Dermatologic Complications with Body Art: Tattoos, Piercings and Permanent Make-Up

Dermatologic Complications with Body Art

Christa De Cuyper, Maria Luisa Pérez-Cotapos S Editors

Dermatologic Complications with Body Art Tattoos, Piercings and Permanent Make-Up

Dr. Maria Luisa Pérez-Cotapos S Pontificia Universidad Católica de Chile, Department of Dermatology, Clinica Las Condes, Lo Fontecilla 441, Santiago, Chile [email protected]

Dr. Christa De Cuyper Department of Dermatology AZ Sint-Jan Ruddershove 10 8000 Brugge Belgium [email protected]

ISBN: 978-3-642-03291-2

e-ISBN: 978-3-642-03292-9

DOI: 10.1007/978-3-642-03292-9 Springer Heidelberg Dordrecht London New York Library of Congress Control Number: 2009933268 © Springer-Verlag Berlin Heidelberg 2010 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: Frido Steinen-Broo, eStudio Calamar, Figueres/Berlin Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Contents

1

History and Epidemiology of Tattoos and Piercings. Legislation in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anne E. Laumann

1

2

Materials Used in Body Art . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Christa De Cuyper and Davy D’hollander

13

3

Tattooing and Scarring: Technique and Complications. . . . . . . . . . . . Maria Luisa Pérez-Cotapos S, Christa De Cuyper, and Laura Cossio

29

4

Piercings: Techniques and Complications . . . . . . . . . . . . . . . . . . . . . . . Christa De Cuyper, Maria Luisa Pérez-Cotapos S and Laura Cossio

43

5

Cosmetic and Medical Applications of Tattooing . . . . . . . . . . . . . . . . . Christa De Cuyper

53

6

Allergic Reaction to Pigments and Metals. . . . . . . . . . . . . . . . . . . . . . . Werner Aberer, Johan E. Snauwaert, and Ulf-Maria Render

61

7

Techniques and Devices Used for Tattoo Removal . . . . . . . . . . . . . . . . Evelien Verhaeghe

91

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

107

v

Introduction

Body art in its different forms dates back to ancient times. Body modification is a common human characteristic that has been practised on all continents and in all races. Specific types of body art have been associated with specific social, ethnic and religious societies. Temporary decorations include the traditional customs, costumes, the use of jewellery and body painting. Permanent modifications such as piercing and tattooing are old forms of body adornment that have gained popularity as a fashion statement in the last decades and that have been accepted in all social classes nowadays. Cosmetic tattoos or permanent make up have been introduced as an excellent alternative for conventional make up. The technique of micropigmentation consists of implantation of pigment into the skin or the mucosa using a small tattoo pen. The same procedure with a modified instrument, known as dermatography, has found its place in the medical world to camouflage pathological skin conditions such as vitiligo and alopecia or to mask scars and birth marks and it can offer the finishing touch in reconstructive surgery. It can also be used for implantation of pharmacological substances for therapeutic indications. Tattoos are also used as a permanent mark for medical procedures. The imagination in body adornment and body transforming techniques is amazing and endless. More invasive body modifying techniques such as implanting, scarification, branding, scalping and even amputation recently seem to attract the young population and unfortunately often result in impressive, irreversible body mutilation. All body-modifying methods can lead to complications, which depend on the hygienic conditions in which the procedures are performed, on the training and the skills of the practitioner and on the materials used. Allergic reactions can be attributed to the substances used. Poor hygienic standards and careless procedures can result in localised infections but can also lead to severe life-threatening conditions or even result in irreversible damage. Blood-borne diseases can be transmitted (hepatitis B, C, HIV), granuloma and keloid formation can occur. Health care professionals should be aware of the complications that can arise from these procedures. The body art industry is one of the fastest growing industries in the last years unaffected by the economic crisis. Considering the high number of people who have chosen for a tattoo, a piercing or any other form of body modification, one can estimate that millions of people on the globe live with a self-inflicted health risk that could have an important impact and consequences for the health care system in general. Many efforts have been done yet to identify risk factors and to develop preventive measures aimed at protecting public health. Regulation of the composition of the products, harmonisation of the methods for the analytical determination of possible harmful substances, guidelines and recommendations to ensure that procedures are vii

viii

Introduction

carried out under appropriate hygienic conditions can offer a big step forward to promoting consumer health. However there is still a lack of uniform universal regulation and control. The purpose of this book is to illustrate the different aspects of body art starting from the history through epidemiology, to improve the knowledge about materials, with their toxic and allergenic potential, to discuss the procedures and the complications that can arise. Therapeutic modalities will be addressed with a focus on laser techniques for tattoo removal. To realise this book we had the assistance and contributions of many people we would like to thank, in particular our colleagues, our secretaries and our families for their help and support. Brugge, Belgium Santiago, Chile

Dr. Christa De Cuyper Dr. Maria Luisa Pérez-Cotapos S

Contributors

Werner Aberer Department of Dermatology and Environmental Dermatology, Medical University of Graz, Auenbruggerplatz 8, 8010 Graz, Austria Laura Cossio Department of Dermatology, Pontificia Universidad Católica de Chile, Santiago, Chile Christa De Cuyper Department of Dermatology, AZ Sint-Jan, Ruddershove 10, 8000 Brugge, Belgium Davy D’hollander Professor Claraplein 14/002, 2018 Antwerpen, Belgium Anne E. Laumann Feinberg School of Medicine, Northwestern University 676, North St. Clair #1600, Chicago, IL 60611, USA Maria Luisa Pérez-Cotapos S Pontificia Universidad Católica de Chile, Department of Dermatology, Clinica Las Condes, Lo Fontecilla 441, Santiago, Chile Ulf-Maria Render Department of Dermatology, Medical University of Graz, Auenbruggerplatz 8, 8010 Graz, Austria Johan E. Snauwaert Augustijnslei 36, 2930 Brasschaat, Belgium Evelien Verhaeghe Department of Dermatology, UZ Gent, De Pintelaan 185, 9000 Gent, Belgium

1

History and Epidemiology of Tattoos and Piercings. Legislation in the United States Anne E. Laumann

Core Messages

› › › › › › ›

Tattooing and body piercing date back to early civilizations. In the past, they were used during initiation rites or as an indication of social status. Tattooing has been used to identify criminals, prisoners, and slaves, and for punishment. Body modification has become more common and more sophisticated over the last 30 years. Body art may be associated with risky behavior. Body piercing may be associated with depression. Regulation in the United States of America is variable from state to state.

1.1 History 1.1.1 Tattoos Tattooing, defined as the practice of producing an indelible mark or figure on the human body by inserting pigment under the skin using needles or other sharp instruments, has probably been around since the beginning of humanity [1]. There is not so much a continuous

A. E. Laumann Feinberg School of Medicine, Northwestern University, 676, North St. Clair #1600, Chicago, IL, 60611, USA e-mail: [email protected]

history related to tattooing, but rather many concurrent happenings in different societies across the world. Tattoos disappear when their canvas goes; in other words, with the death of the individual, so our current information may be more discontinuous than the reality. The famous 5,300-year-old preserved corpse, nicknamed Otzi, found in the mountains of the South Tyrol in 1991 was covered in tattoos. These included linear marks over many of his joints and a cross on the inside of the left knee. They may have been placed to help with pain from his evident arthritis [2, 3]. Dark blackish-blue inscriptions have been found on Egyptian mummies dating as far back as 2100 b.c. Interestingly, it appears that this practice of tattooing was limited to women. It may have been only for decoration, but other hypotheses suggest a ritualistic significance or a relationship to fertility and sexuality. The tattoos were groups of dots and dashes in geometric patterns, often across the abdomen. The oldest of these mummies is that of Amunet, a priestess of Hathor, the Egyptian goddess of love. Later (circa 1532–1070 b.c.), female mummies from the New Kingdom of Nubia (South Egypt) were embellished with representational tattoos, for example, the image of the god Bes, on the thighs. In the late eighth century b.c., Isaiah prophesied “This one will say, ‘I am the Lord’s,’ another will call himself by the name of Jacob, and another will write on his hand, ‘ The Lord’s,’ and surname himself by the name of Israel” [4]. Old testament sayings like this together with the injunction “You shall not make any cuttings in your flesh for the dead nor print any marks upon you: I am the Lord” [5] in Leviticus, composed circa 550–400 b.c., belie the presence of these marks on the bodies of Israelites at that time. This latter admonition may have been motivated by the use of tattoos among non-Jewish people, for example, those of the cult of Baal [6].

C. de Cuyper, M. L. Pérez-Cotapos S. (eds.), Dermatologic Complications with Body Art, DOI: 10.1007/978-3-642-03292-9_1, © Springer-Verlag Berlin Heidelberg 2010

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A. E. Laumann

About the same period, the Pazyryk were a nomadic tribe living in the Altai Mountains of Siberia. A number of their tombs have been opened and previously undisturbed bodies found to be elaborately decorated with real and mythical beasts. These pictures are thought to reflect the societal status of the bearer [6]. Likewise, it is clear that tattooing occurred in China. Although, in some parts men tattooed their hands as a sign of valor and women tattooed the nape of the neck as a sign of marital status, in general, tattooing happened among “barbarian” peoples. Tattoos may have been used as facial cosmetics, to ward off evils spirits, or as marks of slavery or punishment [7]. In Japan, there is evidence from clay figures from the Jomon period (10,000–300 b.c.) of facial tattoos, and later, during the Yahoi period (300 b.c.–300 a.d.) tattooing occurred on the face for decorative and religious purposes and to ward off evil spirits. Later, tattooing fell into disrepute, and during the Kofun period (300–600 a.d.), it was used as a punishment and to

identify “untouchables”. Decorative tattooing, heavily influenced by the imagery of wood-block print artists, developed during the Edo period (1600–1800 a.d.). The Yakuza, who initially were flamboyant and crazy samurai in the service of the emperor, degenerated into the criminal class, and it was this group who became known for elaborate full body tattoos. (Fig. 1.1) These tattoos, even today, may be applied by hand and take many days to complete. Their painful acquisition is a measure of courage and group solidarity. During the Meji era (1868 to present), tattooing has been forbidden, increasing the association with criminality, although, as in the rest of the developed world, tattooing is becoming more mainstream [8]. Little is known about tattooing during the latter part of the first millennium and the early part of the second millennium a.d., but the Inuit (Eskimos), who lived along the Arctic coasts of Siberia, Alaska, Greenland, and Canada, continued to use facial tattoos over the centuries. They served to protect them from enemies,

Fig. 1.1 Nakamura Fukusuke in the role of Koito with Ichimura Ichizo in role of Sashichi. Color woodcut diptych with gauffrage 1858, 7th month. From the play Fuka unbaka ikiji shinwara.

Signed: Toyokuni ga in a Toshidama cartouche. Artist: Utagawa Kunisada (1786–1865). Publisher: Otaya Takishi

History and Epidemiology of Tattoos and Piercings. Legislation in the United States

showed the women could bear pain and were ready for marriage. Traditionally, older women did the tattooing using an unusual method of bone needles blackened with soot, which were threaded through the skin so that the black particles remained embedded in the tracks [8]. Symbols were formed mainly using lines, dots, and geometric designs. Western interest in tattooing reappeared during the second half of the eighteenth century. Captain Cook, a British explorer, and his crew were fascinated by the tattooing they saw on the South Sea Island of Tahiti, the Moko they encountered among the aborigines of New Zealand (Fig. 1.2), and the skin pictures on the inhabitants of Hawaii. The word “tattoo” came from the Tahitian word “tatau,” meaning “the results of tapping,” and it signified the noise made by the mallet when it hit needles made from sharp-toothed bones driven into the flesh. Tattoos among the Marquesan people were used to distinguish rank and age among

Fig. 1.2 Facial Moko. Photographer: Walter Brooks (with permission)

3

men. Tattooing started in the teen years and for men continued throughout their lives to cover the whole body, while women’s tattoos were typically only on the face, lips, ears, feet, and hands. Tattooed individuals, including the famous Omai who was displayed as a human oddity, were brought back on ships to Europe, causing considerable sensation. In turn, the seamen learned the Polynesian tattooing techniques and produced their own designs. A French man, Jean Baptiste Capri, was tattooed on the Marquesas after he had deserted a whaling expedition, and in 1804 he displayed himself in Russia as the first European tattooed attraction, thereby paving the way for many other sideshow human oddities. Traditional tattooing died related to the arrival of protestant missionaries, despite the stories of the English missionary, John Williams, using the local skill to have the word “murderer” tattooed across the upper lip of a woman who had murdered her husband. By 1846, there was sufficient demand among soldiers and sailors and from others who wanted to make livings as “tattooed masterpieces,” for Martin Hildebrandt to open a tattoo shop in New York City. This was followed in 1891 by the development of an electric tattoo machine by “Professor” Samuel O’Reilly and in 1904 by an updated machine with electromagnetic coils set transversely to the tube assembly. Both were based on Thomas Edison’s recently patented electric pens. The design was updated again in 1929 by Percy Waters, a Detroit tattooist, and, with minor modifications, this is the machine that is in general use today. Although still painful, the rapidity of the multiple needle pricks needed to make an elegant tattoo has made the process more bearable, and allowed for the popular spread of the technique. Between the two World Wars, tattoos became so mainstream among working class and military men that Norman Rockwell’s illustration of The Tattooist was on the cover of the middle class magazine, the Saturday Evening Post [9]. Soon after this, a tattoo on the back of the left hand was used in highly successful advertisements disseminated across the United States to sell cigarettes. Even in the modern era, tattooing has not only been used for decorative and voluntary group affiliation purposes, but also for identification purposes, for example for the cataloging of sick Russian and Jewish prisoners in the Auschwitz concentration camp during the Second World War. This was done by using a stamp of numbers made out of needles and rubbing ink into the wounds. Immediately after this during the Korean conflict, it was used to place a permanent marking on the body of an

4

Fig. 1.3 A tear drop at the corner of the eye signifies having committed a murder

individual’s blood type, using a purpose-built electric tattoo machine [10]. In the early 1980s, before it was known what caused this new life-threatening disease, there were discussions about tattooing the genital areas of those with acquired immune deficiency syndrome. This never happened, as far as the author knows. The association with criminals and other marginal groups in the West results not from the forceful placement of tattoos, but relates to the use of these for signaling affiliation with such groups. Tattoos may be done in prison, not by the guards, but by the inmates devising make-shift tattoo implements and using ash or other ink for pigment. These tattoos may have meaning, such as a tear drop close to the eye signaling having committed a murder (Fig. 1.3), or they may symbolize membership in a particular gang, for instance, a Pachuco cross or a five point star. This latter type of tattoo is often performed as an initiation rite on the street or in a public place at the time the wearer joins the gang. In the 1950–1980s, many tattoos were associated with motor cycle groups, as well as punks and hippies [11, 12]. More recently, with the advent of fine arts skill among tattooists, the use of many different types of pigment, and the publicity of celebrities, the practice of decorative tattooing has proliferated among those under 30 years of age across first world countries.

A. E. Laumann

studs, or pins. Like tattooing, body piercing has been practiced in almost every society, but has usually been confined to the ears, mouth, and nose, possibly for religious purposes [13]. Less has been written about this practice than about tattooing, although antique statues and remnants, for instance, from the Mayan civilizations in central America, temple carvings in India, and stone figures in Cambodia [14], as well as remaining jewelry items attest to its happening. It may have been used during initiation ceremonies, for status recognition and for sexual purposes, but, mainly piercing and stretching of the earlobes and the lower lip, and puncturing the nasal septae were done for the practical purpose of keeping jewelry in place. Ear piercing of children and penile piercing are specifically mentioned in the fourth century a.d. Hindu text, the Kama Sutra [15]. The traditional practice of piercing of the cheeks during the Hindu festival, Thaipoosam, is still performed as an act of penance or the fulfillment of a vow [16]. Another traditional Hindu practice, karnavedha, is the piercing of the ears of 3 to 5-year old children. It is usually done by a local goldsmith for beauty, and in some castes, the father will not see his child until after this is done. In parts of Africa, the stretching of the lower lip of women continues to be done for the insertion of large wooden plates, and similarly, earlobes were and still are stretched for beautification (Fig. 1.4). The tribesmen of Papua, New Guinea, continue the tradition of wearing bird’s bone or feathers through their nostrils when they dress for religious, ceremonial, or festive occasions [17]. More recently, it is clear from jewelry pieces and journal articles that only very limited ear piercing was practiced in the West during the first half of the twentieth century [18, 19]. Stories about the Roman senators having nipple piercings and Prince Albert, Queen Victoria’s husband, having a penile ring are probably fictitious, purely designed to market body piercings during the last two decades of the twentieth century [20]. In fact, the modern fashion of body piercing really did not start until the late 1980s [21], although ear piercing was starting to become popular outside the punks and hippies in the United States during the late 1960s.

1.2 Epidemiology 1.1.2 Body Piercing Body piercing is defined as the cosmetic piercing of body parts for the implantation of objects such as rings,

One only has to look around to see that having either a tattoo or a body piercing is quite common place. Despite the many traditions, stories, and injunctions,

History and Epidemiology of Tattoos and Piercings. Legislation in the United States

Fig. 1.4 A semi-nomadic Masai woman from Entesopia-Magadi in the Rift Valley, Kenya. Photographer: Dale Glasser (with permission)

there is limited data on the absolute prevalence of these practices prior to recent years. Even today, most studies are convenience studies of particular groups, usually teenagers and young adults (Tables 1.1 and 1.2). It is by no means clear how much of these data can be generalized to a larger population even in the country of origin. The majority of studies are cross-sectional studies. One can see that in the older age groups, the practices are not common, but clearly, given the permanent nature of the attribute, tattoos are cumulative, and, with time they may be more generally distributed across the generations. Interestingly, the two identical surveys of undergraduates at Pace University, which were done in 2001 and 2006, showed no change in the prevalence of both tattooing and body piercing and similar results were found when Harris Poll looked at tattooing in representative samples of the American population in 2003 (16%, phone survey, data not shown) and 2008. It is too soon to know whether this means that in the United States of America the numbers of those interested in these forms of body modification have reached a plateau or even peaked.

5

In general, the numbers of women with tattoos are fewer than men with tattoos, but the figures are approaching equality. Eighty percent of the women have tattoos that are smaller than the palm of the hand and that figure is only 56% for the men. Also 90% of the tattooed men, but only 48% of the tattooed women, have an easily visible tattoo, that is a tattoo on the face, neck, arms, hands, fingers, legs, ankles, feet, or toes. The data are different for body piercings. Body piercing, as we now recognize it, was hardly seen before the end of the 1980s, so that earlier surveys only relate to soft earlobe piercing. Figures for this latter activity are fairly consistent. Between 30 and 35% of the general population and up to 50% of women have soft earlobe piercings. Some of the more recent body piercing surveys separate soft earlobe from hard cartilage piercings, others include soft earlobe piercings in men only, and others do not make any distinction. The 2008 Harris Interactive Poll, mentioned previously, found that 50% of adults aged 18 and over have ear piercings. Body piercing over all, even excluding soft earlobe piercing, is more common in women than in men. The second study in Table 1.2 where this was not the case was based on a biased clinic sample with 78% of females and only 22% of males. The piercings are in easily visible locations in nearly all men with body piercings, whereas this is only the case in 77% of the women. Covered piercings include nipple (Fig. 1.5), umbilical (common in women), and genital piercings. Although both body piercing and tattooing come under the general appellation of body modification, only one-third of those with a tattoo and approximately half of those with a body piercing, excluding the soft earlobe, have both forms of decoration. Other forms of body modification, such as branding, inserting steel balls under the skin (Fig. 1.6), embedding jewelry under the conjunctivae, or even splitting the tongue are much rarer. It appears that there are different motivations and meanings behind the two activities. In the recent past, a soft earlobe piercing in a man might have signified homosexuality. Nowadays, this is not the case, although it is rare to see a lower back tattoo in a man unless he is committed to same sex sex. Of course, a tattoo or a brand may signify the membership of an organization, for instance, the membership in a college fraternity or a street gang, whereas the insertion of body piercings has not, in general, been used that way. Tattoos may be applied in prison (Fig. 1.7), whereas a simple body piercing does not usually occur, as the inserted jewelry would be rapidly confiscated by the

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Table 1.1 Tattoo prevalence in various countries Country sample Year of sample United States of America Nationally representative school-based [35]

Patients presenting at an Emergency Department [36] Randomly selected undergraduates at Pace University [37] Adolescent clinic for dependent children of military personnel [38] General population representative sample [21] Randomly selected undergraduates at Pace University [39] General population representative on phone [40] Nationally representative on-line (Harris Poll) [41]

Germany General population representative sample [42, 43] Italy School children [Eurispes] Representative sample of high school Students in Cagliari [44] Canada Representative sample of high school students in Quebec [45, 46] Australia General population representative sample [47] Brazil Representative sample of adolescents in two public schools [48]

N

Age (years)

Total (%)

Males (%)

Females (%)

1995

5837

4.2

294

2001

454

4.6 0.5 2.6 7.6 35 28 5 23

4.8

1999

11–21 11–13 14–16 17–21 16–35 36–50 51–65 Mean 21

35 28 5 22

35 28 5 26

2001

484

16.6

500

26

22

2006

661

13.2 2 26.3 24 36 24 15 21.8

8.1

2004

12–22 £15 ³18 18–50 18–29 30–40 41–50 Mean 21

23

21

2006

1501

–

2302

36 40 10 14 9 32 25 12 8

–

2008

18–25 26–40 41–64 18–64 18–24 25–29 30–39 40–49 50–64

15

13

Accepted for publication 2005

2043

14–93 14–44 25–34

8.5 15

– 22

2002 2004

3800 820

12–18 15–19 15–16 17–18 ³19

6.6 8.5 6.0 7.2 15.8

7.2 14.5

5.7 5.4

2002

2145

12–18 12–13 14–15 16–18

7.9

9.8 4 4.9 8.5

5.8 3.5 7.6 18.1

1998

10,340

³14 ~20 ~50–60

10

11.9 25

8.5 20

12–19 Mean 15.2

3.2

–

–

2003

664

5

History and Epidemiology of Tattoos and Piercings. Legislation in the United States

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Table 1.2 Piercing prevalence in various countries Country sample

Year of sample

N

Age (years)

Total (%)

Males (%)

Females (%)

1996ª

4337

13–18

4.3ª

1.5ª

7.2ª

2000b

225

12–21

48b

54b

46b

2001b

454

Mean 21

51b

42b

60b

2004

500

21c 49f

661

35c 34f 32c 13c 2c 51b

8c 19f

2006b

18–50 18–50 18–29 30–40 41–50 Mean 21

36b

62b

2002c

2145

12–18 12–13 14–15 16–18

27.6c

10.6c 9.4c 9.0c 13.7c

43.6c 29c 44.5c 55.5c

Accepted for publication 2005c

2043

14–93 14–24 14–44

6.8c

–

2002d

234

Mean 20.6

3.4d

0d

4d

2002c

7457

16–20

20.2c

7.4c

33.8c

2004ª

817

15–19 15–16 17–18 ³19

20.3ª 20.7ª 19.3ª 23.1ª

18.4ª

21.3ª

England General population representative sample [53]

2005c

10,503

³16 16–24 25–34 35–44 45–54 55–64 ³65

10c 27c 18.7c 2.8c 2.8c 1c 0.3c

5c 13c

14.6c 46c

Australia General population representative sample [47]

1998

10,340

³14 ³14 14–23 24–33

31.5e 6.7c

18.2e 6.5c 25e 30e

44.4e 7.0c 70e 70e

2003c

664

12–19 Mean 15.2

6c

–

–

1999c

966

26

19c

9c

29c

United States of America Nationally representative school-based [49] Adolescents presenting to an urban Hospital-based clinic [50] Randomly selected undergraduates at Pace University [37] General population representative sample [21]

Randomly selected undergraduates at Pace University [39] Canada Representative sample of high school students in Quebec [45, 46] Germany General population representative sample [42, 43] Finland Students at dental visit [51] Switzerland Multicenter Adolescent classroom questionnaire [52] Italy Representative sample of high school Students in Cagliari [44]

Brazil Representative sample of adolescents in two public schools [48] New Zealand Cohort living in Otago age 3 in 1975–76 [54] a

Excludes the ear Excludes earlobe piercing in females c Excludes earlobe piercing d Oral piecing only e Pierced ears f Soft earlobe pierced b

38c 14c

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guards. On the other hand, a tattoo once placed is not easily removed. There are a number of cultural traditions, for instance, among Hispanic peoples and among Indian Hindus, where babies’ ears are pierced soon after birth, but in general, tattoos are not even considered until puberty. It is true that nearly all those with either a tattoo or a body piercing have close friends or family with a similar characteristic, but it is not true that most people initially choose to apply these forms of body decoration when they are drunk or high. Often

Fig. 1.5 Nipple piercing. This is more common in men than in women

Fig. 1.6 Steel balls inserted under the skin of the forearm of a man preparing a woman for a suspension

A. E. Laumann

considerable thought has gone into the idea. Both activities involve pain during the application and this may add to the significance of the event. Studies, mainly in the United States of America but also in some European countries, have looked at various personality characteristics associated with tattooing and body piercing [22–26]. Adolescents and young adults who have these body modifications may describe themselves as more adventurous, creative, artistic, and individualistic than their peers, but they are more likely to play truant from school, be arrested for criminal activity, be drinkers, use illegal substances, have multiple sexual partners, and to suffer from various psychiatric disorders, including, particularly among the body pierced, clinical depression. Reasons for getting body art include not only as a fashion statement, but often as an expression of independence and self-validation. This may relate to reduced social integration, as indicated by the finding in a number of studies that those with tattoos or body piercings often do not have a strong religious affiliation. Association with risky, rather than deviant behavior, is emphasized by studies among military recruits revealing that up to a third of those with tattoos obtained them prior to joining the military [27, 28] (Fig. 1.8). Clearly, volunteering for military duty is, in itself, a risk-taking activity, but these individuals a

History and Epidemiology of Tattoos and Piercings. Legislation in the United States

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It should be noted that, although all the above associations are real, and finding a tattoo or a body piercing on an individual should send a signal to the alert clinician, as these activities have become more mainstream, any single association is less likely to be relevant.

1.3 Legislation in the U.S

Fig. 1.7 This tattoo was applied in prison

Fig. 1.8 Tattoo placed in 1943 at the age of 16 prior to joining the army. Mom is in the heart. Below is a wreath, an American eagle, a peace arrow, and God Bless America

also more likely to partake in other risk-taking activities such as smoking, drinking heavily, or being willing to ride in a car driven by an inebriated individual than their nontattooed counterparts.

As the numbers of tattoos and piercings have increased in the population, there has been call for more regulation of the body art industry [29]. Unfortunately, new rules are usually a reaction to a concern related to a local disease outbreak or an individually specific event rather than a general regard for the health of the population at large. Codes are variable from state to state; where they exist, they are rarely enforced. Interestingly, a large incidence of hepatitis B (30 cases) resulted in New York City banning tattooing in 1961 [30]. The ban was rescinded in 1997 when it was realized that tattoo establishments were operating in the city without authorization. In 1979, only three states had standards or inspections and seven states prohibited tattooing completely [31]. During the past 25 years, the trend in a number of states has been to permit tattooing and body piercing by licensed tattoo artists and body piercing practitioners [32], and in 1999 the National Environmental Health Association published a model code as a suggested basis for regulation [33]. Now at least 48 states have some form of regulation, although this is highly variable, and the rules are constantly changing [34]. A court ruling in Massachusetts in 2000 held that the right to have a tattoo is protected by the first amendment of the U.S constitution and thereby struck down the statutory requirement that only physicians be allowed to provide tattoos. Eight states require the reporting of adverse events and a number of states prohibit tattooing of persons suspected to be under the influence of drugs or alcohol. At least 18 states prohibit the tattooing or piercing of anyone under the age of 18 and other states allow it, but only with parental presence or written consent. Certification, licensing, and the successful performance on examinations are required in a few states and some require documentation of attendance at a training program in sterilization techniques. Facility regulation and certification requirements likewise vary from state to state and only some states have specific requirements or prohibitions for temporary studio locations, such as in a stall at a street fair.

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Illinois is an example of the ongoing changing regulatory scene. The legal age for getting a tattoo was reduced from 21 to 18 years in 2005, but regulations related to licensing and hygiene of the facilities were only enacted starting in July 2007. This was the result of an ongoing shortage of blood donations, as the American Association of Blood Banks standards require a 12-month deferral of blood donation after the nonsterile skin penetration with instruments or equipment, including those used for tattooing and body piercing, unless it is done by a state-regulated entity with sterile needles and non re-used ink. In general, regulations related to body piercing lag those related to tattoos, partly because of the more recent popularity of the practice and partly because a body piercing is a very quick event and, as such, hard to supervise. Body piercing regulations are often an afterthought added to those for tattooing. The Association of Professional Piercers is an international nonprofit association dedicated to the dissemination of vital health and safety information related to body piercing. It publishes information on piercing aftercare, troubleshooting, choosing a piercer and jewelry standards. Interestingly, as tattooing and body piercing have become more mainstream, employers and the military have found it necessary to be very specific about their regulations. For instance, since early 2007, large and elaborate tattoo designs were banned in the marines, and more recently, the assignments of those who already had these decorations were limited, such that they may not serve as recruiters or security guards because of their daily dealings with civilians. Similarly, many service industry employers prohibit visible tattoos and piercings among those employees who deal with the public. It is not uncommon to be served by a waitress who has covered the outer end of her eyebrow with a band-aid to hide the hole made for an appropriate jewelry piece. Currently, in the United States tattoo pigments are considered cosmetics and are approved for application on to, rather inside, the skin. The Food and Drug Administration has not approved any pigments for injection into the skin. Following reports of bad reactions, some products have, in fact, been banned from importation or removed from the market. Meanwhile under the auspice of the National Center for Toxicological Research, there is ongoing investigation into the toxic or carcinogenic potential of some of the pigments, including the commonly used titanium dioxide, when exposed to light or in photo-exposed skin.

A. E. Laumann

Similarly, unlike in Europe, there is no regulation of the metals used in the jewelry left in the skin after a piercing procedure.

1.4 Conclusion Tattooing has been widely practiced across the world and in all eras. At times, it has been associated with criminality and punishment, and used for the identification of slaves and prisoners. In other societies and at other times, tattoos have been a marker of social status and religious affiliation. Body piercing has a more limited history, although there is evidence, in ancient societies, of its use in the soft earlobe, lower lip, and nasal septum for the insertion of decorative pieces, as well as its use in the genital area for sexual inhibition or pleasure. Encouraged by modern sophisticated techniques, both tattooing and body piercing are in the mainstream of fashion in first world countries. It is unclear whether this is a passing fad or an ongoing process. In the fairly recent past, having a tattoo or a body piercing was a sign of marginality. Nowadays, the more extreme among us need to resort to even more daring insertion practices to maintain their individuality. In the United States of America, there has been increasing legislative activity, but it still varies widely from state to state. Where there are regulations, these are not always enforced and they do not necessarily address the important problems of the spread of infectious disease, the allergenic potential, or the carcinogenicity of the inserted materials.

