger of systemic disease subsequent removal of the pigment from or atypical infections. the tattoo. Although professional tattooing is typically done under aseptic conditions, non‐tuberculous mycobacterial infections continue to occur and should be suspected in any tattoo reaction.
Forbat E and Al Niaimi F. Dermatol Ther 2016;6:13-23. Simunovic C, Shinohara MM. Am J Clin Dermatol. 2014;15(6):525-36.
Newer Trends in Laser Tattoo Removal
• Gold Standard: Q Switched Lasers • R20 Method – repeated exposure of laser light in a single session • RO Method • Combination of Imiquimod and Q Switched Laser • Diascopy and QSYL • Dermal Scatter Reduction • Microencapsulation of tattoo ink • Picosecond laser
Shah SD and Aurangabadkar SJ. J Cutan Aesthet Surg 2015 Jan-Mar;8(1):25-9.
Treatment of Red Pigment Reactions
• Allopurinol
• Topical and intralesional steroids
• Sun protection
• CO2 laser
• Surgical excision
Forbat E and Al Niaimi F. Dermatol Ther 2016;6:13-23.