References 1. Sperry K (1991) Tattoos and tattooing. Part I: History and methodology. Am J Forensic Med Pathol 12:313–319 2. Dorfer L, Moser M, Bahr F et al (1999) A medical report from the stone age? Lancet 354:1023–1025 3. Lowenstein EJ (2004) Paleodermatoses: lessons learned from mummies. J Am Acad Dermatol 50:919–936 4. Isaiah (44:5) The Bible 5. Leviticus (19:28) The Bible: King James Version 6. Scheinfeld N (2007) Tattoos and religion. Clin Dermatol 25:362–366 7. Reed C (2000) Tattoo in early China. J Am Orient Soc 120:360–376

History and Epidemiology of Tattoos and Piercings. Legislation in the United States 8. Demello M (2007) Encyclopedia of body adornment. Greenwood Press, Westport 9. Rockwell N (1944) Cover page. Saturday Evening Post 216:1 10. Wolf EK, Laumann AE (2008) The use of blood-type tattoos during the cold war. J Am Acad Dermatol 58:472–476 11. Papachristos A (2005) Gang world. Foreign Policy 147: 49–55 12. Steward S (1990) Bad boys and tough tattoos. Harrington Park Press, Binghamton 13. Beckwith C, Fisher A (1991) The eloquent surma of Ethiopia. Natl Geogr Mag 179:77–91 14. Waugh M (2007) Body piercing: where and how. Clin Dermatol 25:407–411 15. Daniélou A (1994) The complete kama sutra. Part Street Press, Rochester 16. Ng KH, Siar CH, Ganesapillai T (1997) Sarcoid-like foreign body reaction in body piercing: a report of two cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 84:28–31 17. Gröning K (2002) Decorated skin. Thames and Hudson, New York 18. Kanee B (1950) Technic of ear piercing. Arch Derm Syphilol 61:502 19. Lerner C (1932) History of feminine beautification. Arch Derm Syphilol 26:1022–1031 20. Stirn A (2003) Body piercing: medical consequences and psychological motivations. Lancet 361:1205–1215 21. Laumann AE, Derick AJ (2006) Tattoos and body piercings in the United States: a national data set. J Am Acad Dermatol 55:413–421 22. Armstrong ML (1994) Adolescents and tattoos: marks of identity or deviancy? Dermatol Nurs 6:119–124 23. Brooks TL, Woods ER, Knight JR et al (2003) Body modification and substance use in adolescents: is there a link? J Adolesc Health 32:44–49 24. Carroll L, Anderson R (2002) Body piercing, tattooing, selfesteem, and body investment in adolescent girls. Adolescence 37:627–637 25. Ceniceros S (1998) Tattooing, body piercing, and Russian roulette. J Nerv Ment Dis 186:503–504 26. Drews DR, Allison CK, Probst JR (2000) Behavioral and self-concept differences in tattooed and nontattooed college students. Psychol Rep 86:475–481 27. Armstrong ML, Murphy KP, Sallee A et al (2000) Tattooed army soldiers: examining the incidence, behavior, and risk. Mil Med 165:135–141 28. Stephens MB (2003) Behavioral risks associated with tattooing. Fam Med 35:52–54 29. Healy B (2008) The dangerous art of the tattoo. US News World Rep 145:69 30. Silvers DN, Gelb H (1991) The prohibition of tattooing in New York City. Am J Dermatopathol 13:307–309 31. Goldstein N (1979) Laws and regulations relating to tattoos. J Dermatol Surg Oncol 5:913–915 32. Tope WD (1995) State and territorial regulation of tattooing in the United States. J Am Acad Dermatol 32:791–799 33. National Environmental Health Association? (1999) Body art: a comprehensive guidebook and model code. National Environmental Health Association, Denver 34. Armstrong ML (2005) Tattooing, body piercing, and permanent cosmetics: a historical and current view of state regulations, with continuing concerns. J Environ Health 67:38–43; 54; 53

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35. Roberts TA, Ryan SA (2002) Tattooing and high-risk behavior in adolescents. Pediatrics 110:1058–1063 36. Rooks JK, Roberts DJ, Scheltema K (2000) Tattoos: their relationship to trauma, psychopathology, and other myths. Minn Med 83:24–27 37. Mayers LB, Judelson DA, Moriarty BW et al (2002) Prevalence of body art (body piercing and tattooing) in university undergraduates and incidence of medical complications. Mayo Clin Proc 77:29–34 38. Carroll ST, Riffenburgh RH, Roberts TA et al (2002) Tattoos and body piercings as indicators of adolescent risk-taking behaviors. Pediatrics 109:1021–1027 39. Mayers LB, Chiffriller SH (2008) Body art (body piercing and tattooing) among undergraduate university students: “then and now”. J Adolesc Health 42:201–203 40. Pew Research Center (2007) How young people view their lives, futures and politics. Pew Research Center, Washington 41. http://www.harrisinteractive.com/harris_poll/index. asp?PID=868 42. Stirn A, Brahler E, Hinz A (2006) Prevalence, sociodemography, mental health and gender differences of tattooing and body piercing. Psychother Psychosom Med Psychol 56: 445–449 43. Stirn A, Hinz A, Brahler E (2006) Prevalence of tattooing and body piercing in Germany and perception of health, mental disorders, and sensation seeking among tattooed and body-pierced individuals. J Psychosom Res 60:531–534 44. Preti A, Pinna C, Nocco S et al (2006) Body of evidence: tattoos, body piercing, and eating disorder symptoms among adolescents. J Psychosom Res 61:561–566 45. Deschesnes M, Demers S, Fines P (2006) Prevalence and characteristics of body piercing and tattooing among high school students. Can J Public Health 97:325–329 46. Deschesnes M, Fines P, Demers S (2006) Are tattooing and body piercing indicators of risk-taking behaviours among high school students? J Adolesc 29:379–393 47. Makkai T, McAllister I (2001) Prevalence of tattooing and body piercing in the Australian community. Commun Dis Intell 25:67–72 48. Oliveira MD, Matos MA, Martins RM et al (2006) Tattooing and body piercing as lifestyle indicator of risk behaviors in Brazilian adolescents. Eur J Epidemiol 21:559–560 49. Roberts TA, Auinger P, Ryan SA (2004) Body piercing and high-risk behavior in adolescents. J Adolesc Health 34: 224–229 50. Gold MA, Schorzman CM, Murray PJ et al (2005) Body piercing practices and attitudes among urban adolescents. J Adolesc Health 36(352):e17–e24 51. Venta I, Lakoma A, Haahtela S et al (2005) Oral piercings among first-year university students. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 99:546–549 52. Suris JC, Jeannin A, Chossis I et al (2007) Piercing among adolescents: body art as risk marker. J Fam Pract 56: 126–130 53. Bone A, Ncube F, Nichols T et al (2008) Body piercing in England: a survey of piercing at sites other than earlobe. BMJ 336:1426–1428 54. Skegg K, Nada-Raja S, Paul C et al (2007) Body piercing, personality, and sexual behavior. Arch Sex Behav 36: 47–54

2

Materials Used in Body Art Christa De Cuyper and Davy D’hollander

Core Messages

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Body art is increasingly popular, resulting in the raising occurrence of complications and adverse reactions, some of them related to the substances used. To identify the causative agent, it is essential to know the exact composition and nature of the materials applied. Nickel allergy is the most common complication of body piercing and can easily be avoided by the use of ornaments made of high-grade stainless steel or inert plastic material. Tattoo compounds in comparison to cosmetics are in general not officially controlled. Moreover, the origins as well as the chemical and toxicological specifications of these colouring agents are hardly known by the producers, the performers and by the consumers. From the medical perspective, uniform worldwide regulation would certainly offer opportunities to reduce the risks and complications involved in the use of chemical components that might be potentially hazardous and may threaten the health of the tattooed individual with special concern for heavy metals and carcinogenic aromatic amines. Recent studies have demonstrated that sunlight exposure and laser treatment of tattoos can induce decomposition products with carcino-

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genic properties. The clinical implications of these findings have not yet been identified. Recommendations on the hygienic conditions of piercing and of the application of tattoos and permanent make up (PMU) are available. Respecting these guidelines could minimise the risk of transmission of infectious diseases. The occurrence of contact allergy to temporary (henna) tattoos is linked to the presence of PPD in high concentration.

2.1 Introduction Body art has become increasingly popular in the last decades resulting in the raising occurrence of complications and adverse reactions, some of them related to the procedures, other side effects caused by the substances used. In order to identify the causative agent it is essential to know the exact composition and nature of the materials applied. Although a lot of research has been done in this field, there is still a lack of uniform worldwide regulation on the procedures and materials. This chapter will give an overview of materials used nowadays in the different forms of body art.

2.2 Piercings 2.2.1 Materials C. de Cuyper () Department of Dermatology, AZ Sint-Jan, Ruddershove 10, 8000, Brugge, Belgium e-mail: [email protected]

A diversity of materials has been used over the centuries. Natural materials such as wood, ivory and bones

C. de Cuyper, M. L. Pérez-Cotapos S. (eds.), Dermatologic Complications with Body Art, DOI: 10.1007/978-3-642-03292-9_2, © Springer-Verlag Berlin Heidelberg 2010

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Fig. 2.1 Traditional golden piercing

have always been popular in tribal, religious and ritualethnic piercings (Fig. 2.1). Large ranges of metals (copper, silver, gold, iron) have been recovered in excavations. Earrings like most jewellery were often made of silver and gold, pearls and precious stones, but in recent times many cheap jewels are just made of plated nickel. Most common materials used nowadays for piercing or embedding are stainless steel, titanium, niobium, gold, glass and plastics (Figs. 2.2 and 2.3; Table 2.1). Different qualities of stainless steel are produced. To check if number 316 grade steel corresponds to the requirements, International Organization for Standardization (ISO) [1] and American Society for Testing and Materials (ASTM) [2] standards can be used. Stainless steel is specified with letters and numbers, letter L corresponding with low carbon (higher corrosion resistance) and VM signifying vacuum arc remelted (a technique used to improve homogeneity, with better crystalline structure and mechanical properties); number 316 grade steel corresponds with this composition (Fe, <0.03% C, 16–18.5% Cr, 10–14% Ni, 2–3% Mo, <2% Mn, <1% Si, <0.045% P, <0.03% S). To

Fig. 2.2 Modern stainless steel piercing

Fig. 2.3 Modern glass jewel

control one can check the “mill sheets” delivered by the producer if they correspond to these standards [3]. Polytetrafluorethylene (PTFE) an inert thermoplastic polymer with non-stick properties and Bioflex/bioplast a Tygon-like material are also suitable for initial piercings, and piercings taking a long time to heal [4]. Individuals allergic for nickel can use the dimethylglyoxime nickel

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Table 2.1 Piercings 316 L stainless steela 316 LVM stainless steela 15–17 stainless steela Titanium Ti6A14V (90% titanium, 6% aluminium, 4% vanadium)a Niobium Gold 18 kt PTFE (polytetrafluorethyleen or Teflon) Bioflex/bioplastb a To check if number 316 grade steel corresponds to the requirements, ISO (http://www.iso.org/iso/home.htm) and ASTM (http://www.astm.org/) standards can be used Stainless steel is specified with letters and numbers, L corresponding with low carbon (higher corrosion resistance) and VM signifying vacuum arc re-melted (a technique used to improve homogeneity, with better crystalline structure and mechanical properties); number 316 grade steel corresponds with this composition (Fe, <0.03% C, 16–18.5% Cr, 10–14% Ni, 2–3% Mo, <2% Mn, <1% Si, <0.045% P, <0.03% S). To control one can check the “mill sheets” delivered by the producer if they correspond to these standards Information and sources:http://www.bmezine.com/pierce/articles/surgste.html b A Tygon-like material (http://www.tygon.com)

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Fig. 2.5 Disinfection

Fig. 2.6 Ultrasonic cleaner

Fig. 2.4 Nickel spot test

spot test to check nickel-releasing objects and jewels (Fig. 2.4). The test kit consists in a bottle with dimethylglyoxime. A drop of the product must be applied on a cotton tip. The suspected metallic item must be rubbed with this moistened cotton tip. If a pink–red colour is produced the item contains nickel.

2.2.2 Sterilisation of Instruments A sterile and hygienic work method while placing a piercing or changing jewellery is imperative to avoid infections. We have explained below how to work.

All instruments and the jewellery used for placing piercings are sterilised in the following manner: After each use and before the first use, instruments are placed in a disinfection tray for 20 min to remove tissue residue and lower the bacteria count with 99% (Fig. 2.5). Instruments are rinsed and placed in an ultrasonic cleaner. They are treated during 60 min with imploding air bubbles to ensure thorough cleaning to a molecular level (Fig. 2.6). The instruments are rinsed and laid out to dry (Fig. 2.7). When they are completely dry they are wrapped in sterilisation foil (Fig. 2.8). After wrapping, the instruments are placed in the vacuum autoclave to sterilise them. The use of a vacuum is needed because the equipment is wrapped (Fig. 2.9).

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Fig. 2.7 Drying

C. de Cuyper and D. D’hollander

Fig. 2.10 Washing hands

Fig. 2.11 Set-up 1 Fig. 2.8 Wrapping

Fig. 2.9 Sterilisation in the autoclave

Fig. 2.12 Set-up 2

After sterilising, the equipment is stored in closed cabinets and drawers till use. Equipment that is not used within a month is re-sterilised. To avoid cross-contamination with disposable material, gauzes, corcks, rubber bands, cotton tips and toothpicks are sterilised in bulk and set-up is done on a

sterile field. Needles are bought sterilised and used only once. When coming in for a piercing, we first wash our hands (Fig. 2.10). We remove the equipment from its wrapping and put it on a sterile field (Figs. 2.11 and 2.12).

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Materials Used in Body Art

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• Wristwatch cases, watch straps and tighteners • Rivet buttons, tighteners, rivets, zippers and metal marks, when these are used in garments If the rate of nickel release from the parts of these products coming into direct and prolonged contact with the skin is >0.5 µg/cm²/week 3. In products listed in point 2 where these have a nonnickel coating unless such coating is sufficient to ensure that the rate of nickel release from those parts of such products coming into direct and prolonged contact with the skin will not exceed 0.5 µg/ cm²/week for a period of at least 2 years of normal use of the product. Fig. 2.13 Needle container

After the piercing procedure, the equipment is disposed in the disinfection tray to be re-sterilised. Needles are disposed of in a sharp container (Fig. 2.13).

2.2.3 Legislation Non-occupational contact with nickel, primarily through nickel-plated clothing fasteners and cheap jewellery, more in particular ear piercings, is responsible for sensitisation especially in females (5–15% vs. 0.5–1% in males) [5–7]. Because the high incidence of nickel allergy has a strong association with nickel contact, efforts have been done in the last decade to reduce sensitisation by regulating the nickel content in products with intimate and prolonged skin contact. The European Union “Nickel Directive” [8] was amended by the European Commission in 2004 and supported by the Nickel Institute. The amended Nickel Directive prohibits “the use of Nickel (CAS No 7440-0-20 EINECS No 2311114) and its compounds: 1. In all post-assemblies that are inserted into pierced ears and other pierced parts of the human body unless the rate of nickel release from such postassemblies is <0.2 µg/cm2/week (migration limit); 2. In products intended to come into direct and prolonged contact with the skin such as: • Earrings • Necklaces, bracelets and chains, anklets and finger rings

Furthermore, products which are the subject of points 1, 2 and 3 above, may not be placed on the market unless they conform to the requirements set out in those points.” [8] The member companies of the Nickel Institute support communication, education of manufacturers and retailers of consumer products that will be in contact with the skin, jurisdiction to implement measures that will be protective of consumers, and research. They also try to extend their efforts towards other continents in particular Australia and North America [9]. The impact of the EU Nickel Directive on the occurrence of nickel contact allergy has been observed in Europe during the last years and appears to be substantial as was illustrated by the study of Liden [10]. However, cheap materials are still used worldwide and even in Europe on the street, they are often of unknown origin and do not correspond to the requirements of the Nickel Directive. There are no specific FDA regulations corresponding to the European Nickel Directive.

2.3 Permanent Tattoos and Permanent Make-Up (PMU) 2.3.1 Introduction Tattoo compounds in comparison to cosmetics are in general not officially controlled. Moreover, the origin as well as the chemical and toxicological specifications of these colouring agents are hardly known by the producers, the performers, or even by the professionals involved in these procedures, and certainly not by the consumers.

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Drawing and writing inks, such as Indian ink, Pelican ink and printer inks, are very popular in amateur tattoos, although the producers do not recommend their products for these purposes. Considering the safety of the consumer, heavy metals such as mercury, cadmium and lead have been banned for cosmetic purposes by the Food, Drug and Cosmetic Act (FDCA) in 1976 and have disappeared in tattoo inks since. It is rare to find these elements in the tattoo inks nowadays; they have been replaced in the last decades by organic molecules mostly azo dyes. However, azo pigments are manufactured for the production of car paints and textile dyes and not primarily as cosmetics or for the injection use in humans.

2.3.2 Legislation Tattoo inks and the pigments in these inks are considered as cosmetics and colour additives and should be safe. Although some colourants are approved for use in cosmetics none is approved for injection into the skin. The FDA does not strictly regulate and control these materials or the practice of tattooing, and in the USA these matters have been covered by local laws and jurisdictions mainly intended to regulate the body art establishments. In recent years, toxicological research has been done on specific pigments [11, 12]. More details about the USA approach can be found in Chap. 1. The council of Europe has dealt with the safety issue of tattooing and PMU for years and adopted in 2003 the CoE Resolution on the regulation of tattooing/PMU products. Although tattoo inks are implanted intradermally it would have been reasonable to treat these products like medicine, concerning their sterility and composition. However, a more realistic approach has been chosen and the cosmetic approach submitting tattoo and PMU colourants to the requirements and safety assessments of cosmetics has been proposed (the sixth amendment of the Cosmetic Directive 76/768) [13]. Recently, resolution Res AP(2008)1 on requirements and criteria for the safety of tattoos and PMU (superseding resolution ResAP(2003)2 on tattoos and PMU) was adopted by the Council of Europe and recommends that the governments of the member states take into account the principles set out in the appendix of the resolution [14]. This resolution not only “follows a negative list approach by listing the substances which must not be used in tattooing products and PMU, based

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on current knowledge in this field,” but also recommends “to regulate the use of substances in tattoos and PMU by taking steps towards establishing – on the basis of safety assessments carried out by competent bodies and harmonised at European level – an exhaustive list of substances proved safe for this use under certain conditions (positive list).” This resolution has already been implemented in the Dutch law. The resolution includes specifications about the content of the tattoo/PMU products, the labelling, the conditions of application and the obligation to inform the public and the consumer about the health risks of tattoos and PMU and tattooing practice. It proposes two test methods, one developed by the Dutch Food and Consumer Product Safety Authority and the other provided by the Swiss Federal Office of Public Health. See resolution ResAP (2008)1 on requirements and criteria for the safety of tattoos and PMU [14]. The aim is that, according to this EU resolution, tattooing/PMU products are subject to regulation, to be implemented by the member states, which means that for every ready-to-use product that is on the market under the EU Cosmetics Directive, there should be a dossier to be held at the address mentioned in the product label. Any country can ask the “dossier-owningcountry” to consult the content of this dossier. All the products must be labelled and provided with an ingredient-list that can be consulted by the consumer. Products that do not comply with the regulations cannot be sold lawfully and must be removed from the market. Competent surveillance authorities are empowered by law to remove the product judged to pose a threat to the health of the consumer. Obligations are on the EU-based manufacturer of a ready-to-use-product and also on the EU-based juridical subject that for the first time imports this product into the EU, to be used or to be sold on the common market. Also professionals are obliged by law to check that only ready-to-use products complying with the regulation are used on their clients. This means that responsibilities are applicable to the producers, the authorities and professionals [15]. From the medical perspective, this approach certainly offers opportunities to reduce the risks and complications involved in the use of chemical components that might be potentially hazardous and may threaten the health of the tattooed individual with special concern for heavy metals and carcinogenic aromatic amines; recommendations on the conditions of the application of tattoos and PMU should also minimise the risk of transmission of

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Materials Used in Body Art

infectious diseases. It remains an open question whether an efficient enforcement can be installed and surveillance authorities will be able to perform controls and will take their responsibilities to make safety assessments [16]. We still have to deal with current practices not respecting these guidelines and also with the consequences of procedures and products used in the past. Better knowledge about substances used in the practice of body art can be helpful to identify clinical problems occurring in medical practice.

2.3.3 Composition of Tattoo/PMU Products Products used for tattooing and PMU are a mixture of chemicals that absorb visible light, the actual colourants, and a large spectrum of auxiliary ingredients (Table 2.2). The colourants can be divided in two subgroups: the pigments and the dyes. Chemically, the pigments can be metallic salts (oxides, sulphides, selenides) or organic molecules of different origin. The dyes are mostly organic molecules. Ink is defined as a “solution” of a colourant in a liquid. Tattoo ink however is a suspension of pigment particles in a solution of water, glycerine and alcohol (mostly ethanol or isopropanol). Pigments are tiny coloured (black, white or fluorescent), solid particles, insoluble in, and normally not affected by, the medium in which they are incorporated. Pigments will change the appearance of an object by the selective absorption and/or scattering of light. The structure of a pigment will not alter during the colouring process. The size

Table 2.2 Components of tattoo inks Colourant Pigment: eg.Carbon [CI 77266] Dye Auxillary ingredients Vehicle: water (H2O) Solvent Additives Wetting agents: Glycerine, Ethyleenglycol Preservatives: eg.Witch hazel Stabiliser Thickeners: Glycerine pH regulators Impurities from the – production process

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of the microcrystalline particles will define the colour of the end product. The tattoo is the result of the pigment in the skin after healing. To prepare tattoo ink, pure pigment powder or a pre-dispersed paste can be used; the latter is a mixture of pure pigment powder and acrylonitrile butadienestyrene (ABS)-plastic processed to microparticles and wetted to obtain a paste, which is much easier to handle; the amount of plastic can be adapted to obtain different shades. In order to make a stable suspension the polar properties of the pigments can be modified by using additives; this process is called wetting. In PMU also dyes are used. In contrast to pigments, dyes are soluble either in water or in some organic non-polar solvent. The dyes consist of a stabiliser (mostly barium sulphate) with a coloured surface (e.g. acid azo dye). For the traditional tattooing purposes, mostly pigments are used because they offer a high light stability and are chemically resistant, especially the metallic salts. They remain unchanged in contrast to the “stabilised” dyes, which are preferentially used in the PMU products. Dyes have a tendency to fade over time, an advantage in the indication of PMU (semipermanent), while pigments will persist unaffected and permanent, as is the objective in ornamental tattoos. Many tattooists make their own blends of pigments and dyes to obtain their favourite results (Fig. 2.14).

2.3.3.1 Evolution of Colourants In ancient times, materials used for tattooing consisted in minerals, plant extracts, soot, carbon and ochre; the same products are still used nowadays in ethnic tattoos. According to Wikipedia, Indian ink, also called Chinese ink since it may have been first developed in either China or India, has been used since at least the fourth century b.c. [17]. In India, the carbon black from which the Indian ink is produced is obtained by burning bones, tar, pitch and other substances. Other sources mentioned are lampblack, carbon black, bone black, pine sooth and petroleum. Carbon black has been used for centuries in printing inks and paint. Over the past 50 years, it is applied in the rubber industry, particularly for the manufacture of tyres. Since the eighteenth century, tattooing was “imported” and became popular in Europe; mostly soot and carbonbased ink such as India ink and metallic components were used in that time. Colourants mentioned in the literature used for traditional tattooing include mineral pigments and metallic oxides/hydroxides/sulphides/aluminates

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Fig. 2.14 Large variety of tattoo inks

Table 2.3 Colourants Colours Metals Black Brown White Violet Purple/lilac Flesh Green

Red

Yellow Blue

Ferric oxide, cadmium sulphide Lead carbonate, Zinc oxide, titanium dioxide – – Ferric oxide Chromium oxide (Casalic green), Hydrous chromium oxides (Guignets green), chromium sesquioxide (Viridian) Mercury sulphide (cinnabar), cadmium selenide

Cadmium sulphide Cobalt

Organic

Other

–

– – –

Charcoal, carbon – –

– – –

Azo dyes – – Chlorinated copper (phtalocyanine) Azo dyes

Manganese Manganese oxide – –

– Rare allergic reactions – Allergies for hexavalent chromium

Sienna, brazilin, carmine cochinilla red, santalin

Azo dyes Copper (phtalocyanine)

– Indigo

Allergic reactions to mercury Phototoxic reactions Phototoxic reactions Granulomatous reactions

such as chrome (trivalent chromic oxide, hydrated chromium sesquioxide) for green, cobalt and indigo for blue, cadmium sulphide for yellow and mercury sulphide or cinnabar for red. Iron oxide is used for ochre, red and brown, manganese for purple. Titanium dioxide, zinc oxide and barium sulphate are applied or added to obtain light colours (Table 2.3). Soot derivatives and carbon pigments (graphite) are still used nowadays for black inks. In recent years, an important shift has taken place in the use

of colourants. The most important change seems to be that the heavy metals, mercury (cinnabar) and cadmium responsible for allergic reactions in red and yellow tattoos have disappeared today and have been replaced by synthetic molecules [11, 18–20]. During the revival of tattooing in the 1980s, complex organic colourants gained popularity; nowadays, 80% of the pigments are synthetic organic molecules mostly azo pigments and polycyclic compounds [21].

2

Materials Used in Body Art

In the category of organic pigments, we find azo dyes (orange, brown, yellow, red) and other polycyclic amines, dioxazine, phthalocyanine, quinacridone and arylide. Organic pigments listed in tattoo inks include Pigment Yellow 14, 55, 74, 83, 87, 97, Pigment Orange 13, 16, 36, Pigment Red 5, 9, 22, 112, 122, 146, 170, 266, Pigment Violet 19, 23, Pigment Green 7, 36, PB15 and Pigment Brown 25 [11]. In many tattoo inks, titaniumdioxide is used as a lightener. Natural pigments being used nowadays are colourant extractions from trees, flowers and roots such as curcumine (Curcuma), brazilin (Brazil wood = natural red 24) and santalin (red sandalwood = natural red 22/23) (Table 2.3). An excellent and extensive overview of the “chemicals used in tattooing and PMU products” in Western Europe has been made by Baeumler, Vasold, Lundsgaard and Talberg for the Workshop on “technical scientific and regulatory issues on the safety of tattoos, body piercing and related practices” organised in 2003 for the European Commission in order to identify the chemical nature of the colourants that are being used for these purposes these days [18]. They also investigated whether the colourants in question were permitted in the related field of cosmetic products or not. The colourant used in cosmetics is strictly regulated and safety assessments have been carried out by the EU Scientific Committee on Cosmetics since 1997. Summarising this survey, it appears that several colours reported, of which many new organic pigments, to be used by firms performing PMU in Norway, Denmark and Finland, were not allowed at all in any kind of cosmetics. The same applied to the colours reported by the German delegation that were used in tattoo and PMU studios in 2001 and by the Danish authorities that were used for traditional tattooing. The inorganic salts of mercury, cadmium and cobalt seem to be abandoned. Some of the azo-type colourants used in PMU contained aromatic amines as impurities, classified as carcinogens. By direct contact with the market operators, 40 organic and 12 traditional inorganic colourants have been identified. The impression was that the colourants being used were ordinary industrial pigments and dyes that can be easily obtained. Out of the 40 organic colourants identified, 24 (60%) were azo compounds and of these 9 contained an amine that has been classified carcinogenic. Results from the study revealed that of the 52 organic colourants identified in the marketplace 17% contained a carcinogenic aromatic amine as did the 63 samples investigated by the Dutch authorities. In these studies, it was shown that in particular 3,3¢-dichlorobenzidine

21

seems to be the molecule that can possibly be released from the azo-colourants used for tattooing and PMU [18, 22]. Another issue is the fact that colourants in cosmetics, being medium size or large molecules pass through the skin in a small degree only and will have another impact on the underlying tissues than a chemical administered intradermally by the procedure of tattooing. Many of the colours used are allowed only in rinse-off products and others are not allowed in any kind of cosmetics. Concerning the purity of the materials, the European Community expert team concluded that there are many pigment producers, producing industrial pigments with limited information about purity and impurity profiles. They normally know that these industrial pigments are not sufficiently pure to use in food or cosmetics, and in most cases, one can presume that the producer himself will dissuade the use for cosmetics, foodstuff, medicine and also for tattoo colours; as the person manufacturing tattoo colours usually needs very little pigment compared to, e.g., the paint industry, the pigments will very rarely be bought directly from the producer but mostly be obtained in second or third line. Fortunately, however, there are a range of pigment producers and products meeting the approved demands to purity within cosmetics, foodstuff and medicine. The chemical identity of the molecules used in tattoo/PMU inks is illustrated in (Tables 2.4–2.9) and more can be found in Appendix I of the 2003 document [18]. A personal survey was done by D’hollander in 2006, concerning tattoo inks used in Belgium in body art parlours, checking the colour index (CI) numbers from the list of ingredients supplied by Mario Barth’s Intenze, Starbrite, Diabolo Novum, Diabolo Classic, Micky Sharpz Traditional, Micky Sharpz Easyflow and Millennium Mom’s (Table 2.10). Currently used colourants that can be obtained from suppliers on the Internet are labelled with a CI number. The different CI numbers correspond to different chemical categories (Tables 2.4–2.9); the same CI number is Table 2.4 Mineral Pigments Mineral pigments Iron oxides Heavy metals

Other CI number 77000–77999

FeO, Fe2O3, Fe3O4 HgS, CdSe, CdS, CdZnS, PbCrO4, Cr2O3, PbS, [Cu2(CO3)(OH)2], PbCO3 TiO2, ZnO, BaSO4, C

22

C. de Cuyper and D. D’hollander

Table 2.5 Organic pigments Organic pigments

Table 2.7 Phtalo-cyanine compounds Phtalo-cyanine compounds

Azo compounds Diazo compounds Cu-phthalocyanine Dioxazine Arylide Quinacridone

Very stable and safe Only blue and green Insoluble in water and most solvents CI numbers 74100– 74299

Table 2.6 Azo compounds Azo compounds Light stable Cheap and easy to produce Used in food, plastics, diesel, clothing… Insoluble in water, but often soluble in alcohol or solvents Azo compounds are fragile and under influence of high energetic radiation and heat aromatic amines can be created Mono azo are indicated by CI numbers 11000–19999 Diazo are indicated by CI numbers 20000–29999 Triazo are indicated by numbers 30000–36999 Polyazo are indicated by CI numbers 37000–39999 Azo compounds are mostly yellow, orange, red, magenta or purple

HO

CI N N

CI

CI

N

N

CI

CI N

Cu

N

CI

CI

N

N N

N

CI

N

CI

N Cu

N

N N

N CI

CI CI

CI

CI

CI

used for different qualities of purity. Three different categories of purity exist according to cosmetics, food and medicine and are subject to EU regulations, respectively, EU directive 76/768/EOF (cosmetics), EU directive 95/45/EC (food) and EU directive 78/25/EC (medicine). The results of this survey are summarised in Table 2.10. This survey also illustrates that a great deal of the colourants that can be purchased in an easy way do not respond to the requirements of cosmetics. Timko et al. performed an in vitro quantitative chemical analysis of tattoo pigments with the objective to test the accuracy and completeness of information supplied by tattoo ink manufacturers and to perform an elemental assay of tattoo pigments. They examined 30 tattoo inks by using scanning electron microscopy with energy-dispersive X-ray analysis [20]. As a result of this study, the most commonly identified elements were aluminium (87%), oxygen (73%), titanium (67%) and carbon (67% of the pigments). The relative contribution of elements to the tattoo ink compositions was highly variable between different compounds. Overall, the manufacturer-supplied data sheets were consistent with the elemental analysis, but there were important exceptions. The study showed that individual tattoo inks are complex compounds whose composition may include organic dyes, metals and solvents.

N N

Table 2.8 Dioxazine compounds Dioxazine compounds Very heat and light resistant Mostly violet and magenta colours

C1

N

N

O

O

N C1

N

2

Materials Used in Body Art

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Table 2.9 Natural pigments Natural pigments CI number 75000–76999 Colourants from trees, flowers, roots, … Curcumine (Curcuma), brazilin (Brazil wood), santalin (red sandal wood)

HO H O

RO

O

H3CO

OH

OCH3 O

HO

O

OH HO OH

OH H

OCH3 H3CO

OCH3 OH

HO O OH

Table 2.10 Survey 2006 by D’Hollander. Summary of results Colour index (CI) Conventional name Chemical class CI 11680

Pigment Yellow1

Azo

CI 11741 CI 11767 CI 12466 CI 12470 CI 12475 CI 12477 CI 12485 CI 12490 CI 12510 CI 13980 CI 21095 CI 21108 CI 22095 CI 51319 CI 71105

Pigment Yellow 74 Pigment Yellow 97 Pigment Red 269 Pigment Orange 22 Pigment Red 170 Pigment Red 210 Pigment Red 146 Pigment Red 5 Pigment Brown 25 Pigment Yellow 151 Pigment Yellow 14 Pigment Yellow 83 Oxamine Red B1 Pigment Violet 19 Pigment Orange 43

Azo Azo Azo Azo Azo Azo Azo Azo Azo Azo Azo Azo Azo Oxazin Anthraquinone

CI 73900 CI 73915 CI 74160 CI 74260 CI 74265 CI 74280 CI 77266 CI 77491

Allowed in all kind of cosmetics No (not in those used close to mucous membranes) No No No No No No No No No No No No (only rinse-offs) No No (only rinse-offs) No (not in those used close to mucous membranes) No (only rinse-offs) No (only rinse-offs) Yes Yes No No Yes Yes

Pigment Violet 23 Quinoacridine Pigment Red 122 Quinoacridine Pigment Blue 15 Phthalocyanine Pigment Green 7 Phthalocyanine Pigment Green 36 Phthalocyanine Heliogen Green B Phthalocyanine Pigment Black 6 and 7 (graphite) Pure carbon Pigment Brown 6 and 7 Pigment Iron III oxide Red 101 and 102 CI 77492 Pigment Brown 6 and 7 Pigment Hydrated ferric oxide Yes Yellow 42 and 43 CI 77891 Pigment White 6 Titanium dioxide Yes Currently used colourants that can be obtained from several suppliers on the Internet are listed here. Each colourant corresponds to a colour index (CI) number. The same CI number is used for different qualities of purity. Three different categories of purity exist, cosmetics, food and medicine and are subject to EU regulations, respectively, EU directive 76/768/EOF (cosmetics), EU directive 95/45/EC (food), EU directive 78/25/EC (medicine) CI numbers from the list of ingredients of suppliers (Mario Barth’s Intenze, Starbrite, Diabolo Novum, Diabolo Classic, Micky Sharpz Traditional, Micky Sharpz Easyflow, Millenium Mom’s, survey March 2006 by Davy D’hollander).

The influence of laser light on tattoo pigments such as titanium dioxide and iron oxide, inducing oxidative–reductive changes resulting in darkening

is discussed in this article. The authors consider the identification of ink constituents as a first, but not final, step in the improvement of laser treatment. They

24 Fig. 2.15 Multicolour tattoo

C. de Cuyper and D. D’hollander Fig. 2.17 Red disappearing with QS NdYag 532; yellow and purple appear to be difficult to treat colours

Fig. 2.18 Red tattoos have high risk for paradoxical darkening Fig. 2.16 Black pigment fading easily with QS NdYag 1064

suggest that further investigation could result in listing inks that are “permanent” but “laser removable” (Figs. 2.15–2.17). The relationship between the presence of titanium dioxide and poor response to laser therapy is also observed by other authors [23]. It appears that titanium dioxide is used as a brightening agent in many tattoo inks to obtain a lighter colour; titanium dioxide however has a risk for paradoxical darkening when treated with laser. [20] (Fig. 2.18). Blue and brown inks containing iron also seem to be more popular for cosmetic purposes than the conventional black inks [23–25]. Correct labelling and registration certainly could help in directing laser treatment. This aspect however requires the cooperation from the tattoo

artist, to keep client records and to register the products used and when asked for to inform the client or his physician about the materials that have been used including manufacturer and stock numbers.

2.3.3.2 New Developments Up to 20% of the tattooed individuals regret their decision and many of them seek advice for tattoo removal [26]. The problems arising with laser-resistant tattoos and darkening as a result of laser treatment occurring in tattoos in general, but in particular in PMU has been subject for new developments. The concept of easy removable tattoo inks has been a challenge for the tattoo industry and for researchers involved in lasertherapy [27–31].

2

Materials Used in Body Art

Information obtained from the Internet states that Freedom 2 is developing through the particle encapsulation (P2) and enhancement platform (P2E) a new microbead version of tattoo inks. The removable tattoo ink consists of nanosize pigment particles enclosed in polymer-coated beads of about 1-µm diameter. These microbeads are stored in the dermal macrophage. The polymer beads contain a dopant that absorbs light of a specific wavelength and explode when they are treated with corresponding laser light independent of the colour inside the bead. The liberated pigment particles are small enough to be eliminated from the skin. In fact, an “Infinitink” tattoo is permanent but removable because of its construction. According to the information, the scientists have perfected the dissolution of the pigment so that when treated with laser the tattoo will be gone with fewer treatments. Black will be available by the end of 2008; the full colour line is expected in the future [32–34].

2.3.3.3 Other ingredients To obtain a stable tattoo/PMU ink, additives and a carrier medium are needed. Additives with a thickening effect and surface-active chemicals needed to change the polar properties of the pigments are used in order obtain a homogenous solution. These additives can help to make the ink stick to the tattooing needle. Because organic material and water are subject to bacterial and fungal contamination, preservatives like benzoic acid are often added to the tattooing/PMU products. Other substances, even local anaesthetics, have also been mixed in [18]. The carrier usually consists of water, alcohol and glycerine. Common solvents that function as carriers are ethanol or isopropanol. These substances in concentrations up to 15% are added by some producers to assure sterility. Popular carrier components include hamamelis extract, propylene glycol and glycerol. Listerine is often used for thinning of traditional tattoo inks. Also vodka is used by tattooists to thin tattoo inks. Unsafe substances recovered from tattoo inks are methanol, ethylene glycol, aldehydes (glutaraldehyde), detergents and benzoates. Listerine, a popular mouthwash, not only contains thymol, eucalyptol, menthol and methyl-salicylate as active ingredients but also benzoic acid, sodium benzoate flavouring components, water, alcohol and poloxamer that are frequently used as an additive.

25

In summary, the majority of tattoo and PMU products are a mixture not only containing labelled colourants but also a large variety of known and unknown molecules. The local tattooist makes his preferred blends by mixing different complex pigments and by adding thinners and additives. In this context, it is understandable whenever an allergic reaction occurs, the allergologist is confronted with the almost impossible task to identify the cause of this event (see Chap. 6). To minimise the public health risks, one should expect strict regulation concerning materials used to implant into the human body and draw a parallel between tattoo inks and medicine. The best solution would be that only safe products (colourant and auxiliary products as well) within the limits of toxicological knowledge could be legally sold. However, since this is not realistic in the body art branch a more pragmatic “cosmetic” approach has been chosen, limiting the restrictions to molecules approved for food and cosmetics. Even in that aspect it seems that the implementation of the Resolution Res AP (2008) 1 of the Council of Europe is not respected yet and there is still a long way to go. Besides the toxicological aspects, the sterility of the products is another point of concern. Many of the body art practitioners have only elementary knowledge about sterility, although excellent guidelines exist and are easily accessible on the Internet. The ideal scenario of single-use ink caps and disposable material is wishful thinking.

2.3.4 Risks and Complications Several complications arising after tattooing can be attributed to the technique but in particular to the materials used [35–37]. Infection can be caused by bacterial or fungal contamination of the inks or tattoo devices. The procedure itself, disrupting the integrity of the skin implicates a risk for transfusion-transmitted infections [38, 39]. Not only the consumer but also the practitioner is at risk and should take appropriate measures. As mentioned before, the majority of body art practitioners have only elementary knowledge about sterility and hygienic measures are often neglected. Allergic and toxic reactions can not only be due to additives, to the chemical composition of the colourant, but also due to impurities from the production process of the pigment itself.

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Allergy to pigments and dyes manifesting as immediate and delayed-type reactions have been described and are addressed in Chap. 6. Carcinogenic potential is of major concern. As mentioned earlier, the survey done by Baeumler et al. for the Workshop on “technical scientific and regulatory issues on the safety of tattoos, body piercing and related practices” organised in 2003 for the European Commission has revealed that tattoo inks can contain aromatic amines with carcinogenic potential. The following molecules have been identified: solvent red 1 containing o-anisidine, Pigment Red 7 containing 4-chloro-o-toluidine, Pigment Yellow 87 and Pigment Orange 16 that contain 3,3-dichlorobenzidine, while the Dutch study detected o-toluidine in one sample and 2,4-diaminotoluene in three samples [13, 18]. In these studies, it was shown that in particular 3,3¢-dichlorobenzidine seems to be the molecule that can possibly be released from the azo-colourants used for tattooing and PMU practices. The introduction of the principle of selective photothermolysis has changed completely the therapeutic modalities of tattoo removal [24]. Good knowledge about the physical properties of the devices used and the absorption spectrum of the pigments treated can influence the clinical outcome of the treatment [20, 28, 30, 31]. The effect of laser irradiation of tattoo inks in vitro was also investigated at Regensburg University, Germany [37, 40–42]. Laser-induced decomposition products were found in a laboratory setting and toxic and even carcinogenic compounds have been identified. This research was extended to experimentally tattooed skin. In a study, Engel et al. [43] investigated the pigment concentration in pig skin and human skin experimentally tattooed with an azo pigment, Pigment Red 22(PR 22). Although many azo pigments such as PR22 are not allowed for use in cosmetics because they may release carcinogenic decomposition products, these azo compounds are commonly used in tattoo inks. The study determined the concentration of tattoo pigment in the skin ranging from 0.60 to 9.42 mg/cm2. Extrapolation gives an indication that in fact very high quantities of carcinogenic products are injected into the skin, while in the meantime the same molecules are even not allowed in cosmetics in Europe because their absorption could cause health problems in humans. Photodecomposition of tattoo pigments was demonstrated by Cui. Pigment Yellow 74, a pigment used in commercial tattoo inks, was irradiated with a Xenon

C. de Cuyper and D. D’hollander

lamp simulating solar exposure and decomposition products that could potentially have toxic properties identified [11]. The effect of natural sunlight on tattoo pigments was also studied by Engel et al. [44] and the presence of primary decomposition products with carcinogenic properties was also demonstrated. From these data, one could conclude that a tattooed individual has a risk to be exposed to a carcinogenic product in the ink as such and through the natural exposition to sunlight. When treated with laser there is even an increased risk because carcinogenic decomposition products are released due to the treatment [37, 40–42]. Until now, the malignancies reported in tattooed individuals have been considered as coincidental, but large epidemiologic studies are needed to prove a relationship between tattooing and cancer [45–48]. It is unclear whether considerable change in the composition of tattoo products in the last decades, switching more and more to organic azo compounds, will lead to an increase in malignancies. To our knowledge it has not been demonstrated yet that people with extensive tattoos covering large body areas had a higher incidence of malignancies. Fortunately, after the initial healing period following the tattooing procedure the colourants are stored (safely?) in the fibroblasts and remain there unchanged for years. The relation between tattoo pigments and skin cancer is discussed by Kluger [49]. It is questionable if the exposure to the carcinogens released from tattoos could have an influence that could be comparable to, for example, the exposure to tobacco smoke on the lungs or to sunlight on the skin, an interesting subject for epidemiologists. One could suppose that this impact will only be noticed after many years taking into account the time needed for inducing malignant transformation. Considering the high number of tattooed individuals one can estimate that millions of people on the globe are living with a self-inflicted risk factor that could have important consequences for public health. The fact that about 10% of them seeks medical advice for removal and will be exposed to laser therapy could even mean that an extra element should be taken into account. More research concerning the chemical analysis of tattoo pigments and decomposition products as well as an assessment of the influence and risks of laser treatment of tattoos is needed. Careful observation and recording of adverse events in tattooed individuals can offer important information leading to a better knowledge and estimation of the possible side effects of tattooing.

2

Materials Used in Body Art

2.4 Temporary Tattoos The natural source of henna is the plant Lawsonia inermis, which is part of the family Lythraceae. The name is derived from Isaac Lawson, assistant of the famous botanist Linnaeus. The active component is lawsone = 2-hydroxy-1, 4-naphthoquinone [35]. Henna has been used as medicine for centuries to treat skin diseases such as leprosy and smallpox. In the Orient, extracts of dried leaves were made to dye hair, nails and skin. The product used is a thick mixture of the dried and powdered plant with water or oil. The paste or liquid is applied with a stick, brush or cotton swab or directly from a syringe, or cone-shaped container onto the skin; it can dry for 20–30 min and/or be covered with an occlusive dressing or plastic sheet to enhance penetration in the skin; the staining is temporary and lasts a few weeks. This ritual originally observed as touristic attraction is nowadays considered as exotic and popular in youngsters during holidays around the Mediterranean Sea. Although natural henna has a very low allergic potential an increase of reports of allergic reactions to temporary henna tattoos (THT) was observed in the last decades due to the use of new mixtures (see Chaps. 3, 6). Natural henna gives a red colour and is known as “red henna.” Coffee, black tea, a variety of plant extracts, limejuice and even urine of animals have been used since ages to obtain darker colours. More recently, the addition of other colouring agents creates a larger variety of colours. Ingredients added by the artists include paraphenylenediamine (PPD) and indigo blue to obtain “black and blue henna.” The extremely high concentration of PPD up to 15% in these paintings and the use of occlusion may be responsible for subsequent sensitisation. The incorporation of PPD in cosmetic products in the EU is restricted to a maximum concentration of 6% and to a maximum 10% for diaminotoluenes by the Cosmetics Directive of the EU. However, this concentration exceeds in many of the street side THT and is not controlled anyway. The consequence of PPD sensitisation is the risk of cross-sensitisation and allergic reactions to other para-derivatives as sulphonamides. Side effects are described in Chaps. 3 and 6.

2.5 Conclusion The increasing popularity of body adornment through piercing and tattooing in its different forms has raised many questions about the safety of the techniques and

27

the materials used. Many efforts have been done yet to identify the risk factors and to develop preventive measures aimed at protecting public health. Regulation of the composition of the products, harmonisation of the methods for the analytical determination of possible harmful substances and recommendations to ensure that procedures are carried out under appropriate hygienic conditions offer a big step forward to promoting consumers health.

References 1. International Organization for Standardization (2009) http:// www.iso.org/iso/home.html. Accessed 26 May 2009 2. ASTM International, standards worldwide (2009) http:// www.astm.org/. Accessed 26 May 2009 3. Surgical stainless steel: the definitive standards, specifications, and tests (2009) http://www.bmezine.com/pierce/articles/surgste.html. Accessed 28 May 2009 4. http://www.tygon.com. Accessed 04 Jun 2009 5. Gawkrodger DJ (1996) Nickel dermatitis: how much nickel is safe? Contact Dermatitis 35:267–271 6. Kaatz M (2001) A trend and its complications: piercing. Kosm Medizin 24:188–193 7. Kwangsukstith C, Maibach HI (1995) Effect of age and sex on the induction and elicitation of allergic contact dermatitis. Contact Dermatitis 33:289–298 8. http://www.teg.co.uk/nickel/94-27-EC.html. Accessed 04 Jun 2009 9. http://www.nickelinstitute.org. Accessed 04 Jun 2009 10. Liden C, Norberg K (2005) Nickel on the Swedish market. Follow-up after implementation of the nickel directive. Contact Dermatitis 52:29–35 11. Cui Y, Spann AP, Couch LH et al (2004) Photodecomposition of pigment yellow 74, a pigment used in tattoo inks. Photochem Photobiol 80:175–184 12. h t t p : / / w w w. f d a . g o v / d o w n l o a d s / F o r C o n s u m e r s / ByAudience/ForWomen/FreePublications/UCM132814. pdf. Accessed 04 Jun 2009 13. van Buuren R (2003) Testing of tattoo ingredients for their safety evaluation. In: Papameletiou D, Schwela D, Zenie A, Baeumler W (eds) Workshop on the technical/scientific and regulatory issues on the safety of tattoos, body piercing and related practices. European Commission, Ispra. pp 89–92 14. https://wcd.coe.int/ViewDoc.jsp?Ref=ResAP%282008%29 1&Language=lanEnglish1Ver=original&Site=COF&BackC olorInternet=DBDCF2&BackColorIntranet=FDC864&Bac kColorLogged=FDC864. Accessed 26 May 2009 15. Talberg HJ (2003) The question of positive or negative lists. In: Papameletiou D, Schwela D, Zenie A , Baeumler W (eds) Workshop on the technical/scientific and regulatory issues on the safety of tattoos, body piercing and related practices. European Commission, Ispra. pp 84–88 16. Worp J, Boonstra A, Coutinho RA et al (2006) (2006) Tattooing, permanent make-up and piercing in Amsterdam; guidelines, legislation and monitoring. Euro Surveill 11:1–6

28 17. Wikipedia (2009) http://en.wikipedia.org/wiki/India_ink. Accessed 26 May 2009 18. Baeumler W, Vasold R, Lundsgaard J, Talberg HJ (2003) Chemicals used in tattooing and permanent make up products. In: Papameletiou D, Schwela D, Zenie A, Baeumler W (eds) Workshop on the technical/scientific and regulatory issues on the safety of tattoos, body piercing and related practices. European Commission, Ispra. pp 21–37 19. Sowden JM, Byrne JP, Smith AG et al (1991) Red tattoo reactions: x-ray microanalysis and patch test studies. Br J Dermatol 124:576–580 20. Timko AL, Miller CH, Johnson FB et al (2001) In vitro quantitative chemical analysis of tattoo pigments. Arch Dermatol 137:143–147 21. Lehmann G, Pierchalla P (1988) Tattooing dyes. Derm Beruf Umwelt 36:152–156 22. Reus HR, van Buuren RD; Inspectorate for Health Protection North, Ministry of Health (2001) Tattoo and permanent make-up colorants. An exploratory examination of: chemical and microbiological composition, Legislation, Report no ND COS 012 23. Ross EV, Yashar S, Michaud N et al (2001) Tattoo darkening and nonresponse after laser treatment: a possible role for titanium dioxide. Arch Dermatol 137:33–37 24. Anderson RR, Geronimus R, Kilmer SL et al (1993) Cosmetic tattoo ink darkening. A complication of Q-Switched and pulsed-laser treatment. Arch Dermatol 129:1010–1014 25. Kim JW, Lee JW, Won YH et al (2006) Titanium, a major constituent of blue ink, causes resistance to Nd-YAG (1064 nm) laser: results of animal experiments. Acta Derm Venereol 86:110–113 26. Armstrong ML, Roberts AE, Koch JR et al (2008) Motivation for contemporary tattoo removal: a shift in identity. Arch Dermatol 144:879–884 27. Anderson RR, Parish JA (1983) Selective photothermolysis; precise microsurgery by selective absorption of pulsed radiation. Science 220:524–527 28. Goldman MP, Fitzpatrick RE (1999) Treatment of tattoos. In: Goldman MP, Fitzpatrick RE (eds) The art and science of selective photothermolysis, 2nd edn. Mosby, St Louis, pp 250–252 29. Hodersdal M, Bech-Thomsen N, Wulf HC (1996) Skin reflectance-guided laser selections for treatment of decorative tattoos. Arch Dermatol 132:403–407 30. Pfirrmann G, Karsai S, Roos S et al (2007) Tattoo removal – state of the art. J Dtsch Dermatol Ges 5:889–897 31. Zelickson BD, Mehregan DA, Zarrin AA et al (1994) Clinical, histologic , and ultrastructural evaluation of tattoos treated with three laser systems. Lasers Surg Med 15:36–72 32. Wu C (2007) Disappearing ink: tattoo technology for modern impermanence. Sci News 172:232–234

C. de Cuyper and D. D’hollander 33. http://www.freedom2inc.com/bodyart.html. Accessed 26 May 2009 34. http://www.infinitink.com. Accessed 26 May 2009 35. Kazandjieva J, Grozdev I, Tsankov N (2007) Temporary henna tattoos. Clin Dermatol 25:383–387 36. Papameletiou D, Schwela D, Zenie A et al ( 2003) Risks and health effects from tattoos, body piercing and related practices. In: Workshop on the technical/scientific and regulatory issues on the safety of tattoos, body piercing and related practices. European Commission, Ispra, pp 8–36 37. Vassold R, Engel E, Koenig B et al (2008) Health risks of tattoo colors. Anal Bioanal Chem 391:9–13 38. Nishioka S, Gyorkos T, Joseph L et al (2003) Tattooing and transfusion-transmitted diseases in Brazil: a hospital-based cross-sectional matched study. Eur J Epidemiol 18:441–449 39. Samuel MC, Doherty PM, Bulterys M et al (2001) Association between heroin use, needle sharing and tattoos received in prison with hepatitis B and C positivity among streetrecruited enjecting drug users in New Mexico, USA. Epidemiol Infect 127:475–484 40. Baeumler W (2009) Laser therapy of tattoos. Kosm Medizin 30:8–11 41. Baeumler W (2003) Possible risks of tattoo removal using laser therapy. In: Papameletiou D, Schwela D, Zenie A, Baeumler (eds) Workshop on the technical/scientific and regulatory issues on the safety of tattoos, body piercing and related practices. European Commission, Ispra, pp.66–69 42. Baeumler W, Eibler E et al (2000) Q-switch laser and tattoo pigments: first results of chemical and photophyssical analysis of 41 compounds. Lasers Surg Med 26:13–21 43. Engel E, Santarelli F, Vassold R et al (2008) Modern tattoos cause high concentrations of hazardous pigments in skin. Contact Dermatitis 58(4):228–233 44. Engel E, Spannberger A, Vasold R et al (2007) Photochemical cleavage of tattoo pigment by UV radiation or natural sunlight. J Dtsch Dermatol Ges 5:583–589 45. Birnie AJ, Kulkarni K, Varma S (2006) Basal cell carcinoma arising in a tattoo. Clin Exp Dermatol 31(6):820–821 46. Goldenberg G, Patel S, Patel MJ et al (2008) Eruptive squamous cell carcinoma, keratoacanthoma type, arising in a multicolor tattoo. J Cutan Pathol 35(1):62–64 47. Paradisi A, Capizzi R, De Simonne C et al (2006) Malignant melanoma in a tattoo: case report and review of the literature. Melanoma Res 16:375–376 48. Vassileva S, Hristakieva E (2007) Medical applications of tattooing. Clin Dermatol 25:367–374 49. Kluger N, Phan A, Debarbieux S et al (2008) Skin cancers arising in tattoos: coincidental or not? Dermatology 217: 219–221

3

Tattooing and Scarring: Technique and Complications Maria Luisa Pérez-Cotapos S., Christa De Cuyper, and Laura Cossio

Core Messages

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Body modifying techniques and body art more in particular tattoos and piercings have become increasingly popular in western world in the last decades. Body art practitioners and customers are often unaware of the risk of complications associated with body art procedures. Major complications include infections, allergies, and permanent disfiguring deformities. Although in many countries tattoo inks are subject to regulations for food and cosmetics and guidelines for save procedures have been developed, there is still a lack of control. In the objective to reduce the side effects, heavy metals have been banned from tattoo inks and have been replaced by azo dyes. However, azo dyes can also have hazardous potential in particular when tattoos are treated with lasers. Allergic contact dermatitis to temporary henna tattoos is mainly caused by the presence of PPD (paraphenylenediamine).

M.L. Pérez-Cotapos S.() Associate Professor at Pontificia, Universidad Católica de Chile Department of Dermatology, Clinica Las Condes, Lo Fontecilla 441, Santiago, Chile e-mail: [email protected]

3.1 Introduction Body modification is a common human characteristic that has been practiced all over the world for ages [1]. In his fascinating book, Spiritual tattoo. A cultural history of tattooing, piercing, scarification, branding, and implants, Rush describes the origin of body art in all its aspects “from primitive tribes to advanced civilization” [2, 76]. Permanent modifications such as piercing and tattooing are old forms of body art that have gained popularity in the last decades as a fashion statement, promoted by celebrities. In adolescents, piercing and tattooing are often a manifestation of rebellion and can be considered as indicators of risky behavior [3]. In a survey, 9% of tattooed patients admitted that their first tattoo had been acquired while under the influence of alcohol or drugs [4, 5]. More invasive body modifying techniques such as implanting, scarification, branding, and even amputation recently seem to attract the young population and often result in impressive, irreversible body mutilation [6, 7]. All body modifying methods can lead to complications depending on the conditions in which the procedures are performed, on the training and the skills of the practitioner and on the materials used. Allergic reactions can be attributed to materials and substances used or can occur during removal procedures. Poor hygienic standards can not only result in localized infections, but can also lead to severe life-threatening conditions or even result in irreversible damage. Health care professionals should be aware of the complications that can arise from these procedures [3, 4].

C. de Cuyper, M. L. Pérez-Cotapos S. (eds.), Dermatologic Complications with Body Art, DOI: 10.1007/978-3-642-03292-9_3, © Springer-Verlag Berlin Heidelberg 2010

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3.2 Tattooing

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In general, the word tattoo evokes the picture of a skin mark realized by the application or implantation of a colorant. The definition of tattooing and the word “tattoo” has been subject to many etymological explanations [8]. One of them refers to a signal on a drum and is derived from the Dutch word “taptoe,” meaning to shut of the taps of the casks in the taverns at night. Another explanation dates back to Captain Cook visiting Tahiti where the sound “tatau” was used to indicate “marking the skin with pigments.” Tattoos can be divided in two groups, the first group including nonpermanent or temporary tattoos that last for a few days to weeks. The second group includes the semi-permanent tattoos such as permanent makeup (PMU) used for cosmetic purposes, lasting for years and permanent tattoos meant to persist during the whole life. Permanent tattoos and semi-permanent tattoos can be classified depending on their origin or purpose. There are several types of tattoos ranging from a few small black dots to large multicolor figures and elaborate designs covering extensive body areas. Amateur tattoos often mention love names, heart, and arrow symbols. Professionals have an endless inspiration of symbolic figures, animals, flowers, etc. Traumatic (accidental) tattoos can either occur after accidental dermabrasion in road accidents (Fig. 3.1) or can be seen in people involved in constructing or mining industry. Traumatic tattoos can also be the result of an explosion and firearm accidents or they can be due

to accidental implantation of graphite pencil points or ink punctures. Amalgan tattoos of the oral mucosa can occur after dental filling. These tattoos are unintentional and unwanted, in contrast, to the majority of the following group. Cultural, ethnic, and tribal tattoos varying from dots and lines or geometric symbols to beautiful designs covering the whole body represent an old art practiced all over the world (Fig. 3.2). Extensive body decoration has been a common practice for ages in the South Pacific. Japanese tattoos covering nearly the entire body surface are often represented in paintings and can as such be considered as real pieces of art. Tattoos have always been an expression of culture and religion [1, 2]. Many different purposes have been attributed to tattooing. It is a ritual that is even nowadays practiced as an act of passage to adulthood in many African communities. Tattoos can represent an expression of religious devotion, a protection against evil spirits, or a passport to cross the river of death and guidance in the afterlife. Cosmetic tattoos include PMU simulating conventional makeup and the therapeutic variant known as dermatography, which is often used for scar correction. Dermatography is also well known as adjunctive to plastic and esthetic surgery and has also been used to introduce pharmacological substances into the skin. Medical tattoos are often applied in oncology to delineate the radiation field or for directing endoscopic procedures. Identification tattoos have been used as a symbol of royalty, nobility, and status in some cultures but tattoos have also been used to mark slaves and prisoners and for a long time represented a symbol of the outcast or criminality. Tattoos are also associated with the introduction in certain communities and represent

Fig. 3.1 Traumatic tattoo

Fig. 3.2 Ethnic tattoo

3.2.1 Definition and Classification

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Tattooing and Scarring: Technique and Complications

a sign of clan or gang affiliation with the intention to promote solidarity between members of a particular group. Ornamental tattoos represent the largest group and are nowadays accepted as a fashion statement in all the social classes.

3.2.2 Technique/Tattooing Procedures Depending on the way and in which circumstances the procedure is performed we can distinguish two kinds of procedures. Amateur tattooing is often done by individuals in poor hygienic circumstances or by unauthorized amateurs who do not comply with the corresponding health regulations. Professional tattooing is performed by skilled specialists (professionals) in places that usually comply with hygienic standards and local health regulation (Fig. 3.3). Unfortunately many body art professionals are not aware of the risks involved in body modifying procedures and do not respect the guidelines concerning hygiene. The practice of tattooing consists in the implantation or injection of a colorant into the skin or the mucosa using a needle, a pen, or a hand-held device with two or more needles, which are dipped into the tattoo ink containing various pigments or dyes. The level of implantation will depend on the skill of the performer, the purpose of the tattoo, and the type of device. For professional use, a wide range of electric-

Fig. 3.3 Procedure

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driven devices has been developed with specific designs and indications. Tattoo “guns” equipped with an ink reservoir and different needle sets can puncture the skin at high speed, making hundreds of little holes about 1-mm deep, forcing the pigments into the skin. A large variety of equipment can easily be purchased on the Internet (See Chap. 6). Before starting the procedure the skin is disinfected, a tattoo print is transferred to the skin, and then a fine layer of solid Vaseline is applied on the skin before and during the procedure, as to avoid accidental staining of the surrounding skin by the pigments. Once the process is finished, the area is cleaned using a mild soap or an antiseptic solution, then again more Vaseline is applied. The procedure leads to a localized inflammatory reaction giving a relief-like appearance to the design in the first weeks. During the first 10 days following the procedure, a significant amount of pigment will extrude through the epidermis. The pigments located in the dermis will be phagocyted by macrophages and consequently stored in the dermal fibroblasts and macrophages. The end location of the pigment can be in the superficial, mid, and deep dermis. In cosmetic tattoos or PMU, the colorant is applied in the superficial layer of the dermis. In ornamental tattoos, the pigment particles will be located deeper in the dermis, although it is more superficial and heterogeneous when performed by amateur tattooists. The pigments penetrate the fibroblast membranes, and sometimes, perivascular mast cells. They can also be found in hair follicles and sebaceous glands and in small aggregates in the interstitial space. Larger pigment molecules usually do not migrate; however, pigment migration may eventually happen leading to blurring (Fig. 3.4) of the design. Unwanted migration

Fig. 3.4 Blurring due to migration of the pigments

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of water soluble dyes used in PMU can result in fanning. Lymphatic transport is responsible for the presence of pigment in the corresponding lymph nodules.

3.2.3 Pigments in Tattooing (see Chap. 2) The composition of the ink used for tattooing purposes is complex [9, 10]. In general, the ink consists of oneor more colorants, a carrier, and some additives. Amateur tattoos are usually made with nonsterile materials, Indian ink being one of the favorites. Tribal tattooists commonly use black pigments based on soot, frequently obtained from charcoal and coal. The materials used by professionals are subject to regulations for food and cosmetics but these regulations are neither imposed nor respected worldwide and there is still a lack of control from the side of the local authorities. Several natural pigments have been used such as the ones originated from tropical wood (Caesalpinea gender or Brasiline from Brasil or the Pterocarpus santalinus or Santilin from India), as well as other elements and compounds like minerals and metals (aluminum, cadmium, calcium, copper, iron, phosphorus, silica, sulfur, titanium, and barium sulfate). The use of heavy metals such as mercury, cadmium, and lead was banned for cosmetic purposes by the Food, Drug and Cosmetic Act (FDCA) in 1976 and it is rare to find these elements in the tattoo inks nowadays. In modern tattoo inks, mostly, organic azo dyes are used. Many inks may contain impurities because they are originally developed and produced for industrial purposes like printing ink and motorcar paint [11]. An extensive list of components used in tattoo inks can be consulted in Chap. 2.

3.2.4 Complications 3.2.4.1 Allergic Reactions (See Chap. 6) Different allergic reactions have been reported varying from eczematous to lichenoid and granulomatous reactions [12]. In red tattoos, the reactions have often been attributed to mercury salt, cinnabar (HgS) (Fig. 3.5); however, also azo dyes have been indicated as the agent responsible for adverse reactions [13, 14]. Quinacridon has also been reported as a cause of contact allergy [15]. Photosensitivity reactions have occurred in yel-

Fig. 3.5 Allergic reaction to red ink

low tattoos and have been attributed to the presence of cadmium sulfide [10, 75]. When the pigment has traces of nickel sulfate, it can cause allergic reactions in people with preexisting nickel allergy. Allergy to implanted metal molecules can manifest as eczema, lichenoid reactions, or pseudolymphoma that can become apparent months or even years after the skin has been tattooed, illustrated in Chap. 6 [16]. Granulomatous skin reactions resulting from the presence of foreign bodies should be differentiated from allergic reactions and sarcoidosis [17–20]. Allergic granulomatous reactions have been discussed by Aberer in Chap. 6. Bachmeyer reports a granulomatous reaction on the blue pigment areas of a tattoo, presenting as asyptomatic, erythematous, and papular lesions in a 39-year-old man 1 month after starting etanercept for ankylosing spondylitis. As possible underlying mechanism, the hypothesis is suggested that an “exaggeration of the production of TNF-a or other inflammatory mediators, or an activation of a select population of monocytes to an agent (such as the pigment of the tattoo) may result in granulomatous reactions in patients treated with etanercept” [21]. In the new era of immunomodulatory drugs and biologicals, more unusual reactions can probably be expected in the future [20]. Wollina in a recent publication presents a young woman with erythema nodosum and a granulomatous tattoo reaction; coincidence or relationship is discussed [22]. Tattoo-induced vasculitis located in the red part of a tattoo with a protracted course was described by Jolly [23]. Hermida reports a generalized cutaneous vasculitis occurring in a 21-year-old man, appearing 1 week after the placement of a black and red tattoo on his leg. A delayed hypersensitivity reaction triggered by the red pigment was thought to be the

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cause because he had not reacted on black pigment in a previous tattoo [24]. There have also been reports of lesions mimicking morphea and pseudoepiteliomatous hyperplasia [25–27]. Exceptional allergic reactions after Q-switched laser treatment of tattoos manifesting as generalized urticaria and localized dermatitis have been reported [28]. Case report: A localized vesiculobullous dermatitis was observed by De Cuyper in a patient with a black tattoo treated with a Q-Switched Nd-Yag 1064 laser and occurring 24 h after the third laser treatment. Patch testing with the black ink that had been lasered with the same wavelength produced a strong positive reaction; the pure ink in contrast did not elicit an allergic reaction. These observations suggest that laser treatment can induce chemical changes in the tattoo pigments and result in the production of allergenic substances. (Figs. 3.6 and 3.7)

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Experiments on laser-induced cleavage of tattoo pigments (azo compounds) have been performed by Baeumler. This research indicates that hazardous decomposition products with toxic and carcinogenic properties are produced [9] (see later). Other rare chemical reactions can occur after laser removal of unwanted tattoos. Paradoxical darkening of iron pigment containing tattoos has been reported [29, 30] and has also been observed in several of our patients treated for unacceptable PMU [31]. This is probably caused by the reduction of red–brown colored ferric oxide (Fe2O3) to black-colored ferrous oxide (FeO) (see Chap. 5). Titanium dioxide used to obtain lighter colors can also turn black due to the exposure to high energy and heating during laser treatment [32, 33]. Pigment darkening is not always predictable because it is a quite complex phenomenon but it should be considered in particular when treating multicolored tattoos and PMU with Q-Switched lasers [10].

3.2.4.2 Infections

Fig. 3.6 Allergy in a black tattoo treated with QS Nd-YAG 1064 laser

Fig. 3.7 Positive patch test to black ink treated with QS Nd-Yag 1064 laser

The risk of tattoo-related infections depends on the hygienic conditions under which the procedure was carried out, and the expertise of the tattooist. Materials can be contaminated and devices are often difficult to sterilize [12, 34, 35]. Bacterial infections are more common following piercing than tattooing procedures. The most frequent are local bacterial infections at the site of the procedure. They are often caused by common pathogens such as Streptococcus pyogenes and Staphylococcus aureus. Nevertheless, severe secondary infections have been reported such as erysipelas, cellulitis, sepsis, and spinal abcesses, either due to Streptococcus pyogenes, Staphylococcus aureus, or Pseudomonas species [12, 35, 36]. Severe bacterial infections can occur when the procedure is performed in poor hygienic conditions or in patients at risk, some of these infections can be serious and life threatening such as gangrene and endocarditis [37]. Tattoo infections due to typical and atypical mycobacteria have been reported (Fig. 3.8) [38, 39], the first dating back to 1895 when a tattooist with pulmonary tuberculosis was responsible for the transmission to his fellow prisoners of tuberculosis through his saliva, licking the tattoo needle. A similar recent outbreak of Mycobacterium chelonae infection was identified in six

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Fig. 3.8 Infection caused by atypical mycobacteria

Fig. 3.10 Viral warts

Fig. 3.9 Ulceration caused by Mycobacterium tuberculosis in a 17-year-old student

Fig. 3.11 Mollusca contagiosa

patients after the placement of a tattoo by the same artist in the USA [40]. Case report: Pérez-Cotapos presents the history of a 17-year-old healthy student. A friend of his tattooed his legs at home. One month later skin lesions presenting as erosions and ulcerations started to appear in the tattooed area. He was treated with a systemic antibiotic (Flucloxaciline in a dose of 1.5 g/day for 10 days), without any improvement. He consulted in the dermatology clinic. A biopsy of the ulceration was performed, showing an aspecific histopathology analysis, without granulomas. However, through PCR, Mycobacterium tuberculosis was confirmed. Chest X-ray was normal. The origin of the contamination with M. tuberculosis could not be detected. The patient is undergoing the proper treatment with Isoniazide and Rifampycin for minimal 6 months (Fig. 3.9).

Inoculation of leprosy after religious ritual tattooing in an endemic area in India has been described by Ghorpade [41]. Inoculation of Syphilis was documented from the nineteenth century and the protective effect of mercury (cinnabar) in red tattoos was observed [12]. Transmission of Syphilis from a tattoo needle moistened with the tattoo artist’s saliva occurred in a group of US soldiers [34]. Unusual cutaneous lesions in two patients with visceral leishmaniasis and HIV infection have been reported [42]. Different types of viral infections can be transmitted. Papiloma virusinduced warts, [43] (Fig. 3.10) Mollusca contagiosa [44] (Fig. 3.11), herpes simplex, blood-transmitted diseases such as hepatitis and HIV [5, 35, 45–49] have been linked to tattooing. Reactivation of viral infections, such as herpes simplex and herpes zoster, has been observed in

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Tattooing and Scarring: Technique and Complications

association with tattoos [18]. A Brazilian study showed that people with tattoos in their skin had a higher risk of infections due to hepatitis C [47, 48]. The risk of Hepatitis B and C, as well as HIV transmission by tattooing and piercing should not be underestimated [5]. Moreover, not only the clients but also the tattooists are at risk. Preventive hygienic measures and Hepatitis B vaccination are highly recommended for professionals involved in body modifying techniques. In some countries, persons who have several tattoos or extensive skin areas tattooed or/and have piercings cannot be blood donors. Some rare cases of systemic mycoses such as Candida endophthalmitis, sporotrichosis, and zygomycosis following tattooing procedures have been reported [50–52]. Site-related complications depend on the body region concerned. 3.2.4.3 Other Conditions Reported in Association with Tattoos Concomitant diseases can be triggered by the tattooing procedures, such as psoriasis, lichen planus, and sarcoidosis [17]. Other dermatologic diseases such as discoid lupus and morphea appeared in the tattooed area [18, 27]. Psoriasis can occur as a koebnerization phenomenon in the tattoo area. A psoriatic eruption spreading to the scalp and the feet after the placement of a red tattoo was recently described by Keimig [53]. Hypertrophic scars and keloids (Fig. 3.12) can be observed in particular in dark-skinned individuals. Areas at risk are the face, the upper trunk, and the deltoid area. Different malignant skin tumors have been observed in tattooed skin areas. These can be malignant melanoma [54], basal cell carcinoma [55], and squamous

Fig. 3.12 Keloid

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cell carcinoma [56]. The occurrence of a malignancy in a tattooed area has until now been considered as coincidental but some are questioning a possible relationship [57]. Since there has been an increase in malignant melanoma in the past few years, studies have been carried out to establish a possible link between tattoos and malignant melanoma, however, no significant increased risk has been found [58]. However, the clinical observation and correct diagnosis of pigmented lesions located within in a tattooed area can be problematic and misleading, because the presence of pigment can cause diagnostic problems especially in melanomas [54]. Moreover, whenever surgical excision is required for a tumor arising in a tattoo this will impair the integrity of the tattoo and can result in a disfiguring scar [57, 59]. The fact that there may be tattoo pigment in the regional lymph nodes, mimicking melanin pigment can also be confusing and may hinder the diagnosis of metastatic malignant melanoma. Specific histological staining is necessary for differentiation [60]. A non-Hodgkin primary lymphoma has also been described, which originated from a tattoo [61]. Tattoos, in particular the ones containing metallic (iron) components, can interfere with diagnostic procedures. Rare complications that have been reported in patients undergoing magnetic resonance imaging included tingling and burning sensation and even burns [62, 63, 77]. The tattoo itself can interfere with the quality of the images. Another point of concern is the toxic and carcinogenic potential of the materials used in tattoos and PMU and the lack of extensive pharmacologic and toxicological studies. This aspect is addressed in Chap. 2. The influence of (artificial) sun exposure on tattoo pigments has been studied by Engel and photodecomposition of Pigment Yellow 74, a pigment used in commercial tattoo inks, has been demonstrated by Cui [13, 64]. In addition, as demonstrated in an experimental laboratory setting, laser treatment of pigment suspensions can induce cleavage of pigment molecules of the azo group and generate decomposition products and new chemical compounds with carcinogenic properties [9, 63]. Even in our contemporary society many people consider removal of tattoos acquired earlier in life due to a number of reasons, including embarrassment caused by negative comments, stigma problems in their community, workplace, and school settings. Other motivations are dissociation from the past, a new job or career or simply because they no longer want a tattoo on their

36 Table 3.1 Complications of tattooing Allergic reaction Urticaria Eczematous dermatitis Photosensitivity Foreign body reaction Lichenoid reaction Granulomatous hypersensitivity reaction Vasculitis Erythema nodosum (?)

M. L. Pérez-Cotapos S. et al.

Infection

Miscellaneous

Bacterial infections Pyogenic (streptococci, staphylococci, and pseudomonas) Mycobacterium tuberculosis, atypical mycobacteriae Syphilis Leishmania

Koebner effect Migration of pigments to lymphatic ganglia Malignant skin neoplasias Pseudoepitheliomatous epidermal hyperplasia in tattoos Sarcoidosis Postsurgical complications/scars/keloids MRI complications

Fungal infections Sporotrichosis Candidiasis Zygomycosis Viral infections A, B, C, D hepatitis, HIV Herpes simplex – zoster Papiloma virus, poxvirus

skin [65, 66]. Taking into account that about 20% of tattooed people are dissatisfied and maybe half of them seek advice for tattoo removal, this would represent millions of individuals in the world to be treated and be exposed to hazardous decomposition products. This aspect could have important consequences for the public health and remains a domain for further research.

before clearing and complete resolution cannot be guaranteed. Especially multicolor tattoos (orange and purple) and tattoos containing titanium dioxide (light colors, green, and blue) can be difficult to remove with laser treatment and paradoxical darkening can occur; the same complication can appear in tattoos containing iron pigment. Moreover, persistent textural and pigmentary changes and scarring are possible (Table 3.1).

3.2.5 Therapy 3.3 Temporary Henna Tattooing Many individuals deciding for a tattoo are not aware of the risk and consequences. Information and education of the public and the performers are important preventive measures. The best advice to limit the risk of complications, more in particular the risk of infection, is to have the procedure performed by a professional in optimal hygienic conditions with sterile materials and good antiseptic aftercare. Infections must be treated with appropriate measures. Intolerance and allergic reactions occur more in colored (red/yellow) tattoos but can also been observed in black tattoos. They are mostly unpredictable, but fortunately often limited to the tattooed area. The use of topical or intralesional steroids can reduce the symptoms. The risk of an allergic reaction in a nickel-sensitive person must be considered. Rare, severe reactions can require systemic corticotherapy. Unwanted tattoos or tattoos presenting with side effects can be removed. The different aspects and modalities of tattoo removal are addressed in Chap. 7. One must take into account that except for surgery most of the removal techniques will take months

3.3.1 Materials and Technique The natural source of henna is the plant Lawsonia inermis, which is part of the family Lythraceae [12]. The active component is lawsone (2-hydroxy-1, 4-naphthoquinone). Henna has been used as medicine for centuries to treat skin diseases such as leprosy and smallpox. In the Orient, extracts of dried leaves were made to dye hair, nails and skin. In Muslim tradition the use goes back to the prophet Mohamed who colored his hair and beard with henna [76]. Henna has since been introduced in Europe for dyeing hair. In the Middle East and Northern Africa henna decorations on hands and feet are still common in celebrations and festivities. The traditional temporary henna tattoos (THT) are called “mehndi.” The product used is a thick mixture of powdered leaves, stems and water or oil. The paste or liquid is applied in a decorative pattern with a stick, brush or cotton swab, or a cone-shaped container onto the skin.

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Henna artists preferentially use a syringe to make the elaborate decorations. Once the procedure is finalized the product can dry for 20–30 min. The design can be covered with an occlusive dressing, paper tape bandage or plastic wrapping to enhance the henna impregnation and penetration into the stratum corneum; the staining is temporary and lasts a few weeks, it will disappear spontaneously by natural shedding of the corneocytes. This ritual originally observed as touristic attraction is nowadays considered as exotic and has become increasingly popular among western tourist during summer holidays in the Mediterranean region. Especially, children, teenagers, and young adults are keen to get one of these temporary tattoos. Although natural henna has been used for centuries and rarely causes side effects an increase of reports of allergic reactions to THT was observed in the last decades due to the use of mixtures. Natural henna gives a red color and is known as red henna, it has a very low allergic potential. Coffee, black tea, a variety of plant extracts, lime juice, eucalyptus, clove or mustard oil, and even urine of animals have been used since ages to obtain darker colors. More recently, the addition of other coloring agents in particular hair dyes creates a larger variety of colors. Ingredients added by the artists include paraphenylenediamine (PPD) and indigo blue to obtain black and blue henna.

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Fig. 3.13 Contact dermatitis to henna tattoo

3.3.2 Complications (See Chap. 6) Most adverse reactions can be attributed to hypersensitivity reactions. All the ingredients used in henna mixtures can evoke contact dermatitis but it is very uncommon for users to develop sensitization and manifest allergic contact dermatitis to the original pure henna. In contrast, additives used to obtain darker colors in particular PPD have created an epidemic resulting in a series of reports concerning manifestations of contact allergy to temporary tattoos. The extremely high concentration of PPD up to 15% in these mixtures and the use of occlusion may be responsible for subsequent sensitization. The incorporation of PPD in cosmetic products in the EU is restricted to a maximum concentration of 6% and to a maximum 10% for diaminotoluenes by the Cosmetics Directive of the EU. However, this concentration is exceeded in many of the street side THT and not controlled anyway. Allergic contact dermatitis reactions to PPD are well

Fig. 3.14 Hyperpigmentation as the result of henna contact dermatitis

recognized and most commonly involve an eczematous reaction that may be localized (Fig. 3.13) and can also become generalized. The consequence of PPD sensitization is the risk of cross-sensitization and allergic reactions to other para-derivatives as sulphonamides, sulphonylurea, and dapsone, sunscreens containing para-aminobenzoic acid, azo dyes, and benzocaine. Severe delayed-type reactions have been associated with blistering, skin necrosis, and scarring and frequently result in long lasting even permanent hypopigmentation. Even in the absence of blistering reactions it is also common to observe hypopigmentation and/or hyperpigmentation (Fig. 3.14), fortunately most of it tends to disappear in time, although permanent hypopigmentation can occur. [12] Rare immediate type reactions include urticaria, angioneurotic oedema.

38 Table 3.2 Complications of henna tattoos Localized or generalized contact dermatitis (PPD)(Type IV) Temporary or permanent hyperpigmentation or hypopigmentation Temporary localized hypertrichosis Hypersensitivity reaction (type I) urticaria. Angioedema or anaphylaxis Erythema multiforme Hypertrophic scarring or keloid

There have also been some reports of erythema multiforme-like reactions to PPD and its derivatives [67, 68]. Another side effect that has been reported following the application of a henna tattoo is the appearance of temporary localized hypertrichosis in the previously tattooed area [69]. News reports have mentioned that temporary tattooing is unsafe in atopic children who run a higher risk of developing severe contact dermatitis at the tattoo site, which may become generalized [70]. Life-threatening haemolysis in glucose-6phoshate dehydrogenase deficiency caused by henna has been reported and the use of henna in glucose-6phosphatase deficient individuals and young children in general should be avoided [51, 71].

3.3.3 Other Temporary Tattoos Other temporary tattoos include transfer tattoos, suntattoos, and pseudo (stick-on) tattoos, which are popular in young children. Tattoo stickers can cause local irritation due to their occlusive effect. Face painting is popular in children, while the art of body painting is rather exclusively reserved to adults. Products used are derived from conventional cosmetics and similar to the makeup used by theater artists. Little is known about adverse events of these techniques (Table 3.2). See Chap. 6.

3.4 Scarring, Scalping, Branding and Cutting 3.4.1 Introduction Scarification is a procedure that has been practiced since ancient times in particular in tribal or ethnic groups in Africa, Australia, as well as in some American

M. L. Pérez-Cotapos S. et al.

groups such as Mayas, Huastecas, and the Chichimecas. These practices are used among many indigenous cultures as a ritual of transition into adulthood, or for beauty, social status and power purposes. Ethnic scarifications are often combined with other forms of body art such as body painting, tattooing, piercing, and tunneling. The technique of scarification is still a common practice and has recently become common in western societies too, more in particular in young adults [2, 72]. As with the other forms of body art, scarification or branding is not a manifestation of a psychiatric disorder, but rather, a method of self-expression and a form of rebellion and provocation against the traditional and formal society. In addition, scarring and branding have been shown to be associated with substance abuse and high-risk behaviors among adolescents. Responsible practitioners restrict the procedures to 18+ clients.

3.4.2 Technique The aim of this technique is to raise the skin and to get the effect of a carved-like design. The process can be performed with any sharp tool, electrocautery, laser, chemicals, freezing, and hot metal. Cutting: A pattern is achieved by making fine cuts in to the skin. The wounds are made with sharp instruments. Tribal cuttings are realized with a variety of sharp tools (wood, ivory, metal, or glass) often in poor hygienic conditions. Incisions are made in a manner that stimulates the abnormal growth of scars tissue in order to obtain a hypertrophic or keloid scar. This reaction can be enhanced by the application of foreign body material in the wound such as ashes and sooth. In western society, cuttings and carvings are made with a surgical scalpel 11 or 15 (cutting, carving, scalping, or skin removal) (Fig. 3.15). During this process, pigments may also be added to obtain a colored design. A similar result of scarification can be achieved through the use of branding which is another form of body art [74]. Third-degree burns are inflicted on the skin with the aim of producing permanent scars. Designs are created on the skin by burning caused by fire, cold, or by some chemical agents. Branding normally involves the heating of a metal shape and applying it to the skin to obtain scars with a specific design

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3.5 Conclusion

Fig. 3.15 Scarification

(strike). The same design can be repeated or well-organized series of heated metal plates can be applied to create a specific pattern. The technique is in fact similar to cattle marking. The other form of branding is accomplished by burning the design on the skin with a (medical) electric cautery unit. Intentional cigarette burns represent a more primitive method. Tongue splitting can also be considered in this context and is realized by tearing progressively a monofilament from the middle to the top of the tongue. Ear pointing is a surgical procedure to create “elf-like” ears. An extreme variant of scarring or cutting is intentional amputation of fingers and toes. Extreme body modifying procedures can lead to severe irreversible mutilation. Transdermal implants with spikes protruding through the skin and subdermal implants of bone plates or horns can also create bizarre shapes, transforming human beings to extraterrestrials. The imagination and creativity – or should one call it destructivity – is endless. Photo galleries on the internet provide with the most incredible realizations.

3.4.3

Complications

Adverse events arising from these procedures include bleeding, swelling and inflammation, localized and systemic infection, transmission of blood-borne pathogens, allergic reactions to materials used, and sequels arising from the burns [73]. Hypertrophic scars and keloids exceeding the desired pattern or design can be seen. The more invasive procedures can result in irreversible mutilation and functional impairment.

The old art of body modifying practices has become increasingly popular in western world in the last decades attracting more in particular the younger generations. Body art practitioners and customers are often unaware of the risk of complications associated with body art procedures. Although in many countries tattoo inks are subject to regulations for food and cosmetics, and guidelines for save procedures have been developed, there is still a lack of control. People deciding for more invasive procedures are exposed to even higher risks of side effects. Complications of body art include infections, allergies, and permanent disfiguring scars. Information and education is an important issue for public health.

References 1. Scheinfeld N (2007) Tattoos and religion. Clin Dermatol 25:362–366 2. Rush JA (2005) Spiritual tattoo. A cultural history of tattooing, piercing, scarification, branding and implants. Frog, Berkeley 3. Mayers LB, Judelson DA, Moriarty BW et al (2002) Prevalence of body art (body piercing and tattooing) in university undergraduates and incidence of medical complications. Mayo Clin Proc 77(1):29–34 4. Laumann AE, Derick A (2006) Tattoos and body piercings in the United States: a national data set. J Am Acad Dermatol 55:413–421 5. Samuel MC, Doherty PM, Bulterys M et al (2001) Association between heroin use, needle sharing and tattoos received in prison with hepatitis B and C positivity among street-recruited injecting drug users in New Mexico, USA. Epidemiol Infect 127:475–484 6. Armstrong ML, Kelly L (2001) Tattooing, body piercing, and branding are on the rise: perspectives for school nurses. J Sch Nurs 17:12–23 7. Chimenos E, Batlle I, Velásquez S et al (2003) Appearance and culture: oral pathology associated with certain fashions. Med Oral 8:197–206 8. Goldstein N (2007) Tattoos defined. Clin Dermatol 25: 417–420 9. Baeumler W, Eibler E et al (2000) Q-switch laser and tattoo pigments: first results of chemical and photophyssical analysis of 41 compounds. Lasers Surg Med 26:13–21 10. Beute TC, Miller CH, Al T et al (2008) In vitro spectral analysis of tattoo pigments. Dermatol Surg 34(4):508–515 11. Papameletiou D, Schwela D, Zenie A et al (2003) Workshop on the technical/scientific and regulatory issues on the safety of tattoos, body piercing and related practices. European Commission, Ispra

40 12. Kazandjieva J, Tsankow N (2007) Tattoos: dermatological complications. Clin Dermatol 25:375–382 13. Engel E, Santarelli F et al (2008) Modern tattoos cause high concentrations of hazardous pigments in skin. Contact Dermatitis 58(4):228–233 14. Steinbrecher I, Hemmer W, Jarisch R (2004) Adverse reaction to de azo dye pigment red in a tattoo. J Dtsch Dermatol Ges 2:1007–1008 15. Greve B, Chytry R, Raulin C (2003) Contact dermatitis from red tattoo pigment (quinacridone) with secondary spread. Contact Dermatitis 49:265–266 16. Jäger C, Jappe U (2005) Contact dermatitis to permanent make up: manifestation of a preexisting nickel allergy. J Dtsch Dermatol Ges 3:527–529 17. Ali SM, Gilliam AC, Brodell RT (2008) Sarcoidosis appearing in a tattoo. J Cutan Med Surg 12(1):43–81 18. Jacob CI (2002) Tattoo-associated dermatoses: a case report and review of the literature. Dermatol Surg 28:962–965 19. Verdich J (1981) Granulomatous reaction in a red tattoo. Acta Derm Veneorol 61:176–177 20. Werchniak AE, Cheng SX, Dhar AD (2004) Sarcoidosis presenting as tattoo changes in a patient undergoing treatment with interferon-alpha and ribavirin. Clin Exp Dermatol 29: 547–548 21. Bachmeyer C, Blum L, Petitjean B et al (2007) Granulomatous tattoo reaction in a patient treated with etanercept. JEADV 21:550–552 22. Wollina U, Gruner M, Schoenlebe J (2008) Granulomatous tattoo reaction and erythema nodosum in a young woman: common cause or coincidence? J Cosmet Dermatol 7:84–88 23. Jolly M, Danilla MI (2007) Tattoo: inflicted vasculitis? J Clin Rheumatol 13:143–147 24. Hermida MD, Otero M, della Giovanna P et al (2007) Cutaneous vasculitis following an intradermal tattoo. JEADV 21:1268–1269 25. Balfour E, Olhoffer I, Leffell D (2003) Massive pseudoepiteliomatous hyperplasia: an unusual reaction to a tattoo. Am J Dermatopathol 25:338–340 26. Kluger N, Durand L et al (2008) Pseudoepitheliomatous epidermal hyperplasia in tattoos: report of three cases. Am J Clin Dermatol 9(5):337–340 27. Mahalingam M, Kim E, Bahwan J (2002) Morphea-like tattoo reaction. Am J Dermatopathol 24:392–395 28. Ashinoff R, Levine VJ, Soter NA (1995) Allergic reactions to tattoo pigment after laser treatment. Dermatol Surg 21: 291–294 29. Anderson RR, Geronimus R, Kilmer SL et al (1993) Cosmetic tattoo ink darkening. A complication of Q-Switched and pulsed-laser treatment. Arch Dermatol 129:1010–1014 30. Jimenez G, Weiss E, Spencer JM (2002) Multiple color changes following laser therapy of cosmetic tattoos. Dermatol Surg 28:177–179 31. De Cuyper C (2008) Permanent make up: indications and complications. Clin Dermatol 26:30–34 32. Kim JW, Lee JW, Won YH et al (2006) Titanium, a major constituent of blue ink, causes resistance to Nd-YAG (1064 nm) laser: results of animal experiments. Acta Derm Venereol 86:110–113 33. Ross EV, Yashar S, Michaud N et al (2001) Tattoo darkening and nonresponse after laser treatment: a possible role for titanium dioxide. Arch Dermatol 137:33–37

M. L. Pérez-Cotapos S. et al. 34. Goldstein N (1979) Complications from tattoos. Special issue on tattoos. J Dermatol Surg Oncol 5:870 35. Handrick W, Nenoff P, Müller H et al (2003) Infections caused by piercing and tattoos – a review. Wien Med Wochenschr 153:194–197 36. Korman TM, Grayson ML, Turnidge JD (1997) Polymicrobial septicaemia with Pseudomonas aeruginosa and Streptococcus pyogenes following traditional tattooing. J Infect 35 (2):203 37. Satchithananda DK, Walsh J, Schofield PM (2000) Bacterial endocarditis following repeated tattooing. Heart 85:11–12 38. Ghorpade A (2003) Lupus vulgaris over a tattoo mark – inoculation tuberculosis. J Eur Acad Dermatol Veneorol 17:569–571 39. Wolf R, Wolf D (2003) A tattooed butterfly as a vector of atypical mycobacteria. J Am Acad Dermatol 48(5 Suppl):73–74 40. Drage L, Philips K, Ecker P et al (2009) An outbreak of Mycobacterium chelonae infections in association with tattoos. J Am Acad Dermatol 60:205 41. Ghorpade A (2002) Inoculation (tattoo) leprosy: a report of 31 cases. J Eur Acad Dermatol Veneorol 16:494–499 42. Colebunders R, Depraetere K, Verstraeten T (1999) Unusual cutaneous lesions in two patients with visceral leishmaniasis and HIV infection. J Am Acad Dermatol 41:847–850 43. Ragland HP, Hubbell C, Stewart KR (1994) Verruca vulgaris inoculated during tattoo placement. Int J Dermatol 33: 796–798 44. Pérez Gala S, Alonso Pérez A, Ríos Buceta L et al (2006) Molluscum contagiosum on a multicoloured tattoo. J Eur Acad Dermatol Veneorol 20(2):221–222 45. Doll DC (1988) Tattooing in prison and HIV infection. Lancet 1:66–67 46. Hayes MO, Harkness GA (1998) Body piercing as a risk factor for viral hepatitis: an integrative research review. Am J Infect Control 29(4):271–274 47. Nishioka S, Gyorkos T, Joseph L et al (2003) Tattooing and transfusion-transmitted diseases in Brazil: a hospital-based cross-sectional matched study. Eur J Epidemiol 18: 441–449 48. Nishioka S, Gyorkos T, Joseph L et al (2002) Tattooing and transfusion-transmitted diseases: the role of the type, number and design of the tattoos, and the conditions in which they were performed. Epidemiol Infect 128:63–71 49. Pugatch D, Mileno M, Rich JD (1998) Possible transmission of human immunodeficiency virus type 1 from body piercing. Clin Infect Dis 26:767–768 50. Alexandridou A, Reginald AY, Stavrou P et al (2002) Candida endophthalmitis after tattooing in an asplenic patient. Arch Ophthalmol 120(4):518–519 51. Onder M, Atahan CA, Oztas P et al (2001) Temporary Henna tattoos in children. Int J Dermatol 40:577–579 52. Parker C, Kaminski G, Hill D (1986) Zygomycosis in a tattoo, caused by Saksenaea vasiformis. Australas J Dermatol 27(3):107–111 53. Keimig E, Jackson D (2009) Psoriatic eruption after placement of a red tattoo: a case report and review of the literature. J Am Acad Dermatol 60:1126 54. Khan IU, Moiemen NS, Firth J (1999) Malignant melanoma disguised by a tattoo. Br J Plast Surg 52:598 55. Birnie AJ, Kulkarni K, Varma S (2006) Basal cell carcinoma arising in a tattoo. Clin Exp Dermatol 31(6):820–821

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56. Goldenberg G, Patel S, Patel MJ et al (2008) Eruptive squamous cell carcinoma, keratoacanthoma type, arising in a multicolor tattoo. J Cutan Pathol 35(1):62–64 57. Kluger N, Phan A, Debarbieux S et al (2008) Skin cancers arising in tattoos: coincidental or not? Dermatology 217: 219–221 58. Paradisi A, Capizzi R, De Simone C et al (2006) Malignant melanoma in a tattoo: case report and review of the literature. Melanoma Res 16(4):375–376 59. Kluger N, Catala D, Thibaut I (2008) Naevus and tattooing: a matter of concern. JEADV 22:767–768 60. Jack CM, Adwani A, Krishnan H (2005) Tattoo pigment in an axillary lymph node simulating metastatic malignant melanoma. Int Semin Surg Oncol 2:28 61. Armiger WG, Caldwell EH (1978) Primary lesion of a nonHodgkin lymphoma occurring in a skin tattoo: case report. Plast Reconstr Surg 62(1):125–127 62. Tope WD, Shellock FG (2002) Magnetic resonance imaging and permanent cosmetics (tattoos): survey of complications and adverse events. J Magn Reson Imaging 15: 180–184 63. Vassold R, Engel E, Koenig B et al (2008) Health risks of tattoo colors. Anal Bioanal Chem 391:9–13 64. Cui Y, Spann AP, Couch LH et al (2004) Photodecomposition of pigment yellow74, a pigment used in tattoo inks. Photochem Photobiol 80:175–184 65. Armstrong ML, Stuppy DJ, Gabriel DC et al (1996) Motivation for tattoo removal. Arch Dermatol 132:412 66. Armstrong ML, Roberts AE, Koch JR et al (2008) Motivation for contemporary tattoo removal: a shift in identity. Arch Dermatol 14:879–884

41 67. Jappe U, Hausen M, Petzoldt D (2001) Erythema-multiformelike eruption and depigmentation following allergic contact dermatitis from a paint-on henna tattoo, due to para-phenylenediamine hypersensitivity. Contact Dermatitis 45:249–250 68. Sidwell RU, Francis ND, Basarab T, Morar N (2008) Vesicular erythema multiforme – like reaction to para-phenyllenediamine in a henna tattoo. Pediatr Dermatol 25(2):201–204 69. Del Boz J, Martin T et al (2008) Temporary localized hypertrichosis after henna pseudotattoo. Pediatr Dermatol 25 (2):274–275 70. Kluger N, Raison-Peyron N, Guillot B (2008) Temporary henna tattoos: sometimes serious side effects. Presse Med 37(7–8):1138–1142 71. Raup P, Hassan JA, Varughese M et al (2001) Henna causes life threatening haemolysis in glucose-6-phosphate dehydrogenase deficiency. Arch Dis Child 85:411–412 72. Benecke M (1999) First report of nonpsychotic self-cannibalism, tongue splitting, and scar patterns (scarification) as an extreme form of cultural body modification in western civilization. Am J Forensic Med Pathol 20:281–285 73. Karamanoukian R, Ukato C, Lee E et al (2006) Aesthetic skin branding: a novel form of body art with adverse clinical sequelae. J Burn care Res 27(1):108–110 74. Bjornberg A (1963) Reactions to light in yellow tattoos from cadmium sulfide. Arch Dermatol 88:267 75. Kazandjieva J, Grozdev I, Tsankov N (2007) Temporary henna tattoos. Clin Dermatol 25:383–387 76. Sperry K (1991) Tattoos and tattooing. Part I: history and methodology. Am J Forensic Med Pathol 12(4):313–319 77. Wagle WA, Smith M (2000) Tattoo-induced skin burn during MR imaging. Am J Roentgenol 174:1795

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Piercings: Techniques and Complications Christa De Cuyper, María Luisa Pérez-Cotapos S. and Laura Cossio

Core Messages

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Body piercing is a popular form of body art, especially among teenagers. Many complications of body piercing result from the disruption of the integrity of the skin. The risk of infection is high when performed in unhygienic conditions. Correct procedures and good aftercare can help to reduce this risk but will not exclude the occurrence of complications. Nickel contact dermatitis is the most frequent complication of body piercing. The European Nickel Directive resulted in manifest reduction of Nickel allergy. However, worldwide regulation is needed. High grade surgical steel is safe, and is the most commonly used piercing material in professional piercing. Health care professionals should be aware of the medical consequences of body piercing, and the implications for medical interventions. Not only the customer, but also the body art practitioner is at risk of acquiring a transfusiontransmitted disease during the procedure.

C. de Cuyper () Department of Dermatology, AZ Sint-Jan, Ruddershove 10, B 8000, Brugge, Belgium e-mail: [email protected]

4.1 Introduction 4.1.1 Historical Aspects (See Chap. 1) Piercing is a popular form of body art since ancient times and has been practised worldwide by various cultures. Ear piercings date back to 2000 b.c. Jewellery, and more in particular, earrings have been recovered from many excavations and tombs. Illustrations in paintings and sculptures often represent a symbol of wealth and nobility. The “Kama Sutra” is an historic source that illustrates the use of genital piercing to increase sexual pleasure. Specific cultural and religion related practises and ritual piercings as a passage to adulthood are performed even today (Fig. 4.1). In 1970s, tattooing and piercing have known a revival among the hippy population, and what was then considered as an expression of rebellion has nowadays

Fig. 4.1 Traditional piercings (courtesy of Dr. Van Renterghem)

C. de Cuyper, M. L. Pérez-Cotapos S. (eds.), Dermatologic Complications with Body Art, DOI: 10.1007/978-3-642-03292-9_4, © Springer-Verlag Berlin Heidelberg 2010

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gained universal popularity and is accepted in all social classes and age groups. Nowadays, the body art industry belongs to one of the fastest growing businesses. The popularity of body piercing has increased over the past decade especially among teenagers [1–3]. There are many reasons why people want to have a piercing. It is trendy and looks cool, and is considered as an aesthetic form of adornment and a fashion statement, or it represents a symbol of a certain community, or gang affiliation. Youngsters prefer piercings as a birthday present, and when refused get a piercing to rattle their parents. In adults, piercing is mainly used to enhance physical attraction and to increase sexual pleasure.

4.2 Technique and Materials 4.2.1 Technique The procedure of piercing consists of perforating the skin, the mucosa and often the underlying cartilage with a sharp tool or a piercing gun followed by the insertion of one or more objects, mostly an ornament or jewel, through the created tunnel. In contemporary piercings, often a temporary stainless steel bar or ring, or a piercing retainer made of inert, biocompatible plastic is used during the healing period. After epithelialisation, an artificial tunnel or fistula is created and the temporary piercing material can easily be removed and replaced by another ornamental one. Pocketing, or embedding is a variant of this procedure, making a hole into the skin or the mucosa and implanting the larger part of the material through the defect into the subcutis. The local injury stimulates fibrous reactions to stabilise the implanted material. The base of the ornament is partially buried and in contrast to piercing it is rather difficult to remove. Subcutaneous implantation and burying of the material is another variant of body modification. Flesh tunnels (tunnelling or gauging) popular in tribal art, result from progressive widening of the opening with insertion pins, tunnels or plugs of increasing diameter or with ornaments with increasing size. The predilection site for tunnelling is the earlobe. (Fig. 4.2) Stapling and corset piercing in a ladder-like distribution is mostly done on the chest or in the genital area, more in particular on the scrotum.

Fig. 4.2 Traditional earlobe tunnelling in a Masai (courtesy of Dr. Van Renterghem)

JewelEye was introduced in the Netherlands as a new fashion trend, in 2004. Tiny, specially developed and patented jewels are implanted under local anaesthesia in the conjunctiva of the eye by ophthalmologic surgeons, using an operating microscope [4]. Healing time can vary from a few weeks for earlobe and labial piercings, to months for perforations of the cartilage and navel piercings [5].

4.2.2 Materials (See Chap. 2) In ethnic and ritual piercings, the tools and materials used are often of natural origin: thorns, wooden pins, ivory, bones and different metals are popular. The procedure is often performed in poor hygienic circumstances resulting in a higher risk for infection. In well-organised tattoo and piercing parlours, experienced, trained persons perform the procedure in

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Fig. 4.3 Sterilisation

conditions corresponding to the local regulations, respecting hygienic conditions and using controlled devices and sterile materials (Fig. 4.3). A large variety of instruments for specific piercing sites and piercing procedures can be ordered on the internet. Instructions for sterilisation, and materials needed to work in optimal conditions are easily available and delivered by a large network of suppliers. The procedure is mostly done without anaesthesia. The use of a local anaesthetic cream can reduce the pain during the procedure. Sterile pins or single use needles reduce the risk of transmitting infection. Local disinfection limits the amount of pathogens on the skin, and instructions for aftercare are usually given to the customers. Chlorhexidine, benzalkoniumchloride and Listerine (antiseptic mouth wash) are popular disinfectants. Although piercing guns are difficult to sterilise, they are still accepted for perforating earlobes, and is a common practise even in high-standard jewellery shops. The use of piercing guns is not recommended for other sites, because they easily cause tissue damage due to blunt trauma (Figs. 4.4 and 4.5). In street side or amateur procedures, hygienic measures are often neglected, unsterile needles and even hairpins are used to perforate the skin. The choice of cheap ornamental materials of dubious origin increases the risk of infections and allergic reactions. The same applies to self-piercing, such as the auto inoculation of safety pins, a popular practise in the rebellious hippy community during the seventies. Most commonly used piercing materials of today are made of gold, silver, platinum, titanium, niobium, precious stones, zirconium, surgical steel and plastic. Polytetrafluorethylene or Teflon (PTFE), an

Fig. 4.4 Piercing gun still used for earlobe piercing

Fig. 4.5 Piercing guns are not recommended

inert thermoplastic polymer with non-stick properties, is suitable for initial piercings, and for piercings taking a long time to heal. Piercing retainers or “sleepers”, made of silicone rubber, acrylic, PTFE or Bioflex plastic, nylon or thick fishing line, can be used to keep the tunnel open. For example, they can replace navel and breast piercings during pregnancy. Specific insertion tapers are developed for nursing mothers to replace nipple piercings during breast feeding. Sleepers are useful to replace labial and oral piercings during anaesthesia, during oral and dental interventions or X-ray procedures (Fig. 4.6). Transparent piercing retainers keep the piercing open while hiding it for important occasions, job interviews, and at schools and colleges where piercings are not allowed. Nowadays, high-grade

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Fig. 4.7 Stainless steel internally treaded piercing material Fig. 4.6 Sleeper/retainer

surgical steel is the most frequently used piercing material and is usually well tolerated. Since the introduction of the European Nickel Directive, a substantial decrease in the nickel content of most metal ornaments sold in Europe has been noted. Limiting the nickel release from piercing materials to 0.2 mg of nickel/cm²/ week, and in jewels and other materials in contact to the skin to 0.5 mg of nickel/cm²/week, results in a major impact on the prevention of nickel contact dermatitis [6, 7]. Materials are available in different types, colours and designs. Common shapes are labret studs, captive bead rings or hoops, banana bells, barbells, circular barbells and spirals. There are two types of bead closures. The captive bead ring or ball closure ring is circular and closed by the pressure present in the ring. To insert or remove the piercing, the hoop can be opened by internal or external pressure, thus widening the ring and loosening the ball. In the second type, the balls can be screwed on and of and replaced by a variety of designs and ornaments. Internally, treaded balls and jewellery reduce the risk of tears in the skin and limit irritation (Fig. 4.7). Many accessories can be bought online, including an amazing variety of ornaments, some UV-reactive, glowing bright in different colours, or glowing in the dark, and “tongue ticklers” made of soft silicone that fit on treaded balls and different types of jewellery. The fantasy and possibilities are endless. Specific terms are used for different types of piercings [5, 8]. Although every part of the body can be pierced for decorative purposes, the ears are still the most

Fig. 4.8 Multiple piercings

commonly pierced sites in all generations, with earlobe piercing starting from very young age. Lip and navel piercings are popular among teenagers. Multiple facial piercings in young adults include the cartilage of the ear, eyebrows and tongue (Fig. 4.8). In adults, more intimate sites are often pierced. Nipple, tongue and genital piercing are associated with increased sexual pleasure.

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A specific terminology is used in the body art world referring to the origin or historic background. A “Prince Albert” piercing is supposedly derived from Queen Victoria’s husband, who is said to have pierced a ring through his penis tip to attach his penis to the right or the left of his uniform trousers [5].

4.3 Legal and Social Aspects (see Chap. 1) 4.3.1 Legislation Being aware of the risks involved in the different procedures of body art, many professionals have developed guidelines and several governments have made efforts for the development of appropriate regulations and legislation. However, these guidelines, as proposed by the Professional Piercers Association and many local authorities are not always respected [9]. In the Netherlands, Worp et al. did a survey on the hygienic conditions and practise of body art and discussed the hygienic legislation of tattooing and piercing in Amsterdam [10]. Concerned about the risks and health effects from tattoos, body piercing and related practises, an expert network was appointed by the European Commission on this subject (see Chap. 2). Several European countries adopted legislation for body art establishments but local authorities still fail to control the implementation. The USA has no uniform regulation for body art procedure. These matters are handled through local laws and jurisdictions. The American Academy of Dermatology approved a position statement on body piercing in 1998 and produced a patient information brochure in 2004 entitled” Tattoos, Body Piercing and Skin Adornments” [11]. However, there is still a lack of worldwide universal regulations for body art materials, and for hygienic standard procedures.

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behaviour, associated with the abuse of toxic substances and delinquency [2, 12].

4.4 Complications of Body Piercing Minor side effects are underreported and often dealt with by the piercers and customers. A lot of information concerning aftercare and (correct and incorrect) treatment of minor complications is available on the internet. Professional piercers, concerned about the health risks of their clients and their own reputation, provide easy accessible information and instructions [9]. The short-term side effects are mostly transient and rarely seen by health care professionals, in contrast to infections. The risk of infections largely depends on the hygienic conditions in which the procedure has been performed and on the site of the body that has been pierced. Long-term complications include disfiguring scars, and contact allergy. Health care professionals should be aware of the medical consequences of piercing and the implications for medical interventions.

4.4.1 Short-Term Side Effects During the procedure, the customer experiences the pain of the puncture. It is obvious that because of the traumatic procedure, bleeding, swelling and inflammation can occur and may persist for some hours to days. Piercing guns tend to crush the tissues, causing a blunt trauma, and therefore, should be avoided. They are accepted only for earlobe piercing. Moreover, these guns are difficult to sterilise. Especially, tongue piercing can be complicated by extensive bleeding causing hypovolemic shock [13] and important swelling resulting in airway obstruction.

4.4.2 Infections 4.3.2 Psycho-Social Aspects Although tattoos and piercing are considered by many, as only a manifestation of identity or a representation of self expression and body decoration, they are regarded by others as an indicator of adolescent risk

Since the epidermal barrier is disrupted, microorganisms can be introduced into the skin, resulting in localised and systemic infection [5, 14–17]. The risk of infection largely depends on the circumstances in which the procedure has been performed. Tribal

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piercings and street side procedures are usually done in poor hygienic conditions, but the same applies to amateur piercings in western world. Most common are bacterial infections caused by Streptococcus pyogenes and Staphylococcus aureus (Fig. 4.9). Chronic irritation and bacterial colonisation can lead to the formation of pyogenic granuloma (Fig. 4.10). Oral piercings can be a source of anaerobes [18]. In the genital area, Gramnegative microbial infections must be considered. Multiple piercings of the ear with earrings through the avascular cartilage implicate a higher risk of infection. In chondritis of the ear, Pseudomonas aeruginosa and Staphylococci are the most common causative organisms. Auricular chondritis and perichondritis can result in cartilage destruction leading to a deformity known as cauliflower ear, requiring complicated reconstructive

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surgery [19]. Nipple piercing may be contraindicated in male and female patients with chest implants [20, 21]. Case reports of unusual infections such as tetanus, [22] leprosy and tuberculosis have appeared in the literature [5, 12, 23, 24]. Ferringer et al. report two cases of atypical mycobacterium infection associated with body piercing, one in a 12-year-old child [25, 26]. Lifethreatening complications of piercing have been documented, including Ludwigs angina, sepsis, pneumonia, glomerulonephritis [27] and toxic shock syndrome [12, 28, 29]. A special group at risk for endocarditis concerns patients with pre-existent heart diseases [12]. Awareness of the risk of endocarditis associated with the practise of body art, among patients with congenital heart disease and recommendation of antibiotic prophylactic cover is discussed by Shebani et al. [30–34]. Relapsing condylomata accuminata due to piercing of the penis have been reported [12]. Blood borne infections, more in particular, Hepatitis B, C, D and G [14, 35, 36] and also HIV can be transmitted [37]. Not only the customer, but also the practitioner is at risk of acquiring a transfusion-transmitted disease. Preventive Hepatitis B and tetanus vaccination is recommended for body art professionals. Blood donation is not accepted by the U.S and Canadian Red Cross from anyone who has had a body piercing or a tattoo within a year. This measure applies also to several European countries.

Fig. 4.9 Bacterial infection in a navel piercing

4.4.3 Long-Term Complications (See Chap. 6)

Fig. 4.10 Pyogenic granuloma

Atrophic scars are common in the lateral nasal ala. Unintentional earlobe splitting and tearing can occur, requiring reconstructive surgery. Hypertrophic scars and keloid formation is observed (Fig. 4.11) predominantly in earlobe piercings, but can be present in any other body area [38]. Predisposed individuals from keloid prone families, and more in particular, dark skinned people can develop extensive keloids. In African rituals, this tendency is used to induce ritual scarring and often associated with piercing and tunnelling practises. Formation of keloid scars is more frequent in earlobes pierced at young ages, and after a second or third piercing. Contact dermatitis mostly due to nickel allergy is a well-known side effect of body piercing and related to

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Fig. 4.11 Keloid

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Fig. 4.13 Argyrosis

Fig. 4.14 Tongue and lip piercing Fig. 4.12 Angiofibroma

nickel containing jewellery. Other compounds in the ornaments or materials used during the procedure, such as disinfectants and rubber gloves, and products used for aftercare containing topical antibiotics can be responsible for allergic reactions. Foreign body reactions, sarcoid-like granuloma, angiofibroma and pseudolymphoma can also be manifestations of unusual allergic reactions (Fig. 4.12) [12, 39]. Accidental implantation of silver into the skin can be considered as a traumatic tattoo and can cause a localised argyrosis (Fig. 4.13).

4.4.4 Other Complications Specific site related complications have been reported, ea gingival and dental damage due to tongue en lip

piercing [40–45]. Piercing migration and embedding can lead to surgical intervention. Piercings of the oral cavity can interfere with medical procedures in emergency situations needing intubation (Fig. 4.14). Health care professionals, particularly in emergency, surgery and dental units, should be familiar with the removal of oral and labial piercings to prevent accidental swallowing or aspiration. Genital piercings often require a healing time of several weeks to months, with an increased risk of infection during the healing period. Traumatism can cause genital and urethral injuries resulting in scarring and strictures. Infertility as a consequence of ascending infection has been reported in men and women [12]. Genital piercings can be responsible for condom rupture during sexual intercourse. Urethral strictures caused by genital piercings can hinder the insertion of an urethral catheter.

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Piercings and implants in general can interfere with diagnostic and therapeutic medical procedures. Imaging (ultrasound, radiology, Magnetic Resonance Imaging) can be disturbed by the overlying material. The presence of nipple and thoracic piercings can be responsible for burns during defibrillation. Electrical burns can also occur if metal containing piercings or jewellery are not removed before electro cauterisation. It is recommended to document the piercings in the medical file and to discuss these risks with the patient. If applicable to the situation, it is advised to obtain the patients’ informed consent before removal of the piercings. The use of plastic sleepers offers a good solution in certain conditions [12]. Nipple and navel piercings can cause some discomfort and irritation during pregnancy because of tissue expansion. Retainers made of flexible material can be used as replacement. Genital piercings should be removed before delivery to prevent traumatism of the perineum and the baby during birth. During the nursing period, care should be taken to avoid damaging the babies mouth, and aspiration or swallowing of the piercing, and strict hygiene should be applied to reduce the risk of mastitis. Specific insertion tapers are developed for nursing mothers to replace nipple piercings during breast feeding. Nipple piercing complications that have been reported are hyperprolactinemia, granulomatous mastitis due to mycobacterium infection and breast implant infection [5, 46].

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infection. In localised bacterial infection, frequent rinsing with mild soap or an antiseptic, and application of an antibiotic ointment will mostly be sufficient. The piercing itself can be rinsed and replaced to avoid closure of the opening. Whenever the symptoms of infection are not under control with local measures, systemic antibiotic therapy should be considered, and all foreign materials should be removed. In any individual, where there is a suspicion of transmission of an infectious disease such as tuberculosis or leprosy, a biopsy for histology and microbiology is advised, followed by appropriate measures. Blood-borne infections can be ruled out by serology testing [47].

4.5.3 Allergy Since contact dermatitis is nearly always caused by nickel allergy, only metal piercings made from high grade stainless steel or inert material should be used. Responsible or suspected material must be removed. The use of topical steroids is helpful to reduce itching and inflammation. Secondary impetiginisation can require antiseptic or antibiotic therapy. In granulomatous or sarcoid-like allergic reactions, intralesional steroids can offer a solution (see Chap. 6).

4.5.4 Other complications 4.5 Therapy 4.5.1 General Considerations All the procedures should be performed in hygienic conditions, with sterile equipment and by trained people. Minor local side effects such as pain, bleeding and swelling can be minimised or avoided by experienced piercers. Painkillers containing acetyl salicylic acid should be avoided to reduce the risk of bleeding. Cooling of the pierced area can reduce pain and swelling.

In hypertrophic scars and keloids, infiltration with steroids can be considered, as surgery for keloids has a high risk for relapse. Skin tears, disfiguring scars and stretched earlobes can require complicated reconstructive surgery (Fig. 4.15).

4.5.2 Infections The use of local antiseptics, sterile materials and good aftercare instructions will reduce the risk of wound

Fig. 4.15 Stretching of the earlobe requiring reconstructive surgery

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Specific site related complications require an appropriate approach. Dental complications are dealt with by dentists, while genital and urologic problems should be referred to the gynaecologist or urologist, respectively.

4.6 Conclusion With the increasing popularity of body piercing, health care professionals should be aware of the potential risks of body-modifying procedures and be able to recognise and handle complications in order to avoid irreparable consequences. More in particular young adolescents represent a vulnerable group of customers. Risks of the procedure are bleeding, swelling, local infection and contact allergy. Blood borne diseases can be transmitted (hepatitis B, C, HIV), granuloma and keloid formation can occur. Lip and tongue piercings can damage the gums and teeth. Uniform regulation and guidelines to minimise complications are needed. Although many governments and responsible body art practitioners have realised excellent guidelines, there is still a lack of universal regulation.

References 1. Ferguson H (1999) Body piercing. BMJ 319:1627–1629 2. Laumann AE, Derick AJ (2006) Tattoos and body piercing in the United States: a national data set. J Am Acad Dermatol 55:413–421 3. Panconesi E (2007) Body piercing: psychological and dermatologic aspects. Clin Dermatol 25:412–416 4. Armstrong ML, Koch JR, Saunders JC et al (2007) The hole picture: risks, decision making, purpose, regulations, and the future of body piercing. Clin Dermatol 25:398–406 5. Stirn A (2003) Body Piercing: medical consequences and psychological motivations. Review. Lancet 361:1205–1215 6. Lidén C, Norberg K (2005) Nickel on the Swedish market. Follow-up after implementation of the nickel directive. Contact Dermatitis 52:29–35 7. www.teg.co.uk/nickel/94-27-EC.html. Accessed 19 May 2009 8. Waugh M (2007) Body piercing: where and how. Clin Dermatol 25:407–411 9. The Association of Professional Piercers website. www. safepiercing.org/index.html. Accessed on 12 May 2009 10. Worp J, Boonstra A, Coutinho RA et al (2006) Tattooing, permanent makeup and piercing in Amsterdam; guidelines, legislation and monitoring. Euro Surveill 11:1–6 11. http://www.aad.org/members/publications/pamphlets.html. Accessed 19 May 2009

51 12. Kaatz M (2001) A trend and its complications: piercing. Kosmetische Medizin 24:188–193 13. Hardee PS, Mallya LR, Hutchinson IL (2000) Tongue piercing resulting in hypotensive collapse. Br Dent J 24:57–58 14. Alter MJ (1999) Hepatitis C virus infection in the United States. J Hepatol 31(Suppl 1):88–91 15. Antoszewski B, Jedrzejczak M, Kruk-Jeromin J (2007) Complication of body piercing in patient suffering from type 1 diabetes mellitus. Int J Dermatol 46:1250–1252 16. Handrick W, Nenoff P, Müller H et al (2003) Infections caused by piercing and tattoos – a review. Wien Med Wochenschr 153:194 17. Tweeten SS, Rickman LS (1998) Infectious complications of body piercing. Clin Infect Dis 265:735–740 18. Brook I (2001) Recovery of anaerobic bacteria from 3 patients with infection at a pierced body site. Clin Infect Dis 33:e12 19. Rowshan HH, Keith K, Baur D et al (2008) Pseudomonas aeruginosa Infection of the auricular cartilage caused by high ear piercing: a case report and review of the literature. J Oral Maxillofac surg 66:543–546 20. Javaid M, Shibu M (1999) Breast implant infection following nipple piercing. Br J Plast Surg 52:676–677 21. de Kleer N, Cohen M, Semple J et al (2001) Nipple piercing may be contraindicated in male patients with breast implants. Ann Plast Surg 47:188–190 22. O’Malley CD, Smith N, Braun R et al (1998) Tetanus associated with body piercing. Clin Infect Dis 26:735–740 23. Kaur C, Sarkar R, Kanwar AJ (2003) How safe is nosepiercing? Inoculation cutaneous tuberculosis revisited. Int J Dermatol 42:645–646 24. Trupiano JK, Sebek BA, Goldfarb J et al (2001) Mastitis due to Mycobacterium abscessus after body piercing. Clin Infect Dis 33:131–134 25. Ferringer T, Pride H, Tyler W (2008) Body piercing complicated by atypical mycobacterial infections. Pediatric Dermatol 25:219–222 26. Meltzer D (2008) Commentary-complications of body piercing. Pediatric Dermatol 25:283–284 27. Ahmed-Jushuf IH, Selby PL, Brownjohn AM (1984) Acute post-streptococcal glomerulonephritis following ear piercing. Postgrad Med J 60:73–74 28. Bader MS, Hamodat M, Hutchinson J (2007) A fatal case of Staphylococcus aureus: associated toxic shock syndrome following nipple piercing. Scand J Infect Dis 39:741–743 29. McCarthy VP, Peoples WM (1988) Toxic shock syndrome after ear piercing. Pediatr Infect Dis J 7:741–742 30. Dänhert I, Schneider P, Handrick W (2004) Piercing and tattoos in patients with congenital heart disease – is it a problem? Z Kardiol 93:618–623 31. Hill C (2004) Comment on: antibiotic prophylaxis, body piercing and infective endocarditis. J Antimicrob Chemother 54:278 32. Millar BC, Moore JE (2004) Antibiotic prophylaxis, body piercing and infective endocarditis. J Antimicrob Chemother 53:123–126 33. Ochsenfahrt C, Friedl R, Hannekum A et al (2001) Endocarditis after nipple piercing in a patient with a bicuspid aortic valve. Ann Thorac Surg 71(4):1365–1366 34. Shebani S, Miles HFJ, Simons P et al (2007) Awareness of the risk of endocarditis associated with tattooing and body

52 piercing among patients with congenital heart disease and pediatric cardiologists in the United Kingdom. Arch Dis Child 92:1013–1014 35. Hayes MO, Harkness GA (2001) Body piercing as a risk factor for viral hepatitis: an integrative research review. Am J Infect Control 29(4):271–274 36. de Man RA, Bosman A, Stevens-Schretzmeijer M et al (1999) Two patients with acute hepatitis B from the same piercing salon. Ned Tijdschr Geeneskd 1143:2129–2130 37. Pugatch D, Mileno M, Rich JD (1998) Possible transmission of human immunodeficiency virus type 1 from body piercing. Clin Infect Dis 26:767–768 38. Neiburger E (2006) A large hypertrophic-keloid lesion associated with tongue piercing: case report. Gen Dent 54:46–47 39. Casper C, Groth W, Hunzelmann N (2004) Sarcoidal-type allergic contact granuloma: a rare complication of ear piercing. Am J Dermatopathol 26:59–62 40. Dhir S, Dhir AK (2007) Intraoperative loss of nasal jewellery: anesthetic concerns and airway management. J Clin Anesth 19:378–380

C. de Cuyper et al. 41. Kapferer I, Hienz S, Ulm C (2008) Labial piercing and localized periodontal destruction-partial periodontal regeneration following periodontal debridement and free gingival graft. Dental Traumatol 24:112–114 42. Levin L, Zadik Y (2007) Oral piercing: complications and side effect. (Review article). Am J Dentistry 20: 340–344 43. Lopez-Jornet P, Gomez Garcia F (2008) Retained lips stud: complication of labial piercing. J Eur Acad Dermatol 22:770–771 44. Lopez-Jornet P, Navarro-Guardiola C, Camacho-Alonso F (2006) Oral and facial piercings: a case series and review of the literature. Int J Dermatol 45:805–809 45. Perkins CS, Meisner J, Harrison JM (1997) A complication of tongue piercing. Br Dent J 182:147–148 46. Modest GA, Fangman JJW (2002) Nipple piercing and hyperprolactinemia. N Engl J Med 347:1626–1627 47. Centers for disease control and prevention. www.cdc.gov/ ncidod/diseases/hepatitis/c/index.html. Accessed on 12 May 2009

5

Cosmetic and Medical Applications of Tattooing Christa De Cuyper

Core Messages

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Although cosmetic tattooing is a common and popular procedure and usually well-tolerated, complications can occur, including infections and allergic reactions. One of the problems lies in the lack of uniform legislation worldwide, and the lack of control of the production of the substances used. In Permanent Make-Up (PMU), the most common complications and patient dissatisfaction result from misapplication of the pigment, pigment migration, and pigment fanning. In these cases, the best cosmetic results can be achieved by using lasers, but even these techniques have their pitfalls. Dermatography is a modified tattooing technique used to camouflage pathologic skin conditions for scar correction, and as an adjunct to reconstructive surgery. It can also be used for the implantation of pharmacological substances in specific therapeutic indications. Correct information about the risks and a procedure performed by a well-trained professional can minimize complications and dissatisfaction. This applies to the procedure of tattooing as well as to all tattoo-removal techniques. Tattoos can be used for medical indications, more in particular, for field marking in radiation oncology and endoscopy

5.1 Introduction Tattoos are a form of body art that has been practiced throughout history by various culture. Facial cosmetic tattoos date back to ancient Egypt [1, 2]. The introduction of eyelid tattooing in 1984 [3] was the start of cosmetic tattoos. In the last decades, blepharopigmentation, eyebrow tattoos, and lip-lining simulating make-up have become very popular. There are historic arguments that in ancient times tattooing was also performed for medical purposes. The small parallel tattoo lines located over the lumbar spine and the articulations of the lower legs in the well-preserved “man of Hauslabjoch” correlate with radiographic confirmed osteoarthrosis of these joints, and could be related to a prehistoric form of acupuncture [4]. Since the nineteenth century, several reports illustrate the medical applications of tattooing for camouflage of vascular birthmarks [5] and scars in ocular [6–8] and reconstructive surgery [9]. Endoscopic tattooing in gastroenterological procedures [10, 11] and “black dot” tattooing to demarcate the field and patient positioning in radiation oncology are common medical practices [12, 13]. Intralesional application of drugs using a tattoo technique has been described for the treatment of viral warts and hypertrophic scars [9].

5.2 Technique and Materials 5.2.1 Technique

C. de Cuyper Department of Dermatology, AZ Sint-Jan, Ruddershove 10, 8000, Brugge, Belgium e-mail: [email protected]

The technique of cosmetic tattooing, also called micropigmentation, basically consists of placement of tiny droplets of tattoo ink into the superficial layer of

C. de Cuyper, M. L. Pérez-Cotapos S. (eds.), Dermatologic Complications with Body Art, DOI: 10.1007/978-3-642-03292-9_5, © Springer-Verlag Berlin Heidelberg 2010

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the dermis using a traditional tattoo device or a smaller tattoo pen with an oscillating, preferentially disposable, needle. A variety of devices is available depending on the indications and applications. [14] The procedure is very popular nowadays because it is mainly done for cosmetic purposes; it is mostly performed by an experienced beautician with advanced training. While the education of a traditional tattooist is usually provided by established practitioners and learned through practice, cosmetic tattooing is rather an extension to the basic education of a beautician, who is aware of the requirements of appropriate hygiene and good knowledge of the anatomy of the face. The level of implantation of the pigment in cosmetic tattooing is located at the epidermal–dermal junction or in the dermal pars papillare and much more superficial than in conventional permanent decorative tattoos, where the pigment can be found in the mid-dermis. The more superficial application of the pigment will result in the gradual elimination and a spontaneous fading of PMU within a few years in contrast to the permanent character of dermal tattoos. Before starting the procedure, the area is cleaned and disinfected. The performer wears clean gloves during the procedure. (Fig. 5.1) The application of a local anesthetic cream can make the procedure less uncomfortable. For after care, Vaseline or an antibiotic ointment is mostly used. To prevent contamination, preferentially single-use ink caps are advised, and registration of the colors used can be helpful for later corrections and identification in case of an allergic reaction.

Fig. 5.1 Technique of PMU

C. de Cuyper

The technique of dermatography, a variant of micropigmentation, was introduced in 1984 by van der Velden based on the classic Japanese tattooing techniques [9] and performed by means of a modified tattooing device (a van der Velden Derma injector), consisting of a electromagnetic motor driving a needle holder up and down in a stainless-steel tube. On the needle holder, a bundle of needles is attached; the number and arrangement of the needles, as well as the speed and angle of penetration of the skin is adapted depending on the specific application. The technique requires special training, and the procedure needs several sessions usually with one-month interval. A large variety of standard colors can be used and mixed until complete matching of the surrounding skin color is obtained. When the colors are applied in an open pattern, the natural tanning process is preserved. In this application, the natural translucence of the underlying skin is also partially preserved and enhances the natural result. When required, a complete covering of the underlying skin can also be obtained. Immediately after the procedure of tattooing, usually a thin layer of Vaseline is applied on the treated area. Elimination of pigment can occur in the first days of healing. After a healing phase of 2–3 weeks, the remaining pigment particles are stably stored in the dermal macrophages and fibroblasts. A natural fading of about 10% must be expected over the next few years.

5.2.2 Materials (See Chap. 2) In the procedure of tattooing in general, the nature of the material used and the level of implantation influence the quality and stability of the result. Pigments are insoluble in water and most organic solvents. Dyes in contrast are soluble in water and solvents. In principle, pigments reside permanently and unchanged in the skin, whereas dyes more frequently used in PMU fade. Colors and shades are custom-blended to match the clients’ favorite make-up. (Fig. 5.2) The inks used in tattoos and PMU, and the pigments and dyes used in these inks are classified as cosmetics and color additives, which are inert materials. These materials are subject to FDA regulation; however, the FDA does not control the actual practice of tattooing nor the tattoo inks, and many of the ingredients used are not approved for skin contact. A large range of products can easily be bought on the Internet. In Europe, an attempt has

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5.3 Indications

Fig. 5.2 Materials used in Dermatography

been made by the Council of Europe to regulate the materials according to the standard requirements for food and cosmetics with a recent extension of Resolution ResAP(2008)1 on requirements and criteria for the safety of tattoos and PMU (superseding Resolution ResAP(2003)2 [15]. However, in general, still many materials used for tattooing are not approved for injection or implantation into the skin. Nevertheless, most of the performers do not know the composition of the inks they use, and many individuals unaware of this fact choose to undergo tattooing in its various forms. In dermatography, as proposed by van der Velden, the color pigments are obtained from pharmaceutical suppliers and contain ferri- and ferro-oxide, ferrohydroxide, titaniumdioxide, tartrazine, and carbon. The inks are prepared with alcohol and distilled water to create a set of standard colors with different intensity and can be mixed to obtain a sliding color spectrum. [9] For medical purposes, mostly India ink is used. To assure accurate and reproducible positioning of the patient for oncological irradiation, the skin is marked with a set of “black dots” using a sterile needle dipped in India ink [12, 13]. Endoscopic tattooing is a common technique to mark lesions before surgery and enables subsequent endoscopic follow-up. India ink or a sterile suspension of very fine carbon particles [10] can be used. Drugs can be introduced intralesionally with high precision and exact dosage using a dermatography device as described by van der Velden for the treatment of viral warts with bleomycin and hypertrophic scars with triamcinolon [9, 16, 17]. For tattoo removal, pentamonogalloylglucose is applied with a separate dermatography technique [18].

Advertisements use the advantages of PMU, such as being “waterproof,” make-up that does not smear during sporting and swimming, timesaving “wake up with make-up,” always fresh and permanent. Some people choose this procedure because they have physical problems, such as visual impairment or arthrosis of the hands, the neck, and shoulders, to apply regular, temporary make-up. Eyeliner or blepharopigmentation, lip liner and eyebrow coloring are very popular and nowadays well accepted in all social classes. When applied by an experienced technician, PMU can be more natural and realistic in appearance than conventional make-up. The PMU also offers a solution in patients with allergies to conventional cosmetics. Corneal reconstruction was introduced in ophthalmologic surgery. [6–8, 14] For others, cosmetic tattooing and dermatography are an adjunct to and considered as the finishing touch of reconstructive surgery. [9] Nipple-areola complex (NAC) reconstruction is common after breast reduction or breast-cancer surgery [19, 20]. (Figs. 5.3 and 5.4) This technique can also be used to camouflage traumatic scars, vascular birthmarks, vitiligo, and alopecia. Dermatography has been successfully used over more than 20 years by now for correcting a large spectrum of skin deformities, discolorations and pigmentary changes, and for scar corrections. It is a valuable adjunctive tool in plastic, cosmetic, and maxillofacial surgery. Other therapeutic indications, using pharmacological substances are recalcitrant viral warts, hypertrophic scars, and tattoo

Fig. 5.3 Technique of Dermatography

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Fig. 5.4 Nipple reconstruction after surgery. Spontaneous fading can be expected within the next months

Table 5.1 Indications for cosmetic and medical tattoos Cosmetic indications Medical indications Alternative for conventional make-up Eye liner Lip liner Eyebrows

Camouflage for Scars (accidental and surgical) Nipple reconstruction (NAC) Birthmarks Alopecia/vitiligo

Everyone but in particular Patients with allergy for conventional make-up Disabled persons (arthrosis) Vision impairment Hay fever Contact lenses

Other medical indications Tattoo removal Endoscopy Corneal reconstruction (ophthalmology) Radiation oncology Chemotherapy of viral warts Hypertrophic scars

removal. [9, 16, 17, 18] Medical applications of tattooing include field demarcation for radiation oncology and endoscopy [10–13]. Tattoos in general may play an important role in forensic medicine, and they can simplify identification [21] (Table 5.1).

5.4 Risks and Complications (See also Chaps. 2 and 6) 5.4.1 Short-Term Complications The procedure can be quite uncomfortable in sensitive areas such as the lips and eyelids. Less pain and little or no bleeding occurs when the procedure is performed

Fig. 5.5 Minimal bleeding during the procedure

by an experienced practitioner (Fig. 5.5). Swelling and crusting can be present for a few days, so it is often a “Friday procedure.”

5.4.2 Infection Bacterial infection is rare when the procedure is performed in correct hygienic conditions. The advice for the use of a local antiseptic or antibiotic for a few days after the procedure is quite common. However, unsterile equipment and needles can transmit all types of infections, including herpes simplex and blood-borne diseases such as hepatitis and HIV. Even if needles are sterilized or disposable, the electric part of the tattoo pen is not designed to be sterilized. A sterile plastic cover bag is used by many practitioners.

5.4.3 Long-Term Complications The pigments and dyes used in PMU inks are relatively inert and usually well tolerated. Allergic reactions are rare; when they occur, they may be particularly troublesome because the pigments can be hard to remove (see Chap. 6). Especially red inks, containing mercury, can cause lichenoid reactions [22, 23]. Fortunately, heavy metals are no longer used in tattoo inks nowadays. Contact dermatitis to other ingredients and additives or to the materials used during and after the procedure such as topical antibiotics can occur. Granulomatous

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allergic reactions [24], sunlight-induced reactions [25], foreign body epitheloid granulomas [26], pseudoepitheliomatous hyperplasia [27], and sarcoidosis [28] have been reported.

5.4.4 Other Complications In general, the procedure causes little discomfort and complications are rare, although adverse events such as eyelid necrosis, loss of eyelashes and secondary cicatricial ectropion, hypertrophic scars and keloids have been reported. To reduce the risk of ocular injury, protective eye shields can be used during the procedure [29]. The risk of herpes simplex reactivation and Koebner effect in patients with a preexisting skin disease such as psoriasis must be considered. Swelling or burning experienced in the affected areas has been reported in people with tattoos and PMU, when undergoing Magnetic Resonance Imaging (MRI). It appears only rarely and without lasting effect [30, 31] in a lowfield strength procedure. In high-field strength (>2 T) MRI scan, a crackling sound was reported by Ratnapalan [30], when a tattooed arm entered the magnetic field. The pigment may also interfere with the quality of the image, in particular, in the eye area. This side effect is not a contraindication for the procedure. An informed radiologist can take the appropriate measures to ensure the best results [32]. The most common complications and patient dissatisfaction results from misapplication of the pigment, pigment migration, and pigment fanning. (Figs. 5.6– 5.9)[33] In this situation, the advantage of being

Fig. 5.7 Fanning of the pigment (eye)

Fig. 5.8 Unhappy about the shape of the lipliner

Fig. 5.9 Irregular distribution of the pigment

Fig. 5.6 Misapplication of PMU ink

permanent is probably the greatest disadvantage. Whatever their reason for deciding to get PMU, clients should be informed about the risks of the procedure and the side effects that can occur. The major risk for complications is having the procedure performed by an inexperienced person (Table 5.2).

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Table 5.2 Complications Immediate reactions Bleeding (minutes – 1 h) Crusting (2–3 days) Swelling (2–5 days) Infections Localized Bacterial Viral (herpes simplex) Systemic (blood-borne diseases) Hepatitis HIV

Other reactions Hypertrophic scars / keloids Sarcoidosis Loss of eyelashes Eyelid necrosis Ectropion MRI complications

Allergic reactions Allergic contact dermatitis Lichenoid reaction Granuloma

Dissatisfaction Unnatural aspect Color Shape Fading Fanning Distorsion

tones, which seldom gives satisfactory cosmetic results because skin-toned pigments tend to look unnatural because they lack the skins’ natural translucence; moreover, dark underlying colors are difficult to hide. (Fig. 5.10) Tretinoin has been used in the removal of eyeliner tattoo.[34]. Nonspecific removal techniques such as surgery and dermabrasion are available, but have a high incidence of scarring, textural, and pigmentary changes. Dermatography with penta-monogalloylglucose has been used for tattoo removal by van der Velden [18]. The best cosmetic results can be achieved by using Q-switched pigment lasers, but even this technique has its pitfalls. Dark, black-based colors fade quite easily after laser treatment. Flesh tones and red tattoos, however, containing titanium dioxide and ferric oxide may show immediate darkening when treated with shortpulse lasers. This is probably caused by an oxidation– reduction reaction. Red–brown colored ferric oxide (Fe2O3) changes into black colored ferrous oxide (FeO)

5.5 Treatment of Complications (See Chap. 7) Medical complications are rare and specific case-related measures can be taken. Localized bacterial infection requires antiseptic or antibiotic treatment to avoid scarring. Allergic manifestations can be treated with topical, intralesional, or systemic corticosteroids [24]. Medical advice is sought mostly because of dissatisfaction by people who want their tattoos to be removed. Objectionable tattoos can be camouflaged with conventional make-up and concealers. With time, most cosmetic tattoos fade spontaneously. Some people attempt to cover unwanted tattoos with a new one with flesh

Fig. 5.11 Dissatisfaction about the color and shape of the eyebrow PMU

Fig. 5.10 Unnatural aspect of skin-tone tattoo camouflage

Fig. 5.12 After treatment with Nd-Yag 532 laser

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the production of the substances used. Correct information about the risks and a procedure performed by a well-trained professional can minimize complications and dissatisfaction. Acknowledgment Darline Vierstraete, the Color Studio, Waregem, Belgium

References Fig. 5.13 Darkening after treatment with Nd-Yag 532 laser

Fig. 5.14 Final result with complete clearing after treatment with Nd-Yag 1064 laser

[35–38] (Figs. 5.11–5.14). In our experience, when this paradoxical darkening occurs, the dark color can in most cases be removed by consequently using another appropriate wavelength [35, 37, 39]. However, because the result is unpredictable, we advise performing a test in a small area before treating the complete tattoo. Pulsed CO2 laser has been used successfully in the treatment of lip-liner tattoo [40]. In a case of refractory lip-liner darkening after Q-switched laser treatment] [39], treatment with CO2-laser also offered a solution.

5.6 Conclusions Although cosmetic tattooing is a common and popular procedure and is usually well tolerated, complications can occur. One of the problems lies in the lack of uniform legislation worldwide and the lack of control of

1. Scheinfeld N (2007) Tattoos and religion. Clin Dermatol 25:362-6 2. Sperry K (1991) Tattoos and tattooing. Part I: History and methodology. Am J Forensic Med Pathol 12:313–319 3. Angres G (1984) Eyeliner implants: a new cosmetic procedure. Plast Reconstr Surg 73:833–836 4. van der Velden EM, den Dulk LD, Leenders H et al (1995) The decorated body of the man from Hauslabjoch. Preliminary results. In: Höpfel F, Platzer W, Spindler K (eds) Der Mann im Eis Band II. Springer, Berlin, pp 275–278 5. Brown JB, Cannon B, Mc Dowell A (1946) Permanent pigment injection of capillary hemangiomata. Plast Reconstr Surg 1:106–107 6. van der Velden EM, Sanderubun Kok JHC (1994) Dermatography as a modern treatment for coloring leucoma corneae. Cornea 13:349–353 7. von Wecker L (1872) Das Taetowiren der Hornhaut. Arch Augenheilkunde 2:84–87 8. Ziegler SL (1922) Multicolor tattooing of the cornea. Trans Am Ophthalmol Soc 20:71–87 9. van der Velden EM, Defrancq J, IJsselmuiden OE et al (2001) Review: dermatography: a review of 15 years of clinical applications in surgery. Int J Cosm Surgery Aest Dermatol 3:151–159 10. Askin MP, Waye JD, Fiedler L et al (2002) Tattoo of colonic neoplasms in 113 patients with a new sterile carbon compound. Gastrointest Endosc 56:339–342 11. Sauntry JP, Knudtson KP (1958) A technique for marking the mucosa of the gastrointestinal tract after polypectomy. Cancer 11:607–610 12. Baluyot ST, Shumrick DA (1972) Pre-irradiation tattooing. Arch Otolaryngol 96:151–153 13. Washington C, Leaver D (1996) Principles and practice of radiation therapy: introduction to radiation therapy. Mosby, St Louis 14. Vassileva S, Hristakieva E (2007) Medical applications of tattooing. Clinics Dermatol 25:367–374 15. Council of Europe (2008) https://wcd.coe.int/ViewDoc.jsp? Ref=ResAP(2008)1&Language=lanEnglish&Ver=original &Site=COE&BackColorInternet=DBDCF2&BackColorInt ranet=FDC864&BackColorLogged=FDC864. Accessed 19 May 2009 16. van der Velden EM, Jairath D, Kock JH et al (1984) Dermatografie als behandelingsmethode in verschillende medische disciplines. Ned Tijdschr Dermatol Venerol 4: 11–214

60 17. van der Velden EM, de Jong B, van der Walle HB (1993) Tattooing and its medical aspects. Int J Dermatol 32:381–384 18. van der Velden EM, Oostrom CAM, Roddi R et al (1995) Dermatography with penta-monogalloylglucose as a new treatment for removal of color pigments in the eyebrows. Am J Cosmetic Surg 12:3–9 19. Farhadi J, Maksvytyte GK, Schaefer DJ et al (2006) reconstruction of the nipple-areola complex: an update. J Plast Reconstr Aesthet Surg 59:40–53 20. Velden EM, Drost BHIM (2000) Dermatography: 10 years of applications as adjuvant treatment after nipple and areola reconstruction. Am J Cosmetic Surg 17:23–26 21. Mallon WK, Russel MA (1999) Clincal and forensic significance of tattoos? Top Emerg Med 21:21–29 22. Duke D, Urioste SS, Dover JS et al (1998) A reaction to a red lip cosmetic tattoo. J am Acad Dermatol 39:488–490 23. Taafe A, Knight A, Marks R (1978) Lichenoid tattoo hypersensitivity. Br Med J 1:616–618 24. Turnbull K, Steinkruas V, Boer A (2008) Kontactallergie auf permanent-make up der Lippe. Kosmetische Medizin 29: 206–207 25. Jaeger C, Hartschuh W, Jappe U (2005) Sunlight-induced granulomatous reaction to permanent lip liner. Hautarzt 56: 63–65 26. Yang DS, Kim SC, Lee S et al (1989) Foreign body epitheloid granuloma after cosmetic eyebrow tattooing. Cutis 43: 244–247 27. Coors EA, Wessbecher R, Driesh VD (2004) Beastly nodules instead of beauty: pseudoepitheliomatous hyperplasia developing after application of permanent make-up. Br J Dermatol 150:1027 28. Yesudian PD, Azurdia RM (2004) Scar sarcoidosis following tattooing of the lips treated with mepacrine. Clin Exp Dermatol 29:552–553

C. de Cuyper 29. Konuk O, Evereklioglu C, Handur A et al (2004) Protective eyeshield can prevent corneal trauma during micropigmentation for permanent eyeliner. J Eur Acad Dermatol 18: 642–643 30. Ratnapalan S, Greenberg M, Armstrong D (2004) Tattoos and MRI. 183:541 31. Wagle WA, Smith M (2000) tattoo-induced skin burn during MR imaging. Am J Roentgenol 174:1795 32. Tope WD, Shellock FG (2002) Magnetic resonance imaging and permanent cosmetics (tattoos): survey of complications and adverse events. J Magn Reson Imaging 15:180–184 33. Lee IW, Ahn SK, Choi EH et al (2001) Complications of eyelash and eyebrow tattooing: reports of 2 cases of pigment fanning. Cutis 68:53–55 34. Chiang JK, Barsky S, Bronson DM (1999) Tretinoin in the removal of eyeliner tattoo. J am Acad Dermatol 40: 999–1001 35. Anderson RR, Geronimus R, Kilmer SL et al (1993) Cosmetic tattoo ink darkening. A complication of Q-Switched and pulsed-laser treatment. Arch Dermatol 129:1010–1014 36. Chang SE, Kim KJ, Choi JH et al (2002) Areolar cometic tattoo ink darkening: a complication of alexandrite laser. Dermatol Surg 28:95–96 37. De Cuyper C (2008) Permanent makeup: indications and complications. Clin Dermatol 26:30–34 38. Jimenez G, Weiss E, Spencer JM (2002) Multiple color changes following laser therapy of cosmetic tattoos. J Dermatol Surg 28:177–179 39. Fitzpatrick RE, Lupton JR (2000) Successful treatment of treatment resistant laser-induced pigment darkening of a cosmetic tattoo. Lasers Surg Med 27:358–361 40. Mafong EA, Kauvar AN, Geronimus RG (2003) Surgical pearl: removal of cosmetic lip-liner tattoo with the pulsed carbon dioxide laser. J Am Acad Dermatol 48:271–272

6

Allergic Reaction to Pigments and Metals Body Art from the Allergist’s Point of View Werner Aberer , Johan E. Snauwaert, and Ulf-Maria Render

Core Messages

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Complications after piercing are frequent. About every sixth person who has received a new piercing will suffer from health disturbances on the site of the piercing. Nickel allergy is still the most common cause of contact allergy in Europe and the predominant reason for allergic reactions to piercings. Tattoo colors consist of (inorganic) pigments and (mostly organic) dyes, or both. Allergic reactions have been observed in the form of Type I, III, and IV reactions, according to Coombs and Gell classification. The most problematic colors are red and black. Tattoo reactions are not infrequent, occurring at an estimated incidence of over 150/100,000 new tattoos. Steroids, laser therapy, and excision are the backbone of treatment for allergic reactions to tattoos and permanent make-up. Laser treatment itself may evoke additional reactions. No person with atopic history or immunologic disorders should acquire a tattoo, nor should children and adolescents. Temporary tattoos, presented as “henna” painton motives, often contain illegally high amounts of paraphenylenediamine (PPD). Allergic reactions to PPD are not rare and frequently cause

W. Aberer () Department of Dermatology and Environmental Dermatology, Medical University of Graz, Auenbruggerplatz 8, 8010, Graz, Austria e-mail: [email protected]

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persisting pigmentation disorders; transferable picture tattoos must be rated alike. Health education for parents of especially younger children is urgently needed. Tattoo stickers cause little problems with respect to allergy, but can irritate the skin due to occlusion.

6.1 Introduction Piercing and tattooing as some of the very definite and long-lasting ways of realization of modern body art can claim to have a long tradition [1]. In history, piercings have repeatedly served to indicate social status, positive character traits, or maturity of those who wore it [1]. The earliest documented use dates back to the antique Egyptian empires. Whereas the renaissance of tattoos as an expression of body adornment had its onset in Europe as late as in the fin de siècle of the late nineteenth century, the oldest finding of a well-preserved human body apparently carried as many as 15 tattoos. Presumably, this has to be regarded as a medical procedure, today unknown in its purpose, yet known as a principle 5000 years ago [1]. In current times, piercing procedures and tattooing are very popular forms of body art among the European population. Medical and therapeutic applications of tattooing such as marking for oncologic purposes and dermatography used for scar correction are common techniques nowadays. A survey of Europe’s biggest country in terms of numbers of inhabitants, Germany, revealed tattoos in 11.1% of the population and at least 6.7 % to have undergone piercing procedures [2]. A nonrepresentative spot review by the authors,

C. de Cuyper, M. L. Pérez-Cotapos S. (eds.), Dermatologic Complications with Body Art, DOI: 10.1007/978-3-642-03292-9_6, © Springer-Verlag Berlin Heidelberg 2010

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analyzed the presence of magazines on piercings and tattoos in a modern kiosk in a shopping mall in the second largest city of Austria. With good access to the highways and public traffic routes to downtown areas, the mall traditionally supplies to customers of both sexes, all ages, social classes, and nationalities. No less than five different magazines on piercings and tattoos, priced between 3.00€ and 5.50€ were found (as in January 2009), thus reflecting an actual and vivid interest in a complex of themes arranged around what had originally to be reintroduced to Europe through the ports and sea routes during the nineteenth century. According to actual advertisement, the manufacturer is offering a professional tattooing-pistol equipped with easily alterable single use needles for less than 300.00€. This is illustrative of the widespread availability of the tattoo as a product and – more important – also the means and ways how to produce it. The fascination of temporary tattoos and stable cosmetic modifications like permanent make-up (PMU) seems to affect more and more people, too. Given the numbers quoted above and realizing that, except for temporary tattoos, these techniques have to be regarded as invasive, as they penetrate the intact skin, no expert should be astonished, that allergic reactions to the materials used in piercing or in tattoos gain a rising importance for dermatologists all over the continent (Fig. 6.1).

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6.2 Piercing 6.2.1 Overview The term “body art” originally describes the further development of the so-called Behavior Art, a branch of modern art that achieved its peak in the 1960s and 1970s. It aimed at revealing what is technically known as “traumatic narcissism”, which meant that processes of violation of one’s own body were shown and sometimes presented in short film sequences [3]. This is of interest for the clinically engaged dermatologist, since piercing, as an element of today’s interpretation of body art is nothing but a traumatic procedure in the kind of a penetration of the body with a sharp instrument. Although for many people wearing a piercing, the moment of insertion may be the most unwanted part of it all, the penetration itself is inevitable. Frequently, this phase of the procedure gives rise to the problems the dermatologist is confronted with later on: the opening of the barrier of epidermis and cutis against the environment and the slow process of reepithelialization in the immediate presence of foreign material bear the risk of inflammation and also expose the body to an allergen that it might not react to in the case of normal surface contact.

6.2.2 Symptoms and Diagnosis

Fig. 6.1 Tattoo displaying a certain Omit: Tattoo displaying a certain attitude – an example of body art apt to allude to the content of the words of the term; a Janus head

Local complications after the insertion of a piercing are astonishingly frequent. A German survey found that about every sixth person who has received a new piercing suffers from health disturbances on the site of the piercing [4]. To the allergist, the wide popularization of piercing means that symptoms of metal allergy become an increasingly familiar sight. The dominance of nickel allergy and the early onset, especially in the female population has been stressed already in the 1980s [5]. Swelling, itching, tenderness, and erythema may be the precursors of what can quickly turn into a full-scale manifestation of metal allergy. Discontinuously spreading red maculopapulous efflorescences arranged around the insertion site of the piercing is seen later on. Cases of granuloma

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formation as a special form of hypersensitivity reaction have been reported as induced by palladium [6], titanium–aluminum–vanadium, nickel–palladium–platinum, and gold alloys. The clinical impression and patch testing for nickel, gold and a standard series for metal allergy normally provide for a diagnosis.

6.2.3 Epidemiology and Literature There is general agreement that the main cause of nickel sensitization in females is piercing of ears [7]. Among women allergic to nickel, as many as 95% have pierced ear lobes. Piercing at an early age seems to increase the risk of acquiring nickel sensitivity. It is not the piercing agent, but the nickel earrings used frequently after piercing that usually are the cause of allergy. Environmental factors seem to play an important role: the surrounding area of the penetration in the ear lobe is closed and humid when the rings are left in the ear lobes, and irritant reactions often develop especially after hair washing. The shampoo that remains may cause irritant contact dermatitis, which then can promote nickel sensitization [8]. The cosmetic benefit seems to outdo the ear-lobe eczema for many users, but the resultant life-long nickel allergy may have important and nasty consequences in daily life and at the workplace (Fig. 6.2 and 6.3). Nickel produces more cases of allergic contact dermatitis than all the other metals combined. In spite of full implementation of the EU Nickel Directive in 2001, nickel allergy is still the most common cause of contact allergy in Europe [9], but the prevalence is decreasing – in contrast to the United States, where no such directive exists [10]. (See Chap. materials) Gold salts, such as gold chloride, are a strong sensitizer in humans [8]. Metallic gold in jewelry can readily produce allergic dermatitis. Again, such as in piercing with nickel releasing products, sweat, saliva, pressure, and friction may be required to produce an allergic reaction from a metallic gold object. It has been pointed out before that even the use of pure gold earrings following ear piercing is not safe [11]. In 2004, an author’s group from Sri Lanka, capable of analyzing different ways of wearing gold jewelry because of ethnic rites unknown in Europe, had

Fig. 6.2 Ear lobe eczema, 2 days after removing nickel releasing jewellery because of eczema. CD-Nickel-Schmuck

Fig. 6.3 Original jewellery, reacting positive in the dimethylglyoxime test – indicating nickel release

presented a study on problems in plastic surgery apparently related to gold allergy. [12] In a thorough analysis of 25 patients and 67 persons in control groups, they showed that splitting of the earlobe at sites where piercing for (gold) jewelry was done cannot be explained by the constant mechanic stress originating from more or less heavy golden rings worn in the ears. They found that patients showing local symptoms of contact allergy and inflammatory tissue changes had histories compatible with an ongoing allergic process in 84% of the study group consulting for split ear lobes, while in the control

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group of people wearing rings with up to 12-fold weight due to tribal habits, no allergic symptoms were reported and no splitting of the earlobe had occurred. The authors themselves presume that other metallic components used to provide for mechanical properties in the jewelry might play a role; nevertheless, the hypothesis that coinciding factors like permanent pressure catalyze or lead to the manifestation of metal allergy is bolstered up by these findings. Incidentally, gold dermatitis tends to be persistent, sometimes lasting for several months, even though there is no further contact with gold; the dermatitis may also become papular. Metallic silver in jewelry does not cause dermatitis. Titanium, even when containing other metals such as aluminum and vanadium should be safe, even in nickel allergic patients. Stainless steel, despite containing up to 26% chromium, or as much as 37% nickel and other potentially sensitizing metals such as cobalt and palladium, seems to be of no harm even for Ni- or Cr-sensitized persons since all metals are locked in the final product in a crystalline lattice. Thus, allergy due to piercing seems to be almost exclusively “a nickel problem”. It is meanwhile convincingly shown that there is a strong correlation between ear piercing and nickel sensitization in young women and men [13] and that the number of body piercings has positive bearing on the incidence of metal allergy in men [14]. A recent American study on prevalence of body piercing and tattoos was able to mirror these findings. Allergy to jewelry consisting of metals was found in 12% of participants who had no piercing, in 25% of those who had soft ear lobe piercing only, in 29% of those who had 1–3 piercings (soft ear lobe piercing not counted), and in 39% of participants who had four or more piercings. The differences between the subgroups were statistically significant [15].

6.2.4 Therapy and Recommendations Whenever local problems arise, of course, the piercing has to be replaced immediately. If the allergic reaction affects an extended area and the patient should suffer from strong pruritus, antihistaminic substances may be added to local steroid application for a short period of time orally even if contact allergy is a type IV reaction, and not primarily histamine-mediated. As granuloma

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formation as a special form of hypersensitivity reaction has been reported (see above), intralesional application of steroids can additionally become necessary. Advice must be given that a sensitization implies problems with products containing nickel or other agents of metal allergy, respectively. Nevertheless, it should be noticed that a nickel sensitiztion that has taken place in the ear lobes or the abdominal skin does not necessarily mean the consequent developing of for example, hand eczema when contacting solid material: as Langerhans cells are much less present in the palmae but do play a key role in the pathogenesis of contact dermatitis [16], a manifestation on this site is rather unlikely. Yet, patients should be told to avoid future piercing application on other sites of the body, because preferred locations for piercing like facial area and the navel region are to be regarded as susceptive tissue. If piercing is done, ears – and all other parts of the body – should be pierced exclusively with stainless steel devices. For at least 3 weeks, the supposed time span needed until the pierced opening is completely epithelialized, preferentially stainless steel articles should be left in the holes. Nowadays, as an alternative, plastic spacers that are supposed to be rather inert are often left in the perforation for the time of epithelialization, especially when piercing is done in the nose [1]. So far, data concerning complications caused by these devices have not been presented. The problems surrounding piercing of the ear lobes are well-known. Implications of oral, non-ear lobe facial piercing, and piercing of other sites like navel piercing or genital piercing have so far not been in the center of interest, although there are aspects exceeding the health of the pierced individual subject: 23% of all pierced participants in the US data set on prevalence of body art reported medical problems [15], outdoing even the high rate of complications found by a German author’s group as mentioned above [4], revealing just over 17.2%. Even the most problematic site of insertion in the US study, the navel, is consistent with European literature findings [1]. Therefore, one has to recognize that piercing, a “fashionable injury of the unscathed body” as it has been put in 2000 by a group of oral surgeons confronted with the technique and its adverse effects [4], goes along with known and, as we are being referred more and more consistent data from different countries, calculable health damages. Metal allergy and sensitization toward nickel as a disadvantage in certain occupational situations are a relevant part.

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In the dermatologists’ perspective, this is an argument to decide against the conception of piercing as a harmless variety of body art. The techniques of piercing have been referred to as “mutilating practices” in a recent Spanish source [17]. But, even those who consider this term to be exaggerated should be reminded that “piercings cause […] considerable expense to the public health service” [4]. Especially in times when numerous discussions about the capacity of healthcare systems in Europe are ongoing, this cannot be ignored. Thus, it is inevitable to note that the questionable decision of an individual is turned into the obligation of the society to cope with the unwanted, but not unknown adverse effects of this body-modifying technique.

6.2.5 Clinical Example: Granulomatous Contact Dermatitis to Piercing of Earlobes The first report on this peculiar sarcoidal tissue reaction to piercing with gold earrings dates from 1983 [18], and was later followed by reports of this granulomatous reaction again to gold earrings [19] and to palladium body-piercing ornaments [20]. A similar granulomatous reaction has been reported to a titanium-containing pacemaker [21], after blepharopigmentation with aluminum–silicate [22] and to aluminum in other tattoos [23]. After piercing the earlobes, most of the patients develop papulonodular lesions at the helices. Typically, these lesions are extremely therapyresistant even when the causative piercing has been removed. Intralesional injections with steroids produce only a temporary regression. In the literature, one author’s group treated the lesions with electron-beam [24]. Remarkably, when these patients are patch-tested, they develop a similar granulomatous reaction on the positive patch test site. The following case of a 56-year-old woman was presented for the first time in 2006 [25]. The patient consulted our practice, complaining of itchy nodules at the helices of both ears, located exactly at the sites where she had worn earrings with a small clasp. Clinically, she presented with blue–red papulonodules suggestive of scar sarcoidosis. Histopathological examination of one of the lesions revealed a reaction of the allergic contact-granuloma type: a dense

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inflammatory infiltrate consisting of lymphocytes and histiocytes, some multinucleate histiocytes, as well as small granulomas consisting of epithelioid histiocytes. Patch testing with the standard series and palladium chloride 2% pet. (Chemotechnique, Tygelsö, Sweden) indeed revealed allergic reactions to nickel and palladium (++ at day 2 and 4). Three weeks later, the patient consulted again because of severe itching and infiltration of both the nickel and particularly the palladium patch test site, from which a biopsy was taken. The histopathological examination of the palladium positive test site again revealed a similar picture, that is, a granulomatous reaction of the allergic contact-granuloma type: a dense inflammatory infiltrate consisting of lymphocytes and histiocytes, several foci of epitheloid and giant histiocytes, as well as small granulomas consisting of epitheloid histiocytes surrounded by a dense lymphocytic infiltrate, were found. No necrosis or spongiotic vesicles could be observed. Staining for fungi and acid-fast bacilli were negative. No foreign material could be detected. A chemical analysis of the earrings with Scanning electron Microscope (SEM) and Energy dispersive X-ray analysis system (EDX), Philips SEM-XL30FEG revealed the presence of nickel and copper. Palladium could not be detected in the analyzed portions of the earrings. The lesions were repeatedly infiltrated with corticosteroid injections, that is, Kenacort A® (BristolMyers Squibb; 10 mg/ml, 0.05 mL per session), with only temporary improvement, followed by recurrence of the itching nodules. Electron-beam therapy at a dose of 20 Gy as published in the literature was considered too dangerous by the radiotherapist. At this rather low dose, a delayed sarcomatous degeneration could not be excluded. Up until now, 5 years after diagnosis, the nodules are still present but do not cause itch anymore, so the patient requests no further treatment. The very strong and late reaction to the patch test can be regarded as something remarkable in this case. But, the supposed inconsistence of the findings of chemical and X-ray analysis on the one hand and the patch test results on the other hand should not give cause for confusion: it is not unusual to find additional allergic reactions to other materials not involved in the actual triggering process, too, and sometimes patch testing can also yield false positive results, yet today it remains the gold standard for testing (Figs. 6.4–6.8).

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Fig. 6.4 Papulo-nodulous alterations, slightly encrusted, located exactly where earrings had been worn

Fig. 6.7 Biopsy from a nodule on the ear lobe: in superficial and deeper dermis epitheloid granulomatous infiltrate with zones of fibrinoid necrosis

Fig. 6.5 Positive patch test reaction to nickel in a patient who suffered from an allergic reaction to jewellry

6.3 Tattoos 6.3.1 Overview

Fig. 6.6 Positive patch test reaction to palladium in a patient who suffered from an allergic reaction to jewellry

A tattoo can be defined as an intradermal or epidermal structured formation of colorant, willingly applied and arranged to evoke the optic impression of a subject (of any kind and purpose) in, or on the outer (usually for cosmetic reasons in a wider sense), or inner (as a technique used for certain needs in medicine) surface of a living being. The frequently used term “traumatic tattoo”, referring to the violent and unwanted embedding of gravel, dust, or powder of explosive devices into the skin, could, to our perception, be misleading, as it describes a rather unexpected injury of the skin implying contamination, where immediate removal of the ”pigment” is sought by the person concerned.

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When any incompatibility or allergic reaction to a tattoo occurs, the actual antigen should be identified among different possibly process-triggering substances. Thus, it is clear that colorants used for tattooing, being the main ingredient of the substance brought into the skin (apart from glycerin as a carrier), have been object of a dermatologist’s interest and, this way, object to various attempts of analysis and classification. Tattoo pigments were traditionally based on different metal salts: “Black” being made of carbon, iron oxide, and logwood (that may contain dichromate); “Blue”: cobaltous aluminate; “Brown”: ferric oxide; “Green”: chromium oxide, chromium sesquioxides, hydrous chromium oxide, copper salts mixed with azo dyes; “Red”: cadmium selenide, cinnabar, sienna; “Violet”: manganese violet; “White”: zinc oxide, titanium oxide; “Yellow”: cadmium sulphide. Fig. 6.8 Biopsy from palladium patch test: small granulomas in superficial and deep dermis, in some areas localised around adnexae

Tattoos appear in the form of so-called permanent tattoos which, histologically, are to be found in the middle layers of the cutis; second, they are seen in the sort of temporary tattoos that are placed epidermally; and third, in the form of cosmetic tattoos also known as PMU, which is brought into the border-zone between the basal lamina of the epidermis and the stratum papillare to provide for a longer-lasting effect than a more superficial placing would provide for but avoid the irreversibility of true permanent tattoos [1]. Tattoo stickers are not meant to infiltrate the skin with colorants and, as they do not belong to the above-defined group of body modifying devices, will be dealt with later. For reasons concerning the pathogenic agent and the different mechanism of application, temporary tattoos are discussed apart from permanent ones, as are permanent make-up, the latter for reasons of clarity only. In this chapter, the term “tattoo” is used synonymous for “permanent tattoo” when no other specification is added.

In the past years, it appears that heavy metals, that were the backbone of tattooing for decades, were replaced by (organic) colorants that may be attributed to the chemical class of insoluble azoics, oxidation colors, phthalogens, disperse dyes, and others that can be obtained from several suppliers. The number of marketed colorants is enormous, their qualities of purity variable (and the impurities undefined) and the regulations are inadequate although substantial efforts have been made by many governments and the European community. Neither the cosmetic nor food or medical product regulations offer a perfect solution although they are being applied, with regard to tattoo dyes. This has been a problem in the past and will continue to be problematic in the future. From the allergist’s point of view, within the group of mineral pigments iron oxides, titanium-based colors and many others may be harmless regarding the allergic potential, but heavy metals based on mercury, chromium, and others still seem to exert problems (see below). Cadmium chloride may be phototoxic rather than a sensitizer, yet yellow colored parts of a tattoo have repeatedly been reported to be involved in incompatibility reactions [26, 27]. Natural pigments, such as colorants from trees, flowers, and roots seem to be unproblematic; moreover,

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everything “natural” is supposed to be good for the consumer. However, there have been reports of allergy to, for example, curcumin [28] in the literature. Concerning organic colorants, no conclusion can be made as of now, as they were slowly introduced approximately over the last two decades, and traditional material may still be in use, especially in nonprofessional tattooing. It has to be noted, that even new colorants supposed to be free of metal salts yet do contain mineral components to a note-worthy degree, able to evoke allergic reactions even without the participation of other parts of the formula [29].

6.3.2 Symptoms and Diagnosis Symptoms indicating an allergic reaction to a tattoo can vary but according to our experience and a literature review of case reports published from 1996 to 2007 consist of a more or less simple pattern. The most common signal perceived by the patient seems to be the itching of a circumscriptive area of the skin, normally identical with the site of the tattoo, sometimes exceeding it either in the form of manifestation within older tattoos that were asymptomatic so far or in the kind of a generalized pruritus [26, 29–44]. Among 17 reviewed reports (18 patients), we found only one erythematous eruption of papular lesions unaccompanied by itching in a patient treated with Etanercept for ankylosing spondylitis [31], three patients with generalized cutaneous lesions that were pruringinous [36, 38, 43], and one case of total ulceration of the skin without information about former symptoms [44]; all other patients claimed to suffer from itching only within the tattoo-related area. Other additional complaints are commonly described as burning, sometimes as a stinging pain or simply an uncomfortable feeling in the region of the tattoo. Induration (4 of 18) or thickening or swelling (5 of 18) of the skin seems to be even more frequent than pain (Figs. 6.9–6.12). Among the efflorescences seen in allergic reactions toward tattoos, erythema should be the most frequent clinical manifestation (explicitly registered in 7 of 18). It can often be hidden by the colors of the tattoo, especially in red parts of it, what may be of relevance, as red still tends to be the most important color with respect to emerging trouble after the acquisition

Fig. 6.9 Irritant reactions (?) with erythema, papules and pruritus in the tattoo and the surroundings; patch tests with a battery of metals negative.

of a tattoo (see next). Red or purplish macules alone are less common than papules or papulovesicels (8 of 18), predominantly on erythematous ground, sometimes erupting on other nontattooed parts of the body. When authors use the term “rash” (4 in 18 described), macular and papular forms can be seen alike. Two cases of flaky or scaling skin alterations [33, 34], both in red tattoos, were reported. Incrustations of vesicular lesions have been registered but seem to be rather a rare phenomenon, too [42, 43], as the patient will consult the doctor in an earlier stage of the pathology. The delay between the tattooing procedure and the onset of the first problems or symptoms is known to vary between hours and several years [42]. By studying the literature, we found an overall impression suggesting a span of some weeks to be most common. It should be noticed that this is a rather academic aspect, as we cannot sense a correlation between delay of onset of symptoms and the extent or vehemence of the reaction. The histological appearance of an allergic or an incompatibility reaction toward tattoos is everything but uniform: dermal alterations appear in the form of

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Fig. 6.10 (a, b) Granulomatous reactions due to the red colour of the tattoos

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Fig. 6.11 Allergic reaction to red pigment

Fig. 6.12 Pseudolymphoma in the red area of a tattoo on the breast of a young lady

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lichenoid, granulomatous, or sarcoid changes. In some cases, cell infiltrates can be dense enough to pretend a cutaneous lymphoma; these pseudolymphomas can be found as well as the histological picture of sarcoidosis, becoming manifest in a tattooed area. Less frequent, epidermal alterations like acanthosis or spongiosis can be seen [39]. Over the last decades, a focusing on type IV reactions (according to the classification of Coombs and Gell) as the underlying principle of allergies toward tattoos can be sensed in the literature. It should be reminded, that urticaria as an exponent of type I reactions can also be observed among tattoo reactions. Type III reactions are less common but should be considered, due to their often very impressing symptoms. Table 6.1 shows a systematic approach to tattoo reactions trying to cover allergic and nonallergic mechanisms alike. Despite great effort to come closer to the mechanisms of tattoo allergy over the years, one has to accept that things remain unclear -not only often in the individual clinical case but also sometimes concerning even the theoretical fundaments. Until today, it is not completely explained how tattoo removal by laser therapy works [1], and we could not even find an answer to the question, if pigment brought into the skin lies there exclusively extracellularly when in nonpathogenic

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Table 6.1 Classification of allergic and non-allergic reactions to tattoos Pathomechanism Appearance Coombs and Gell type I Coombs and Gell type IV

Urticaria Erythema multiforme Contact eczema/dermatitis

Coombs and Gell type III

Systemic contact dermatitis Leucocytoclastic vasculitis

Koebner phenonemon

Sarcoidosis

Pseudolymphomatic reaction Malign degeneration/ transformation Photoinduction Unknown

Mimicking cutaneous lymphoma B Cell-lymphoma

Remark

na

Recognisable by immediate onset

– – 11

Typical appearance often modified by tattoo colour’s own shade Rare, but relevant : patients in reduced status Unknown whether triggering function or unmasking function only

Sarcoidosis

Discussed as maximum long term result

Unknown whether triggering function or unmasking function only

1 1 – 1 – – –

Sarcoid Any transitory reaction exceeding pure erythema

1 Not decidable whether allergic mechanisms – involved or not, as often no doctor is consulted. Others e.g., drug-induced reaction 3 Note that it may be extremely difficult to derive the correct diagnosis from the histology and the symptoms even when a complete case history is known a n = number of patients found in our review of case reports, containing a total of 18 patients. The sorting followed authors’ own interpretation. If no interpretation was given, efflorescences and time span till onset of symptoms were used for determining the most probable diagnosis

condition or partly intra- and extracellularly, or if this could be a function of the colorant used. The latter could also be the case as some molecules of the complex formulas may have a better tendency to become absorbed into the cells of the dermis than others – even within the same formula. Thus, it becomes understandable why it can be extremely difficult to make the right diagnosis even when presented with a patient’s full history, a clearly described and observed set of symptoms, a histology of the engaged site, and, in some cases, maybe even a safety data sheet of the applied color. If a patient develops contact eczema, granulomatous reactions, or sarcoid reactions in the area of a certain colorant, allergy is frequently suspected to be the cause. But, some cases of sarcoidosis with the development of granulomatous lesions within tattoos have been reported as well as granulomatous and lichenoid tattoo reactions [35, 39, 40, 42]. Urticaria and erythema multiforme can occur immediately after application of the tattoo. Pseudolymphomas within tattoos may appear after years [39, 42], and, last, but not least, even malign neoplasms as B-cell lymphoma may

develop out of a tattoo. Mechanism and causal relationship between these reactions and the tattoo procedure and ingredients remain obscure. Therefore, and also in an attempt to pay tribute to nonallergic responses to a tattoo that manifest under the appearance of an allergic reaction, we suggest the term Tattoo-Induced Immunologic Reaction (TIIR) as an umbrella term. It may be helpful in cases where a patient’s history suggests a generally enhanced reagibility of the body, as it may be the case with rheumatism, Morbus Crohn, colitis ulcerosa, lupus erythematodes, and other diseases associated with disturbances of the modulation of the immune system. Moreover, it covers in situations when testing completely fails to provide a precise diagnosis based on the agent, but an allergy is very likely. The latter case belongs to the allergist’s standard experience in working with tattoos and their unpleasant implications. The immense number of pigments and dyes available and used for these purposes is sharply contrasted by the small number of correctly diagnosed allergies against these products, as a correct diagnosis is almost impossible since the ingredient of a

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tattoo, causing the problem, is usually unknown to the consumer and the doctor. Many of the dyes may have an allergic potential due to their chemical structure, but specific information is not available. Concerning pigments, literature data is scarce, although one deliberate analysis of colors has been performed [45], showing great variation of composition even in similar colors. Even if all pigments in use had been clearly analyzed, the problem would still exceed the frame of known data about coloring agents. For application and for mixing the colors (not done by the producer, but in the tattooist’s studio), pigments and organic colorants alike need a carrier that, by itself, is able to induce problems: in many formulas glycerin has been used; this substance, for example, is known to cause granulomas due to its chemical properties [1]. This way, one could be completely misled blaming only the colorant parts of the formula when problems within a tattoo arise. Moreover, even if a single substance is available for testing and suspected to be the allergic agent, optimal test concentrations are not defined, which is another problem of practical relevance. Today, as in the past, testing is usually done with metal salts such as mercury, chromate, and others. The patch test results are frequently negative, most probably because nowadays, other (unknown) ingredients from the group of organic colorants are used, and in such a case, the verification of allergic sensitization to tattoos by patch testing may be especially difficult due to the poor penetration of the applied azo dyes into the skin [46]. Therefore, intradermal testing is sometimes recommended as being more sensitive, but it should be mentioned that this technique bears the risk of long-lasting reactions. Because an excision of the area where a positive result becomes manifest may be necessary afterward, the authors do not argue in favor of this rather invasive testing method. Newer findings in the literature confront us with the fading away of the hope that tattoo-ingredient passports referring to the colorants applied by tattooists could at least bring an end to the allergists’ insecurity about the ingredients used. In 2002, an Italian author’s group reported a case of eruption of pruriginous papules in a red tattoo, emerging a few weeks after the patient had acquired the tattoo [29]. As the patient was able to deliver a full safety data sheet of the applied colors, testing was oriented from the list of ingredients

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of the color that even had a specific producer code. Patch testing revealed no specific reaction whatsoever to the putative causative allergens as listed to be components of the color. Instead, the patient showed a positive reaction to nickel, having had no history of nickel allergy. Yet, nickel was not listed on the safety data sheet that primarily appeared to provide for full information about the ingredients. A spectroscopic analysis of the original color (that was unlike in many other cases available) showed nickel to be one of the ingredients among other (declared) parts of the color. Its concentration was, according to the author’s assessment, high enough to elicit an allergic reaction. This impressively shows that testing for suspected allergic reactions can be frustrating, even given the case the patient does have a tattoo-ingredient passport, because substances inserted into the skin do not have to be the substances declared, and original material does not fulfill the criteria (especially concerning purity) of well-defined test substances. The use of the term “TIIR” as a diagnosis may therefore fulfill the needs of a working hypothesis necessary to start a treatment expected by the patient and also let open the direction the diagnostic path may take in challenging cases.

6.3.3 Epidemiology and Literature Allergic and incompatibility reactions have for a long time been classified as a rather infrequent phenomenon. Many articles and case reports of the last 10 years have opened up stating that adverse, especially immunologic reactions to tattoos are a rare sight [26, 30, 41]. Indeed, this view is no longer shared by all. Authors are still aware of the problem that a well-structured statistic approach to allergies and unexpected (noninfectious) reactions toward tattooing does not exist. But, even without a correct incidence, defined as a number of manifesting cases in a certain group within a period of time (thus prerequisiting the number of all freshly acquired tattoos, which is unknown), the general perception among professionals seems to have shifted to a point where the increasing number of problems induced by tattooing becomes remarkable [8, 29, 32, 35, 36, 38–40, 43]. To our knowledge, only one attempt to estimate the incidence of adverse reactions to tattooing has been made so far. In 1999, an Australian group of authors

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Table 6.2 Distribution of colours as causative agents for allergic reactions according to 17 case reports Coloura Onset delayb Scale of recoveryc ne Red Red in combination Black Black in combination Blue

7 4 5 4 1

Immediately – 8 years Immediately – 1 year 11 days – 8 months 1 week – 1 year

Full – complete skin ulceration Alleviation – recurring rashes Full – only partly relief Alleviation – recurring rashes

Blue in combination 3 Immediately – 1 year Recurring rashesd Yellow – In combination 1 Immediately Not reported Purple – In combination 1 1 year Not reported a Colours as named by the authors b Time span between tattoo application and onset of clinical symptoms leading to consultation, as referred by the authors c Range between best results and worst outcome, described in the terms used by the authors. Some authors did not report on treatment and results [32, 37, 39] d For one case of blue pigment use and two cases of green pigment use outcome was not reported, so that recurring rashes as worst result in one patient with blue and green pigment alike in his tattoo are listed. This could mislead to the conclusion (optically derived from the table) that this was one of the most frequent residual symptoms after therapy e Numbers indicate how often a colour was found to evoke a reaction or be involved in a reaction to several colours (“in combination”) when authors were unable to differentiate further, in a total of 18 patients in 17 reports. Note that numbers will not add up to 18 as different colours were present in five tattoos

who used black tattooing as a medically needed procedure for marking the field of application in radiotherapy for neoplastic diseases, had counted the number of patients who had received a marker tattoo and put it in proportion to the cases of symptomatic incompatibility or allergic reactions [41]. They found just one reaction in 1968-treated patients, analyzing a period of 5 years, but failed to convey this into a generally usable conclusion, as the confidence interval was too broad even for their numbers. Nevertheless, this work seems to be the only approach to the problem that is based on controllable figures, as the data were gained from cases of well-documented hospitalized patients, so that a total number of all tattooed persons is known and all cases have been registered. If one in every 1968 persons tattooed with black pigment as in the aforementioned analysis develops an allergic reaction, this should mean an incidence of approximately 51 in 100,000 tattooed persons – not a number to be referred to as negligible. As allergy is more likely to develop when abetting factors like a lack of hygiene, unprofessional insertion technique, and maybe mechanic stress of the site of the tattoo are added, in a set of conditions to be found outside the hospital, the number will tend to be even higher. Moreover, allergic reactions toward red tattoos are

known to be more frequent than toward other colors including black. This is reflected by our own findings in a literature review of 17 case reports (see Table 6.2). On studying the literature, we have not found a precise relationship of frequency between the colors that induce disturbances. Therefore, we can only estimate the number of symptoms-evoking red-colorant-containing tattoos as about twice the number of cases where black is the causative color. That would amount to an estimated incidence of more than 100 in 100,000 new (red) tattoos, and thus nullify the historically grown perception of tattoo allergy as a rare phenomenon. If all colors would be added, one could find a number of more than 150/100,000. Yet, it must be emphasized that our calculations are merely an auxiliary construction to bridge the gap between the need for numbers and the actual impossibility to carry out a survey that will lead to representative results. Another view of safety of tattoo colors seems to have been in need of correction. Until now, black was believed to be among the least problem-bearing colors [42], and was sometimes listed last of all [26, 32, 39]. Due to our review, black is second only to red in terms of evoking reactions. It even rivals red in multicolor tattoos, where the allergic reaction cannot be attributed

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Allergic Reaction to Pigments and Metals

to one color. This is important, as black is being used in medical procedures like intraluminal marking of mucosa for subsequent surgery [47] or, as in the aforementioned publication, for radiotherapy [41]. In many centers, India ink is used for these purposes [48], meaning that a clearly defined and rather well-known substance is deployed. Yet, in 1998 an allergic reaction to India ink was reported [35], thus shaking experts’ faith that severe reactions to black tattoos could be seen as reactions to pigment consisting of soot, contaminated carbon, iron oxide, and logwood only. It could be supposed that many more reactions to medical tattooing would erupt, if patients undergoing medical tattooing were not so frequently treated with systemic steroids for their underlying diseases and sometimes to prevent the side effects of radiotherapy – once again a question impossible to answer by a classic study approach in the form of a clinical trial. To round off the insight into the problematic nature of allergy research on tattoos, it should be mentioned that even in the era of safety data sheets for tattoo colors, the dermatologist is still unable to determine the actual ingredients of the substance used for another reason than declaration of mistakes or insufficiencies. In tattooists’ studios, the colors are frequently mixed to realize a certain shade. This, combined with the necessarily added matrix substance as referred to earlier (glycerin and other unknown carriers that might be not exclusively chemically inert) can easily produce new molecules within the mixed liquid, thereafter brought into the skin. The carrier substance that is apparently needed to enhance the plasticity of the colorant seems to be an individual recipe of every studio or tattooist [1], rendering reflections on the real components of the finally inserted tattoo color nearly impossible. This would finally lead to the conclusion that the adverse effects of tattooing can only be prevented, but not reliably treated and cured. Indeed, with persisting rashes harassing the patient even after the complete excision of the tattoo [36], the dermatologist has to face the fact, that, strictly speaking, only avoidance could solve the problems of tattoo-related health problems for sure. This, again, would make broad, officially supported health educational campaigns necessary. But, even if this was an effective way to establish caution among the population, one has to mention that it is questionable if the intended group could be reached, as especially persons who are known to be rather weak in terms of compliance acquire tattoos quite often [15].

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6.3.4 Therapy and Recommendations Treatment of allergy or intolerance reactions to tattoos depends on the type of reaction and the severity and urgency. Options may be divided into two different groups: Measures for immediate treatment of the allergic reaction, and means for complete removal of the tattoo, if necessary.

6.3.4.1 Immediate Treatment of the Allergic Reaction a) Topical steroids: Eczematous reactions may primarily be treated using topical steroids. Their single use may be sufficient, but a combination with at least one other modality could probably enhance the result (see below). b) Systemic steroids: (Rare) immediate-type reactions can be treated with systemic steroids and antihistamines. Enduring inflammatory changes and pruritus in rather resistant type IV reactions is sometimes an indication for a combination of topical and systemic steroids. c) Systemic or topical steroids and antibiotics: Whenever an impetiginization of primary lesions is suspected, or a leucocytoclastic vasculitis as a representative of type III reactions occurs, and rather high doses of systemic steroids are considered to be necessary, antibiotic treatment added to the primarily suitable measures can help to avoid super infection of the altered skin and antagonize the adverse effects on the immune system. Clindamycine and clarithromycine have been named by authors, but selection of the substance should be orientated from the actual annual resistance report available at most clinics. d) Intralesional steroids: Regarding granulomas or other persistent reactions, application of intralesional steroids may be helpful. e) Antihistamines: Antihistaminic substances should, strictly speaking, be used only in type I reactions as the pathogenic way leads to effects via mast-cell degranulation. Despite that, we found one case, where authors decided to add

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antihistamines to topical steroids in a nonimmediate, but strongly pruritic condition, obtaining good relief – it cannot easily be decided whether steroids alone would have done as well. We can identify no pharmacomechanism for the deployment, although strong itching of the lesion may sometimes challenge the clinician.

IV or type III reaction but might well prevent the rare but more challenging and dangerous development of an unexpected immediate-type reaction that cannot be excluded by what we know by now. Under any circumstances, the patient must be told about this risk, too.

6.3.4.2 Removal Techniques

The techniques of dermabrasion may carry a risk of severe injuries leaving scars and textural alterations behind. A detailed approach is elaborated in Chap. 7.

A detailed insight into removal techniques is given in Chap. 7 (Techniques and devices used for tattoo removal). Therefore, options for tattoo removal are only briefly outlined, as far as allergologic notions are concerned. a) Laser therapy: Tattoo removal by repeated laser application has become the gold standard of therapeutic approaches due to its low grade of invasiveness and reversibility of unwanted damages to the skin. Newer research by a US author’s group has concentrated on absorption maxima of actual tattoo colors and according to wavelengths [49] (for details see Chap. 7). From the allergist’s perspective, laser treatment bears the risk of evoking an additional allergic reaction via generating new antigens by physical processes that lead to chemical alterations in the substances of the tattoo within the dermis – these alterations are primarily wanted as they apparently eliminate the actual allergen, as shown to be clinically effective in treatment of allergies [34]. But, the destruction of pigment and dye molecules inevitably produces fragments that are then presented to Langerhans cells. As today’s comprehension of substances able to serve as a contact allergen displays them to consist of molecules of small size up to roundabout 500 Da [16] the probability of sometimes allergologically adverse effects of laser therapy is nothing merely hypothetical. A generalized allergic reaction after tattoo removal had already been reported in the mid-nineties [50]. In 2002, an immediate cutaneous hypersensitivity reaction was reported after treatment of a tattoo with Nd:YAG laser [51]; the details of the mechanism remained opaque. Despite these implications, laser therapy is not only effective, but also provides for cosmetically acceptable results [52]. Due to the aforementioned mechanisms, it should be worth a thought to weigh up the pros and cons of a general recommendation for antihistaminic substances given to the patient before the start of a sequence of laser therapy. This will not influence the onset of a new type

b) Mechanical (dermabrasion) and chemical (salt dermabrasion) skin ablation:

c) Tretinoin, imiquimod, and allopurinol: Several authors have reported on the clinical [53] and experimental [54] use of tretinoin, and imiquimod has also been tested in a clinical [55] and experimental [54] condition. In 2007, a Spanish author’s group proposed oral allopurinol as a therapeutic option for granulomatous reactions [56]. To us, the techniques are in evolutionary status by now. Further information can be derived from Chap. 7. d) Excision: If the allergic reactions persist after attempts with topical and systemic steroids or the triggering of another allergic reaction by laser therapy itself is feared, excision is the remaining option. Excision may make plastic surgery necessary, and one will in most cases have to take cosmetic aspects into consideration; sometimes the resection of the inflamed area, often restricted to a single color within a tattoo, will already be apt to eliminate the cause of malady. Successful partial resections have been reported in recent publications [2]. The advantage of excision is the mechanic removal of the whole antigen-contaminated area. In the overwhelming majority, this will finally solve the problem, and thus heal the patient. Nevertheless, a case of ineffective, though total excision has been reported [36]. In 1996, the resection of a multicolor tattoo from the skin of a 29 year-old female patient who had experienced a generalized rash and pruritus about four weeks after tattoo placement only produced temporary relief and did not prevent the recurrence of skin eruptions and itching all over her entire body. The continued application of systemic steroids could just lessen the intensity of the symptoms whenever the rash recurred. Following the author’s own interpretation, the ineffectiveness of the excision may be explained by a (supposed) dissemination of the allergen over the whole body, but the allergen itself was not identified, and further investigation

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was not reported. Therapy resistance even to surgical removal may be rare, but a beacon for those who consider a tattoo application to be of reversible character in times of laser treatment. 6.3.4.3 Conclusions Within our literature review of 18 patients, we registered 12 different treatment modalities in the form of combinations and modifications of the aforementioned alternatives (except for dermabrasional techniques and chemical approaches by tretionoin, imiquimod, or the use of allopurinol). Three case-reports did not refer to treatment at all, so only 15 full data sets could be analyzed, meaning that just every fifth case had no individual treatment. Even if numbers are small, it becomes visible that the variety of treatment measures is nearly as great as that of causing agents, and therefore general statements about most successful treatment options cannot be derived from the data we have. It is interesting to note that in none of three cases where topical steroids alone were used, they brought full relief. When topical steroids were used in combination with another therapy option, no outcome was referred to as unsatisfactory. Among the latter, four results were excellent (in the sense of full recovery). Although again these observations do not allow any generalization, it may be worth it to have a close look to future cases and results, having in mind the question whether this tendency is reproducible or not. The authors would, last but not least, like to lay emphasis on the recommendation that no tattoos should be placed in the skin of very young persons, since a large-scale US-prevalence study, though unable to distinguish between allergic and nonallergic reactions, showed a significantly higher risk for local reactions for the below-18-aged [15], while a risk-consciousness of any kind is not existent in this age-group, as a pediatric study on tattoo practises has shown in 2006 [57].

6.4 Permanent Make-Up (PMU) 6.4.1 Overview The PMU should be regarded not just as a permanent tattoo in the facial areas, because the technique of colorinsertion aims at hitting the cell layers between the basal lamina of the epidermis and the stratum papillare, while

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permanent tattoos in other parts of the body are placed deeper in the dermis to keep them unchanged for years (see above). Correct technique would normally provide for a longer-lasting effect than an epidermal placing would; the time span until onset of fading has been named as varying between 6 months and 3 years [1]. Indeed, PMU is often carried out by nonmedically educated persons, and regulatory control of the sites of application will be very different within the European Union; sometimes highly educated and experienced people, even dermatologists themselves, will offer PMU, sometimes beauticians without deeper insight into principles and implications of that body modifying technique may offer their services. This results in a broad quality range. For the allergist, the dangers of PMU are mirrored by the problems surrounding permanent tattoos; there may be a slight difference concerning the risk of infection, because PMU is not applied “in the street” and one can therefore presume a higher hygienic standard in PMU application. That does not only reduce the infection rate of severe transmissible diseases but may also prevent a local infection which itself may be needed to evoke an allergic reaction to the applied substances (see above). Thus, an indirect influence apt to lower the incidence of allergy and incompatibility reactions may exist. However, the pathologic condition, once it has occurred, will not really differ from what can be seen in reactions to noncosmetic permanent tattoos. The allergist is once again confronted with the challenge of having to treat a phenomenon evoked by chemicals unknown to him; this implies that he therefore cannot fully estimate the reaction to treatment measures. Because in such situations, the face – which cannot be concealed by clothing – is affected, the level of suffering will in most cases be much higher than with other sites of the body. This turns out into the enormous gap between the expectations on the patient’s side and means and options on the physician’s part.

6.4.2 Symptoms and Diagnosis As it was impossible for us to find specific allergic reaction patterns only seen in cosmetic tattoos, symptoms will be the same as in permanent tattoos (see above). Literature data on allergic reactions to cosmetic tattoos do not provide for a large quantity of cases – be it due to the greater number of noncosmetic tattoos among the population or due to the aforementioned

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mechanisms of decreasing the incidence of allergy by improving the surrounding (hygienic) conditions. As with permanent tattoos, the ingredients of the colorants are often unknown. It should be mentioned that patients are less likely to give permission to biopsy in the face and this approach should, of course, whenever possible, be avoided. Among the tissue-reactions, granulomatous reactions may dominate, but by now, we cannot derive a rule from our own experience or a thorough analysis of histological reports that may not yet exist to a number high enough to draw conclusions.

6.4.3 Epidemiology and Literature The available data seem to be too scarce to reflect on a ranking of the most problematic colors or application sites within the face. Pigment containing aluminum may cause problems [22], but it is an impossible task to try a pars pro toto access to this field based on just a few cases published so far. As many applications are apparently made in the eye region, the ophthalmologic literature provides for some reports around blepharopigmentation, a technique of PMU intended to replace the use of cosmetic eyeliners [22, 58]. A growing demand for permanent lip-liner has been noted by a German author’s group, indicating that the perioral region may become a center of allergologic concern about PMU over the next years, but the authors themselves, revealing a case of granulomatous reaction after extended UV-radiation, state a lack of information about complications in the medical literature [59].

6.4.4 Therapy and Recommendations Therapeutic principles for coping with allergic reactions are the same as with permanent tattoos (see above), maybe except for the fact that in the frequently concerned eye region, intralesional application of steroids may be painful, risky, and thus unfavorable as a treatment option, though sometimes successful [58]. Attempts of removal with tretinoin have been made [53]. Laser treatment appears to be the best option when steroids fail and removal is needed [52], but it should once again be reminded of the possibility of

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incomplete extinction of the allergen by laser application, combined with the risk of unfavorable reactions to the laser treatment itself, including the triggering of a different allergy toward the reduction products. Local resection of parts of tattooed eyelids has been reported [58], emphasizing how grave implications of facial tattooing can be. As some techniques and – again – many used colorants, be it dyes or pigments of PMU are neither long-established nor systematically investigated and described, it is difficult to draw conclusions and make any appropriate recommendations for PMU. Its use should generally be avoided by persons with atopic history or manifest allergies of any kind. Thorough educational work concerning the public and legislative regulation on obligation to declare all risks is essential, but the desire to embellish the face most probably will outdo every consideration about risks, thus providing for innumerable future cases of incompatibility and allergic reactions toward cosmetic tattooing. This once again displays the need for strict regulatory acts on ingredients, declaration duties, and minimum standards for instruments and techniques used in this sector.

6.4.5 Clinical Example: Itching Dermatitis After Lip Line PMU A 40-year-old female patient consulted for an itching dermatitis on the lips. A rash had appeared about 6 months after a PMU had been applied on the lip line. At the same time, a PMU had been applied on the eyelids without any adverse reaction. It remained unclear if the same pigment had been used or not. Clinically, she presented with red and scaly plaques on the margins of the upper and lower lip, exactly restricted to the area where the PMU had been inserted. (Fig. 6.13) Histopathology revealed focal parakeratosis with occasional necrotic neutrophils in the epidermis. In the superficial dermis, the junction was blurred by a dense lymphocytic infiltration with a lichenoid pattern; here pigmented granules were present, compatible with foreign body granules of the permanent make-up. Deeper in the dermis, the infiltrate contained plasma cells and histiocytes with formation of a granulomatous pattern with focal necrosis. The picture presented as a mixture of lichenoid, pseudolymphomatous, and granulomatous inflammation.

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Fig. 6.13 Pruriginous dermatitis in the area of perioral cosmetic tattoo insertion. Note the scaly status

Patch testing was performed using the European standard series; it revealed a very strong (3+) reaction to nickel. Yet, it was not possible to demonstrate the presence of nickel in the permanent make-up. The skin alterations were treated twice with intralesional injection of triamcinolone acetonide (Kenacort A® (Bristol-Myers Squibb 10 mg/ml, 0.1 cc per session), and hereby cleared completely. It should be noted that about 80% of the PMU disappeared as well.

6.5 Temporary Tattoos 6.5.1 Overview Classical tattooing is an irreversible procedure. An alternative to this painful, definite, and risky way of body adornment is a tradition quoted as being even older than tattooing. Henna pseudo-tattooing, in the recent literature nearly exclusively referred to as “temporary tattooing”, is reported to have a tradition in predominantly Hindu and Moslem countries and adjacent regions since roughly 8000–9000 years [60, 61]. About half the population of India, actually approximating a billion people is considered to have had contact with henna [62], a natural and powerful colorant, derived from the plant Lawsonia inermis that grows in climates with warm nights only [61], mainly in Africa, Sri Lanka, and India, and can be purchased as a gray to greenish powder that turns into a brownish paste, when about the same amount of water is added [63]. This paste may

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then be directly applied to the skin in the lines and forms wished to appear as a picture or motive later on, and should be left in place for some hours to develop a reddish brown shade capable of enduring even in the presence of water and soap for about two weeks [61, 62]. Henna “tattoos” are not brought into the skin, but onto its surface, thus inviting a large number of people to try the benefits of a principally reversible procedure. Temporary tattoos have gained enormous popularity over the last 15 years also in Western societies, here especially, being appreciated by tourists and younger people on holiday. Despite the widespread use of henna, also serving as a hair-dyeing agent, for cosmetic purposes in the past, henna has not been recognized as a relevant sensitizer over the last decades; therefore, it may primarily surprise that in recent years, plenty of reports on allergic reactions to temporary tattoos were published [60– 62, 64–95]. These reactions seem to occur days to weeks after application of “Henna tattoos” and may cause not only localized but also severe contact eczema that may become bullous and last for weeks; long-lasting sequelae can occur in the form of persistent leucoderma or hyperpigmentation as well as permanent scarification. In fact, these reactions are almost never attributable to the name-giving henna, that seems to be a weak sensitizer, but in nearly all instances to the frequently added ingredient PPD. This substance may, due to its high sensitization potential under occlusion and due to the frequently (illegally) high concentrations in these tattoos [69], sensitize naïve persons as well as elicit severe reactions in already sensitized persons. Lifelong allergy to this azoic dye is one consequence; potential cross-sensitization to other paraderivatives such as sulphonamides, dapsone, benzocaine, and other azo dyes is the other one. Disadvantageous effects to routine activities in normal life in the form of occurring textile dermatitis [81, 86] and hair-dyeing problems [75, 79, 81, 88] are among the consequences. Problems in several occupations may arise as well. Substances other than PPD such as indigo blue (to obtain “blue henna”) or fragrances rarely but still may cause problems in such situations. As with permanent tattoos, a thorough analysis of the clinical effects of lawsone, a naphtoquinone, the active dying agent of henna powder [83] on the one hand, and PPD, often present even in so-called pure henna and essential to “black henna” preparations, on

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the other hand, is difficult, and the dermatologist’s knowledge about temporary tattoos has predominantly been nurtured by case reports over the last two decades. This tends to be problematic by now, as more and more sometimes severe adverse effects are seen in the aftermath of an exploding popularity of temporary tattoos. Critical voices have called for a banning of PPD application in general, and the authors’ attempt of a review of the literature on 64 cases reported between 2000 and 2008 seems to bolster up this suggestion.

6.5.2 Symptoms and Diagnosis The time span from the application of a temporary tattoo to the onset of symptoms varies broadly. In the literature, we found delays between about 3 h [72, 76] and a month [73] being arranged around an average of 7–8 days (see also Table 6.5.2.1). It seems that an early onset correlates with a vigorous reaction, but has no predictive character for the further development and the clinical outcome (see Sect. 6.5.3). In the overwhelming majority of allergic or incompatibility reactions toward permanent tattoos, the process is restricted to the area of the tattooed skin. Regarding temporary tattoos, the situation may be different skin (Fig. 6.14). At least 12.5% (eight patients) of 64 patients showed secondary dissemination over their bodies [82, 87, 96], sometimes displaying an erythema-multiforme-like picture [87, 96]. Again, this apparently has no influence on the clinical results, as numbers clearly indicate (see Sect. 6.5.3). The clinical appearance of an allergic reaction to a temporary tattoo is, in most cases, that of an eczematous alteration of the skin, often characterized by blistering and an exsudative condition in the site of the temporary tattoo. Sometimes an immediate bullous reaction is to be found [60, 65, 76, 92, 97]. Those cases of disorders restricted to the tattoo can show even bizarre formations. A Kuwaiti author’s group reported on a tense bullous formation exactly following the ornamental painting for a festivity on the skin of a 19-year-old woman [97]. The lesions were not accompanied by surrounding inflammatory reaction and appeared as a three-dimensional artist’s work on the forearms of the patient. Erythema (that will slightly exceed the borders of the paint-on-tattoo and thus become visible), vesicles, a tendency to secretion as mentioned earlier, itching and, a

Fig. 6.14 Allergic reaction in a child, 2 weeks after the application of a Henna tattoo. The girl had a positive reaction to PPD in the patch test

tendency sensed by reading through the literature, painful condition in more cases than in permanent tattoo reactions can be regarded as a kind of common set of symptoms clinically indicating an ongoing process of incompatibility, allergic reaction, or irritant condition. A reaction to a temporary tattoo may also become manifest as lichenoid [85] and erythema-multiforme– like eruptions, even as urticaria and angioneurotic edema. At the maximum end of the spectrum, an immediate-type reaction leading to collapse has been noticed [98] (Table 6.3). Only two author’s groups in our review have biopsied a temporary tattoo reaction; they described an erosion in the epidermis and a lichenoid dermal infiltrate [85] in one case and spongiotic changes of the epidermis and an edema of the papillary dermis with perivascular eosinophils in the other patient [62]. This is too little data to make a conclusion, but eosinophilic infiltrations can be regarded as affirmative for hypothesizing an allergic process. The diagnosis regarding reactions after application of henna tattoos is simple: a positive patch test with PPD is pathognomonic. Insidiously, PPD may also be present in henna powder or tincture declared to be “pure henna”, which conveys the impression that no additives will be found.

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Table 6.3 Henna tattoos: distribution of clinical parameters Criteria a

vehemence of reaction

79

nd

percentage

mean

range

eczematous or erosive dissemination

56 87.5% – – 8 12.5% – – delay until onset of symptomsb – – 7.2 0.12-30 residual damagec seen 28 58.3% – – not seen 20 41.6% – – Distribution of clinical parameters in a total of 64 patients having consulted a doctor after skin contact to henna tinctures, henna pastes or temporary tattoo colouring agents sold as “henna” of different sorts a Dichotomy for later processing was established by separating reactions that spread over the body from those that remained a local problem. The term “vehemence” does not refer to the degree of vigorous blistering or bullos eruptions that may, clinically, impose to be more vehement than a just maculopapulous rash, e.g. b Values shown in days, defined as span between painting and first registered symptoms by the patient. If repainting was done, first placement of the tattoo was chosen for calculation c Every clinical outcome reported as seen on latest control that differed from complete resolution without any remaining disorders, was rated as residual damage. Hyper- and hypopigmentation were most frequent, but also textural changes and scarification were reported. Note that numbers do not add up to 64, as in 16 cases authors did not report on the clinical outcome. Percentage refers to the remaining 48 cases d Shows the number of individuals belonging to each group. Note that numbers do not add up to 64, as the clinical outcome, giving an insight into the presence of residual damage after therapy, was not reported for 16 patients. Percentage displays the proportion of cases where outcome has been described, only

Should testing for PPD turn out to be negative, a test with lawsone and natural henna powder should be done, as in rare cases, single persons may be allergic to henna itself, and true henna-allergy has also been reported in the literature. It should be mentioned, that, in exceptional cases, henna itself could have toxic effects on the organism in children, according to a Sudanese author’s group up to severe systemic disturbances including renal failure, making intensive care necessary, even if the substance is absorbed through the skin and not ingested [99]. In rather rare cases of nonreactivity to PPD and henna alike, testing for fragrances or the aforementioned indigo blue will most probably be sufficient for a diagnosis. Normally, patch tests are performed with 1% PPD. Among the positive reactions to PPD in our review, we have found nearly exclusively reports on very strong reactions on the testing site. A patch test occlusion lasts at least for 2 days, and this is considered to be enough for active sensitization in the case of a highly potent sensitizer like PPD by some authors [61, 100]. We found the suggestion to step back with concentrations applied in testing in order to avoid sensitizing a naïve person who consults because of a different allergy than to PPD. Indeed, when PPD-patch testing was positive, we counted 31 cases with very strong reactions, only seven cases where reactions were described as strong, and just one simply referred to as “positive” in our review. Among the 31 very strong reactions, two were reported as being necrotic. The authors think that this

suggestion is not an absurd notion and may be worth discussing, given the consequences of an allergy to PPD once it is there.

6.5.3 Epidemiology and Literature Over the past 10–15 years, the number of publications on henna tattoos has remarkably increased. This does not only reflect the dermatologists’ growing interest in this field, but primarily mirrors the frequency to which clinicians are confronted with sometimes severe problems due to temporary tattoos [60, 72, 76, 77, 94]. Temporary tattoos are not subject to any specific kind of legislation – and if so, control would be almost impossible due to the habit of acquiring them street side while vacationing in countries with structural problems concerning enforcement of consumer health. Therefore, the ingredients of every single tattoo color-tincture will vary from vendor to vendor. This, and the known use of PPD as a major part [69] of the formula (which forbids the experimental use on the skin of study participants), prevent a systematic approach in the sense of a controlled prospective study or a clinical trial to identify the most dangerous conditions for application and first choice treatment options for specific constellations, when a patient consults. Nevertheless, enough cases have been published to try a comparative view and analysis of the material, and we decided to carry out a

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basic statistical calculation in a review of 38 publications on temporary tattoos from 2000 to 2008, providing us with a total of 64 cases. Reporting manners differ markedly from case to case, and we had to notice that not so little a number of authors preferred to describe symptoms, circumstances, and biographic data of patients, but not the clinical results of their treatment, sometimes not even naming the kind of treatment itself. Yet, we were able to gain a data set examinable by statistic calculative operations and herein focused on cases where clinical results were described. For establishing dichotomy required for the arithmetic procedure, we followed the definition of sufficient clinical outcome as restitutio ad integrum, meaning that only full recovery without residual pigmentation disorders was counted as sufficient, whereas all other results were counted as unsatisfactory. This view is, to our minds, apt to reflect the patient’s impression of whether an irreversible damage has happened to him or not, regardless of whether or not the clinical outcome in the eyes of the professional would be regarded as successful. Results are shown in Tables 6.4–6.8. Numbers were suggetive and almost persuasive, that some subgroups of patients have a higher risk of acquiring persisting damage than others, had we not submitted the data to statistical analysis. Indeed, it was impossible to show any difference that might be statistically significant. Neither had age or sex of the patients any remarkable influence on the outcome, nor did clinical aspects apt to allude to pathomechanism (delay until Table 6.4 Age of patients and clinical results Age of patients Clinical results unsatisfactory sufficient <18 years 17 13 ³18 years 10 8 As 16 cases were reported without referring to the clinical outcome, a total of n = 48 patients could be analysed. The optic impression suggests there is no dependency of the clinical outcome on age-groups as subdivided according to the age of majority. c2 was 0.0056437 and thus no statistical significance could be found Table 6.5 Sex of patients and clinical results Sex of patients Clinical results unsatisfactory sufficient male 9 11 female 18 10 The optically derived notion that females show a less preferable outcome could not be proven in a c2-test. c2 was 1.7632653 for n = 48, missing statistical significance

W. Aberer et al. Table 6.6 Delay of onset of symptoms and clinical results Delay of onset of Clinical results symptoms unsatisfactory sufficient <7 days 8 10 ³7 days 17 9 Dichotomy was established at 7 days of delay, because roundabout 7 days had turned out to be the mean value in our review and traditional perception of contact allergy as the pathologic principle likely to be underlying in most cases refers to a time span of at least 7 days needed to establish a new allergy [16]. The distribution of numbers is suggestive of a possibly better prognosis in cases with earlier onset, but this, again, fails to reach statistical significance, displaying c2 at 1.9009266 for n = 44. Note that numbers do not add up to 48: Four data sets are missing, as authors did not tell about the delay of onset of symptoms in these cases

Table 6.7 Dissemination of eruptions and clinical results Dissemination of Clinical results eruptions/efflorescences unsatisfactory sufficient local (restricted to tattoo) 23 18 disseminated 4 3 Normally, the reaction to a henna tattoo remains restricted to the area of the tattoo, maybe slightly exceeding the sharp outer lines due to a surrounding inflammatory reaction. In some cases a generalised reaction adds on, with efflorescences becoming manifest over other parts of the body. Among the 16 authors who did not report on outcome, one described a generalised reaction in the form of an erythema multiforme like rash. Due to missing description of the outcome it could not be included, but figures show that essential changes would not have been observed even with the integration of the eighth case of dissemination in our review: c2 was 0.0026547 for n = 48, a result far from statistical significance at a = 0.05

Table 6.8 Treatment and clinical results Treatment Clinical results modality unsatisfactory

sufficient

oral steroids 5 4 no oral steroids 19 14 Note that only 42 of a total of 64 reviewed cases were described naming the treatment measures that had been applied. Systemic treatment with oral steroids was compared to other approaches, regardless of additional options that were sometimes combined with oral steroids. All therapeutic regimes abstaining systemic steroids were summarised in the group “no oral steroids” in this analysis. It failed as well to display any remarkable difference; no statistical significance for the slight difference in favour of oral steroids could be detected with c2 at 0.0117845 for n = 42

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onset of symptoms) or vehemence of the reaction of the skin and immune system (dissemination) serve as a predictor concerning the outcome. Even a fundamental difference in treatment – the use of systemic corticosteroids in many cases – did not result in a corresponding difference in clinical results. Our approach cannot provide for results based on stratification, but the numbers of cases suitable to be analyzed exceed the arithmetic minimum demands for the possibilities of generalization and thus can serve as a frame for orientation. It is remarkable that the situation is completely different from the nearly desperate tries to fathom the problems of permanent tattoos. While the latter confront the dermatologist with an unknown allergen, PPD has been identified as the trouble-producing agent in temporary tattoos long ago. Nevertheless, no rule or tendency can be identified for various parameters in a situation of more or less clear etiology. We therefore conclude that broadly varying reactions of different organisms indicate that the concentration or toxicity of the allergen itself – as presented to the skin – and not the immunologic constitution and reagibility of the organism determines the things to come. There will, of course, be a difference between first contact and reexposition, with a much fiercer response of the skin on second exposition – this can easily be seen by two cases of temporary tattoo reactions preceded by recallable prior temporary tattoos that already produced discrete symptoms [60, 76]. But, this does not explain the variation of ways and strength of reactions in all other cases in our review. In support of the hypothesis that the toxicity or concentration of the ingredient – and not individual factors – determines the reaction is the observation that henna preparations contain amounts of PPD strictly forbidden by law to have contact with the skin. While a EU directive restricts the concentration of PPD to 6% [65] in cosmetic products, compositions containing up to

Table 6.9 Distribution of biographic parameters Criteria n age

20% have been found [72]. A mass spectrometry analysis of “black henna” powder showed PPD but no lawsone as the dying ingredient of henna powder to be in the preparation [61]. This means that henna was completely absent and the powder, misleadingly named “black henna” achieved its coloring properties by the content of PPD, and maybe other auxiliary substances only. This can easily lead to disaster instead of only dyeing and makes us understand the aforementioned calls for a general ban of PPD. Another alarming aspect in this evolving field of dermal pathology is the age of receivers of temporary tattoos 62.5% of patients consulting for health disturbances after placement of a temporary tattoo were minors (Table 6.9). We recognized with astonishment – as did the authors of the case report – that the youngest patient in the collective of our review was 4 years old. This is illustrative of the absence of any caution among parents concerning exposure of their children to unknown, undeclared, or untested substances in early infancy. It should also be noted that the average age of minors in this collective was just below 11 years. Thus, temporary tattoos seem to be a typical product for the infantile customers rather than for the adolescent one. Children, unable to weigh the pros and cons in a decision that may have severe disadvantageous effects on health, should normally be given advice and thus support by their parents. In contrast to this idea, we reviewed a case of severe, recurring bullous manifestation of a reaction to a temporary tattoo in a 7-year-old boy [60], whose mother reported him having had a temporary tattoo 5 months earlier with an eczematous reaction to this first tattoo. This convincingly displays the urgent need for health education of the populations among Europe, as the aforementioned mother’s decision to let the child have another tattoo will most probably not be expression of venturesomeness, but complete incapability to

percentage

meana

rangea

<18 years 40 62.5% 10.9 4-17 ³18 years 24 37.5% 28.6 18-57 sex male 27 42.2% – – female 37 57.8% – – Distribution of biographic parameters in a total of 64 patients in 38 case reports. Only the dermal reaction (see Table 6.5.2.1), age and sex of every patient were consequently reported by all authors. Note that temporary tattoos are subject to desire of the minors predominantly; here, again, an average age of just below 11 years is remarkable a Values in years of age, with separated mean values for those below and above 18 years

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estimate a risk. Another vigorous eruption occurred in a male 40-year-old patient who, again, had a symptomatic incompatibility or allergic reaction in the past – with a temporary tattoo. He decided to get a new one placed and suffered from a painful condition of hefty skin reaction [76]. The two cases may be among the more extreme examples, but it is evident that no consciousness about dangers and implications of so-called temporary tattoos exists among the people. We would like to remind readers about the proportion of residual damages of more than 58% among those cases where outcome was referred to (see 6.5.2.1) in order to reflect on the term “temporary” tattoo. A persisting hypo- or hyperpigmentation exactly reproducing the former shape of the tattoo was a common long-term consequence [68, 81], when a reaction had occurred, giving good reason to doubt the transitory character of these tattoos.

6.5.4. Tranferable picture tattoos Danger for minors, especially for very young children, may arise from another form of pseudo-tattooing. Nonpermanent motives are also available in the form of transferable picture tattoos; these prefabricated painton tattoos are brought onto the skin after slightly moistening it and left there for a short period of time. When peeled off, the motive can be seen on the skin and will remain there for a time span of some days. In 2008, a Polish authors’ group reported on a pruritic, vesicular reaction to such a black transferable picture tattoo in an 8-year-old girl who had stuck the picture tattoo 2 days earlier [101]. The lesion left persistent hypopigmentation at the site of the tattoo behind, although a successful treatment with topical steroids was described. Referring to the analysis of color ingredients in transferable picture tattoos done by a Danish authors’ group in 2005 [102], the causative agent may have been some other substance than PPD, because in the Danish analysis PPD was not detected in black colorants. But, the colorants of the transferable picture tattoo used by the little girl were not analyzed and a strong patch-test reaction to PPD was found 4 months later when the girl reacted to dark-colored cotton tights, developing eczematous lesions and again persistent hypopigmentation. The authors therefore called into question the absence of

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PPD. We also want to emphasize the fact that there are no mechanisms to control standards for the production of transferable picture tattoos that are apt to prevent PPDuse. Given the black color, the little time span of delay of onset of symptoms, the well-known high potency of PPD as a sensitizer, the persistent hypopigmentation, and the acute dermatitis after wearing dark-colored cotton tights 4 months later, when allergy toward PPD was proven, it would appear that PPD was one of the ingredients of the coloring agents in the transferable tattoo picture that had produced strong adverse effects on the skin of the child. It should therefore be pointed out that seemingly harmless coloring procedures that may not even be realized as a coloring process can involve considerable risk, just like street side temporary tattoos do.

6.5.5 Therapy and Recommendations The diversity of ways of treatment for permanent tattoos has been mentioned earlier (see 6.3.4). Coping with the adverse effects of temporary tattoos seems to be a task that is better-guided by more or less established treatment principles. Treatment for the acute reaction will be done by using topical steroids and oral antihistamines. The most common approach seems to be the exclusive use of topical steroids. These, sometimes combined with other means like antibiotic substances (when an additional infection of the weakened skin is imminent), antihistamines, or the infiltration of steroids into the lesions, did not differ in outcome from a systemic approach with oral steroids in a review of 42 reported cases. Nine patients in our review received oral steroids. Only one case where infiltration was thought to be helpful was registered [91]; in this case testing for both PPD and henna had produced negative results. A completely different approach was chosen for a case in which topical steroids had shown no effect. Here topical pimecrolimus and antihistamines were tried; nevertheless, hypopigmentation occurred [70]. Local treatment was done by flammazine ointment in a case characterized by skin changes in the appearance of a local burn [92], resulting in persisting textural changes and hypopigmentation; patch testing was not reported in this case. Local aluminum powder has been used in a generalized condition in addition to topic and local steroids,

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bolstered up by antibiotic treatment with cephalexin [62]. Whenever an allergy to PPD or, less likely, henna has been proven by patch testing, it is essential to provide the patient with adequate information about potential future exposure and avoidance strategies. Because PPD and henna are both frequently used in hair dyes and cross-reactions to substances with an amino group in the paraposition of a benzene ring, like in PPD, are possible [62, 88], patients must be advised to check new products thoroughly before use. Many authors have proposed a cause for generally discouraging henna tattoos in children. With respect to biographic data of the patients as sex and age, a number of 64 reviewed cases is already high enough to mirror the situation in the totality of temporary tattoo receivers who develop serious local, sometimes spreading symptoms of allergy, incompatibility, or hypersensitivity. Noting the young age and visible helplessness of customers of these products, we prefer to advice against temporary tattooing of minors, too. Another recommendation aims at enforcing and improving international research on temporary tattooing. During our review, we had to face the fact that sometimes elaborate and well-presented case reports focused on symptomatology, biographic data, and surrounding conditions, but later on turned out to be unsuitable for statistic calculation procedures as important information was missing. In fact, controlled studies will not be realizable in the future due to the aforementioned reasons. Research will therefore be restricted to chemical analysis and toxicological in vitro findings on the one hand, and further case reports serving as material for analysis like the one we tried on the other hand. It is therefore essential to include a basic data set of criteria into every publication. We want to encourage a discussion on these minimum data and suggest age, sex, symptoms, delay of onset of symptoms, results of patch testing (if performed), comorbidity, history of possible former contact, therapy, and clinical outcome to be described in every single case. Depending on the interest of governmental structures, EU-driven support could help to provide for a uniform pattern or data sheet in the sense of a European temporary tattoo evaluation scheme (ETTES). The by now theoretical ETTES could help to structure the urgently needed information and thus provide for a meta-analysis approach to a subject not easily amenable to study by the individual dermatologic clinician.

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6.6 Tattoo Stickers and Glues 6.6.1 Overview A special form of body modification not common in adults (due to a lack of acceptance), is a technique for children who already show interest in pictures and motives applied to the skin. Tattoo stickers, little transfers made to be placed upon the skin to adhere there for a period of time and then be peeled off again, avoid all implications of an invasive procedure, but are able to supply for optical effects easily removable when the fascination has gone. The use of this “tattoo,” indeed a mere sticker, is normally allowed by the parents, and therefore not so rare a sight among the infantile population. Tattoo stickers should be regarded as safe concerning colorants, as the colored side of the sticker is not contacting the skin. Nevertheless, there may be problems concerning the adhesive substances necessary to make the film of the sticker firmly stick even in the presence of little amounts of water, and also during various movements that force the epidermis to follow the deeper structures and thus extend or contract its surface.

6.6.2 Symptoms and Diagnosis Dermal problems due to the application of tattoo stickers will be seen in the kind of either an erythema or a beginning maceration sharply following the shape of the sticker, or a combination of both. This does not necessarily have to be the expression of a specific allergic or inflammatory process, but is often simply the same effect to be observed with (medical) plasters that were left in place for too long, especially if humidity developing after repeated contact with water or other liquids is added to the occlusion by the plaster. The lesion normally disappears after hours, maybe days, without any necessity of specific treatment. It should be kept in hygienic, nonocclusive condition. If erythema alone has developed, this may eventually be interpreted as a sign of atopic disposition. Whenever any signs of sensible irritation like itching, burning, or the subjective impression of swelling or hyposensivity or paresthesia occur, an allergic reaction should be suspected, and a patch test with glues

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pediatrician, or dermatologist, and it may also unnecessarily upset the parents of the young patient.

6.6.3 Epidemiology and Literature

Fig. 6.15 Hypopigmented areas and signs of recent sunburn in a child, a few days after removal of temptoos that had been in place for several weeks. Heavy sun exposure immediately after removal of the temptoos

and plaster components may be considered. As with any possible allergen, identification by contacting the producer should be tried, but will fail in most cases, as tattoo stickers are often distributed as an extra when buying a completely different product, so that no product information will be available. Should efflorescences, apart from the application side occur, other causes have to be taken into account, though a systemic reaction cannot be excluded. It should be noted that for the two latter scenarios not one case has so far come to the authors’ knowledge, despite the mass distribution of tattoo stickers. Thus, symptoms arising from a tattoo sticker must be viewed with vigilance, but interpreted with deliberateness (Fig. 6.15). Another disturbance after tattoo sticker application may have a delayed onset, depending on the time the tattoo sticker remains on the skin, a sunburn limited to the area covered by the sticker can develop, when extensive sun exposure follows the removal from the skin, this especially at sea-side, where solar radiation’s effects are raised to a higher degree by the special atmospheric conditions. Although an erythema and maybe burning and itching can be found, here the diagnosis is not “(allergic) reaction to a sticker” but “sunburn”, reactive to (physiologically) downregulated pigmentation in a part of the skin that was kept away for a longer time from UV-radiation, which normally gives stimuli to the production and ripening of melanin. This possibility should always be explored in a thorough case history, as it may be a diagnostic trap for the general practitioner,

The distribution and frequency of application of tattoo stickers may even outdo the exposure to nickel in the general population, as the overwhelming majority of children experience a phase when tattoo stickers become of interest, be it due to family influence, trends in school, or indeed driven by advertisement or occasional contact through product selling practices (see above). Although no data have been available on the actual dimensions of tattoo sticker use in Europe and worldwide, one can presume that sticking decorative devices on one’s own skin belongs to childhood, herein with a tendency to younger age and with no preference of sex (despite piercing in the adult population, i.e., see above). In contrast to that, not one serious case of incompatibility reaction or severe allergic reaction has been reported or observed by the authors themselves. A computer-aided literature review checking just under 27.5 millions of documents in 15 databases with multiple search modes failed to reveal even one case report. This is especially stunning because numerous data on occupational and nonoccupational allergies to (and irritations by) glues in all their variety exist [103–109] and plaster allergy – even toward transdermal application-forms of drugs – has been a vivid field of discussion and publication over decades [110– 113]. It may be the case that producers of tattoo stickers are well-aware of the importance of harmless formulas and strictly (internally) supervised purity of the substances used in products especially made for the infantile customer. On the other hand, a declaration of ingredients is not available at all. One of the world’s largest producers of toys runs a magazine addressing female children from an age of 5 years (verbal information by the hotline of the enterprise) onward. In the last available item before final editing of this book ,tattoo stickers were being announced as a part of a prize game. A call to the hotline of the enterprise revealed that the stickers were considered suitable to rest upon the skin for 3 days and to cause no problems, but it was not possible to get access to a description of contents or any detailed information on the way the product had been tested before being made available to the public.

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With tattoo stickers granted as an extra when buying certain foodstuffs, the situation for the retail customer will be no different, what raises fundamental questions about end-user security in a highly relevant sector of commerce.

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of the melanocytes, thus making the covered area more vulnerable for UV-radiation after a certain time. Considering all this justifies the recommendation not to let tattoo stickers rest on the skin for longer than a couple of hours, even if no serious case of irritant or allergic reaction was documented so far.

6.6.4 Therapy and Recommendations 6.7 Summary It is evident that in most cases, a therapy is not necessary at all. When erythema or maceration can be observed with no other accompanying symptom and there is no history of atopy, no specific treatment is necessary. The patient should be advised to keep the site of the irritation dry and under hygienic condition. In the case of itching, pain, or neurologic sensations, an antihistaminic substance adapted to age and weight of the patient can be given and a patch test for plaster and glue antigens should be made after full recovery. As no case of persistent disturbances is known, it seems superfluous to consider topical steroids. A constellation of symptoms exceeding the borders of the tattoo sticker has to be treated as an onset of an allergic reaction of unknown origin with extreme care for the patients’ status – to the authors’ assessment this should remain a theoretical scenario. Regardless of the apparently minimal potential of so far produced tattoo stickers to sensitize children, we would like to draw interest to the fact that the child’s developing organism is being immediately exposed to a foreign multicomponent material. This foreign material device is closely stuck to the body surface for an indefinite period of time. This should be avoided not only for immunologic reasons. The necessary pH-regulation of the epidermis is strongly influenced by the local humidity, which grows immensely under any tight coverage. The relation and compilation of the epidermal barrier lipids that are responsible for the immunologic, hygroscopic, and mechanic integrity of the stratum corneum interacts with the pH-value and becomes directly affected by the rise of humidity. Furthermore, the nonpathogenic resident dermal flora experiences extreme alterations in living conditions if sealed up for days, and will therefore be a weaker stronghold against pathogenic flora trying to colonize the skin in the time after sticker removal. Last, but not least, will any tight enclosure of the skin, as given with the application of a sticker, take away the adequate stimulus for the activity

• Piercings cause more problems than so far considered. The primum movens in allergic reactions to piercings is still nickel allergy. • If piercing is done, piercing instruments and spacers should consist of stainless steel. Within the first few weeks no metallic material other than stainless steel should contact the perforated area. • Swelling, itching, tenderness, and erythema at the site of the piercing hole are indicators of a beginning metal allergy. • Even splitting of the earlobe at sites where piercing for (gold) jewelry was done can occur due to an allergic reaction; other metallic components than gold that are necessary to provide for mechanical properties in the jewelry might play a role. • Incompatibility and allergic reactions to permanent tattoos are more frequent than has been estimated by experts so far. • Especially minors experience local medical problems at the site of a tattoo rather often. • Black as a tattoo color, also used for medical purposes, is no orphan cause for allergy, exceeding all other colors except for red in the recent literature. • Symptoms of allergic or incompatibility reactions to tattoos will appear in the form of itching of a circumscript area of the skin (normally identical with the site of the tattoo) induration, thickening or swelling, and sometimes pain. • The time span between the tattooing procedure and the rise of clinical symptoms varies broadly. • A correct diagnosis of specific colorant-allergy is often impossible due to reasons of insufficient testing conditions. The term “tattoo-induced immunologic reaction” (TIIR) could supply for classification in certain cases. • Tattoo passports for the customer referring to safety data sheets of individual colors enhance safety, but

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•

•

•

•

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cannot provide for maximum security due to undeclared, low concentrated substances. Among the treatment options for allergic reactions to tattoos are systemic or topical steroids (sometimes backed up by antibiotics to prevent superinfection), intralesional steroids, antihistamines, and different removal techniques, among which laser therapy and excision are most important. Nonsurgical treatment aiming at the elimination of the allergen in a tattoo may fail; in rare cases, symptoms can recur even after surgical replacement of the tattoo. Cosmetic tattoos, synonymous with permanent make-up seem to evoke reactions less frequently than permanent tattoos. If they do, problems are very similar to those seen in permanent tattoos. Temporary tattoos elicit allergies to PPD (paraphenylenediamine) rather often. Severe bullous reactions are likely to occur after sensitization to PPD when a temporary tattoo containing PPD is placed. Sometimes, reaction patterns indicate toxic rather than allergic reactions. “Pure henna” temporary tattoos are not reliably free of PPD. Henna alone can also evoke allergic reactions in rare cases. Transferable henna picture tattoos for children bear similar risks. Prefabricated transferable picture tattoos may lead to pruritic, vesicular reactions of the skin and persistent pigmentation disorders, mirroring adverse effects of temporary tattoos applied by artisans. Long-term sequelae in the form of persistent pigmentation disorders occur in about half the patients who consult because of health disturbances after a temporary tattoo, according to data published from the year 2000 onward. Tattoo stickers cause less skin reactions than should be presumed with regard to allergies to glues, which are necessary for the device to stick upon the skin. Nevertheless, risks associated with occlusion and light deprivation can cause unwanted effects.

References 1. Worret WI, Raulin C, Greve B (2004) Spezielle Indikationen zur kosmetischen Behandlung. In: Worret WI, Gehring W (eds) Kosmetische dermatologie. Springer, Berlin, pp 332–350 2. ZwadJ,JakobA,GrossCetal(2007)Behandlungsmöglichkeiten bei Unverträglichkeitsreaktionen auf Tätowierungspigmente.

Treatment modalities for allergic reactions in pigmented tattoos. J Dtsch Dermatol Ges 5(1):8–13 3. Lexikon der Kunst (1987) Dörfler edition, Lexikon der Kunst. Nebel Verlag, Eggolsheim 1987, ISBN 978-3-89555386-8, vol 2, p. 219 4. Krause H, Bremerich A, Sztraka M (2000) Komplikationen nach Piercing im Mund und im Gesicht. Mund Kiefer Gesichtschir 4(1):21–24 5. Larsson-Stymne B, Widström L (1985) Ear piercing – a cause of nickel allergy in schoolgirls? Contact Dermatitis 13(5):289–293 6. Thijs L, Deraedt K, Goossens A (2008) Granuloma possibly induced by palladium after ear piercing. Dermatitis 19(5): E26–E29 7. Boss A, Menné T (1982) Nickel sensitization from ear piercing. Contact Dermatitis 8(3):211–213 8. Rietschel RL, Fowler JF Jr (2008) Metals. In: Rietschel RL, FowlerJF Jr (eds) Fisher’s contact dermatitis. BC Decker, Hamilton, pp 641–699 9. Mortz CG, Andersen KE (2008) New aspects in allergic contact dermatitis. Curr Opin Allergy Clin Immunol 8(5): 428–432 10. Thyssen JP, Maibach HI (2008) Nickel release from earrings purchased in the United States: the San Francisco earring study. J Am Acad Dermatol 58(6):1000–1005 11. Fisher AA (1974) Ear piercing hazard of nickel-gold sensitization. JAMA 228(10):1226 12. Raveendran SS, Amarasinghe L (2004) The mystery of the split earlobe. Plast Reconstr Surg 114(7):1903–1909 13. Meijer C, Bredberg M, Fischer T et al (1995) Ear piercing, and nickel and cobalt sensitization, in 520 young Swedish men doing compulsory military service. Contact Dermatitis 32(3):147–149 14. Ehrlich A, Kucenic M, Belsito DV (2001) Role of body piercing in the induction of metal allergies. Am J Contact Dermat 12(3):151–155 15. Laumann AE, Derick AJ (2006) Tattoos and body piercings in the United States: a national data set. J Am Acad Dermatol 55(3):413–421 16. Rietschel RL, Fowler JF Jr (2008) Pathogenesis of allergic contact hypersensitivity. In: Rietschel RL, FowlerJF Jr (eds) Fisher’s contact dermatitis. BC Decker, Hamilton, p 3 17. Chimenos-Küstner E, Batlle-Travé I, Velásquez-Rengijo S et al (2003) Appearance and culture: oral pathology associated with certain “fashions” (tattoos, piercings, etc.). Med Oral 8(3):197–206 18. Mann RJ, Peachy RDG (1983) Sarcoidal tissue reaction – another complication of ear piercing. Clin Exp Dermatol 8: 199–200 19. Armstrong DKB, Walsh MY, Dawson JF (1997) Granulomatous contact dermatitis due to gold earrings. Br J Dermatol 136:776–778 20. Jappe U, Bonnekoh B, Gollnick H (1999) Persistent granulomatous contact dermatitis due to palladium body-piercing ornaments. Contact Dermatitis 40:111–112 21. Viraben R, Boulinguez S, Alba C (1995) Granulomatous dermatitis after implantation of a titanium-containing pacemaker. Contact Dermatitis 33:437 22. Schwarze HP, Giordanie-Labadie F, Loche F et al (2000) Delayed-hypersensitivity granulomatous reaction induced by blepharopigmentation with aluminium-silicate. J Am Acad Dermatol 42:888–889

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23. Mc Fadden N, Lyberg T, Hensten-Pettersen A (1989) Aluminium-induced granulomas in a tattoo. J Am Acad Dermatol 5:903–908 24. Nagashima C, Tomitaka-Yagami A, Tsuruta K et al (2004) Electron-beam treatment of allergic granuloma due to gold pierced earrings. Contact Dermatitis 51:90–91 25. Goossens A, De Swerdt A, De Coninck K et al (2006) Allergic contact granuloma due to palladium following ear piercing. Contact Dermatitis 55(6):338–341 26. Cui W, McGregor DH, Stark SP et al (2007) Pseudoepitheliomatous hyperplasia – an unusual reaction following tattoo: report of a case and review of the literature. Int J Dermatol 46(7):743–745 27. Goldstein N IV (1979) Complications from tattoos. J Dermatol Surg Oncol 5(11):869–878 28. Liddle M, Hull C, Liu C et al (2006) Contact urticaria from curcumin. Dermatitis 17(4):196–197 29. Corazza M, Zampino MR, Montanari A et al (2002) Lichenoid reaction from a permanent red tattoo: has nickel a possible aetiologic role? Contact Dermatitis 46(2):114–115 30. Amann U, Luger TA, Metze D (1997) Lichenoide pseudolymphomatöse Tätowierungsreaktion. Hautarzt 48(6): 410–413 31. Bachmeyer C, Blum L, Petitjean B et al (2007) Granulomatous tattoo reaction in a patient treated with etanercept. J Eur Acad Dermatol Venereol 21(4):550–552 32. Bagwan IN, Walker M, Theaker JM (2007) Granuloma annulare-like tattoo reaction. J Cutan Pathol 34(10):804–805 33. Bhardwaj SS, Brodell RT, Taylor JS (2003) Red tattoo reactions. Contact Dermatitis 48(4):236–237 34. Dave R, Mahaffey PJ (2002) Successful treatment of an allergic reaction in a red tattoo with the Nd-YAG laser. Br J Plast Surg 55(5):456 35. Gallo R, Parodi A, Cozzani E et al (1998) Allergic reaction to India ink in a black tattoo. Contact Dermatitis 38(6): 346–347 36. Goldberg HM (1996) Tattoo allergy. Plast Reconstr Surg 98(7):1315–1316 37. Greve B, Chytry R, Raulin C (2003) Contact dermatitis from red tattoo pigment (quinacridone) with secondary spread. Contact Dermatitis 49(5):265–266 38. Hermida MD, Otero M, Della Giovanna P et al (2007) Cutaneous vasculitis following an intradermal tattoo. J Eur Acad Dermatol Venereol 21(9):1268–1269 39. Mahalingam M, Kim E, Bhawan J (2002) Morphea-like tattoo reaction. Am J Dermatopathol 24(5):392–395 40. Morales-Callaghan AM Jr, Aguilar-Bernier M Jr, MartínezGarcía G et al (2006) Sarcoid granuloma on black tattoo. J Am Acad Dermatol 55(5 Suppl):S71–S73 41. Sewak S, Graham P, Nankervis J (1999) Tattoo allergy in patients receiving adjuvant radiotherapy for breast cancer. Australas Radiol 43(4):558–561 42. Treudler R, Tebbe B, Krengel S et al (1997) Allergic contact dermatitis from black tattoo. Contact Dermatitis 37(6): 295 43. Tsuruta D, Sowa J, Higashi N et al (2004) A red tattoo and a swordfish supper. Lancet 364(9435):730 44. White N, Rauf G (2002) Sensitisation to red tattoo pigment. Br J Plast Surg 55(4):365–366 45. Timko AL, Miller CH, Johnson FB et al (2001) In vitro quantitative chemical analysis of tattoo pigments. Arch Dermatol 137(2):143–147

87 46. Steinbrecher I, Hemmer W, Jarisch R (2004) Unverträglichkeitsreaktion auf den Azofarbstoff Pigment Rot 170 in einer Tätowierung. J Dtsch Dermatol Ges 2(12):1007–1008 47. Park JW, Sohn DK, Hong CW et al (2008) The usefulness of preoperative colonoscopic tattooing using a saline test injection method with prepackaged sterile India ink for localization in laparoscopic colorectal surgery. Surg Endosc 22(2):501–505 48. Aboosy N, Mulder CJ, Berends FJ et al (2005) Endoscopic tattoo of the colon might be standardized to locate tumors intraoperatively. Rom J Gastroenterol 14(3):245–248 49. Beute TC, Miller CH, Timko AL et al (2008) In vitro spectral analysis of tattoo pigments. Dermatol Surg 34(4):508– 15; discussion 515–516 50. Ashinoff R, Levine VJ, Soter NA (1995) Allergic reactions to tattoo pigment after laser treatment. Dermatol Surg 21(4): 291–294 51. England RW, Vogel P, Hagan L (2002) Immediate cutaneous hypersensitivity after treatment of tattoo with Nd:YAG laser: a case report and review of the literature. Ann Allergy Asthma Immunol 89(2):215–217 52. De Cuyper C (2008) Permanent makeup: indications and complications. Clin Dermatol 26(1):30–34 53. Chiang JK, Barsky S, Bronson DM (1999) Tretinoin in the removal of eyeliner tattoo. J Am Acad Dermatol 40(6 Pt 1): 999–1001. (Abstract) 54. Solis RR, Diven DG, Colome-Grimmer MI et al (2002) Experimental nonsurgical tattoo removal in a guinea pig model with topical imiquimod and tretinoin. Dermatol Surg 28(1):83–86; discussion 86–87 55. Ricotti CA, Colaco SM, Shamma HN et al (2007) Laserassisted tattoo removal with topical 5% imiquimod cream. Dermatol Surg 33(9):1082–1091 56. Martín JM, Revert A, Monteagudo C et al (2007) Granulomatous reactions to permanent cosmetic tattoos successfully treated with topical steroids and allopurinol. J Cosmet Dermatol 6(4):229–231 57. Sweeney SM (2006) Tattoos: a review of tattoo practices and potential treatment options for removal. Curr Opin Pediatr 18(4):391–395 58. Vagefi MR, Dragan L, Hughes SM et al (2006) Adverse reactions to permanent eyeliner tattoo. Ophthal Plast Reconstr Surg 22(1):48–51 59. Jäger C, Hartschuh W, Jappe U (2005) Sonnenlichtgetriggerte granulomatöse Reaktion auf permanent lip-liner. Hautarzt 56(1):63–65 60. Le Coz CJ, Lefebvre C, Keller F et al (2000) Allergic contact dermatitis caused by skin painting (pseudotattooing) with black henna, a mixture of henna and p-phenylenediamine and its derivatives. Arch Dermatol 136(12):1515–1517 61. Wolf R, Wolf D, Matz H et al (2003) Cutaneous reactions to temporary tattoos. Dermatol Online J 9(1):3 62. Mohamed M, Nixon R (2000) Severe allergic contact dermatitis induced by paraphenylenediamine in paint-on temporary ‘tattoos’. Australas J Dermatol 41(3):168–171 63. Thami GP, Kaur S, Kanwar AJ (2001) Allergic contact dermatitis to henna. Allergy 56(10):1013–1014 64. Al-Qattan MM (2007) Henna skin reactions in the hand. Ann Plast Surg 59(4):476 65. Avnstorp C, Rastogi SC, Menné T (2002) Acute fingertip dermatitis from temporary tattoo and quantitative chemical analysis of the product. Contact Dermatitis 47(2):119–120

88 66. Baron S, Baxter K, Wilkinson M (2003) Allergic contact dermatitis to henna tattoo. Arch Dis Child 88(9):747 67. Borrego L, Hernández-Machín B, Gonzalez O et al (2005) Sensitization to paraphenylenediamine in a streetside temporary tattoo artisan. Contact Dermatitis 52(5):288–289 68. Bowling JC, Groves R (2002) An unexpected tattoo. Lancet 359(9307):649 69. Chung WH, Wang CM, Hong HS (2001) Allergic contact dermatitis to temporary tattoos with positive paraphenylenediamine reactions: report of four cases. Int J Dermatol 40 (12):754–756 70. Corrente S, Moschese V, Chianca M et al (2007) Temporary henna tattoo is unsafe in atopic children. Acta Paediatr 96(3): 469–471 71. Davies EE, Grabczynska S (2007) Paraphenylenediamine allergy from a henna tattoo. Arch Dis Child 92(3):243 72. De Souza B, Russell P, Moir G (2003) Henna skin reaction. Plast Reconstr Surg 111(7):2487–2488 73. Di Landro A, Valsecchi R, Marchesi L (2005) Allergic reaction with persistent hypopigmentation due to temporary tattoing with henna in a baby. Contact Dermatitis 52(6):338–339 74. Gonzalo-Garijo MA, Fernández-Durán DA, Pérez-Calderón R et al (2008) Allergic contact dermatitis due to a temporary henna tattoo, a hair dye, and a marker pen. J Investig Allergol Clin Immunol 18(3):226–227 75. Jasim ZF, Darling JR, Handley JM (2005) Severe allergic contact dermatitis to paraphenylene diamine in hair dye following sensitization to black henna tattoos. Contact Dermatitis 52(2):116–117 76. Jung P, Sesztak-Greinecker G, Wantke F et al (2006) A painful experience: black henna tattoo causing severe, bullous contact dermatitis. Contact Dermatitis 54(4):219–220 77. Jung P, Sesztak-Greinecker G, Wantke F et al (2006) The extent of black henna tattoo’s complications are not restricted to PPD-sensitization. Contact Dermatitis 55(1):57 78. Lim SP, Prais L, Foulds IS (2004) Henna tattoos for children: a potential source of paraphenylenediamine and thiuram sensitization. Br J Dermatol 151(6):1271 79. Marcoux D, Couture-Trudel PM, Riboulet-Delmas G et al (2002) Sensitization to paraphenylenediamine from a streetside temporary tattoo. Pediatr Dermatol 19(6):498–502 80. Martin JA, Hughes TM, Stone NM (2005) ‘Black henna’ tattoos: an occult source of natural rubber latex allergy? Contact Dermatitis 52(3):145–146 81. Matulich J, Sullivan J (2005) A temporary henna tattoo causing hair and clothing dye allergy. Contact Dermatitis 53(1): 33–36 82. Neri I, Guareschi E, Savoia F et al (2002) Childhood allergic contact dermatitis from henna tattoo. Pediatr Dermatol 19(6):503–505 83. Nikkels AF, Henry F, Piérard GE (2001) Allergic reactions to decorative skin paintings. J Eur Acad Dermatol Venereol 15(2):140–142 84. Onder M, Atahan CA, Oztaş P et al (2001) Temporary henna tattoo reactions in children. Int J Dermatol 40(9):577–579 85. Rubegni P, Fimiani M, de Aloe G et al (2000) Lichenoid reaction to temporary tattoo. Contact Dermatitis 42(2): 117–118 86. Saunders H, O’Brien T, Nixon R (2004) Textile dye allergic contact dermatitis following paraphenylenediamine sensiti-

W. Aberer et al. zation from a temporary tattoo. Australas J Dermatol 45(4): 229–231 87. Sidwell RU, Francis ND, Basarab T et al (2008) Vesicular erythema multiforme-like reaction to paraphenylenediamine in a henna tattoo. Pediatr Dermatol 25(2): 201–204 88. Simpson-Dent SL, Hunt SH, Davison SC et al (2001) Tattoo dermatitis from primary sensitization to clothing dyes. Contact Dermatitis 45(4):248 89. Stante M, Giorgini S, Lotti T (2006) Allergic contact dermatitis from henna temporary tattoo. J Eur Acad Dermatol Venereol 20(4):484–486 90. Tan E, Garioch J (2007) Black henna tattoos: coexisting rubber and paraphenylenediamine allergy? Clin Exp Dermatol 32(6):782–783 91. Temesvári E, Podányi B, Pónyai G et al (2002) Fragrance sensitization caused by temporary henna tattoo. Contact Dermatitis 47(4):240 92. Tomlinson JE, Winterton RI, Liddington MI (2007) Henna reaction. J Plast Reconstr Aesthet Surg 60(10): 1164–1165 93. Valsecchi R, Leghissa P, Di Landro A et al (2007) Persistent leukoderma after henna tattoo. Contact Dermatitis 56(2): 108–109 94. Van den Keybus C, Morren MA, Goossens A (2005) Walking difficulties due to an allergic reaction to a temporary tattoo. Contact Dermatitis 53(3):180–181 95. Wöhrl S, Hemmer W, Focke M et al (2001) Hypopigmentation after non-permanent henna tattoo. J Eur Acad Dermatol Venereol 15(5):470–472 96. Jappe U, Hausen BM, Petzoldt D (2001) Erythemamultiforme-like eruption and depigmentation following allergic contact dermatitis from a paint-on henna tattoo, due to paraphenylenediamine contact hypersensitivity. Contact Dermatitis 45(4):249–250 97. Evans CC, Fleming JD (2008) Images in clinical medicine. Allergic contact dermatitis from a henna tattoo. N Engl J Med 359(6):627 98. Abdulla KA, Davidson NM (1996) A woman who collapsed after painting her soles. Lancet 348(9028):658 99. Sir Hashim M, Hamza YO, Yahia B et al (1992) Poisoning from henna dye and paraphenylenediamine mixtures in children in Khartoum. Ann Trop Paediatr 12(1):3–6 100. Devos SA, Van Der Valk PG (2001) The risk of active sensitization to PPD. Contact Dermatitis 44(5):273–275 101. Kiec-Swierczynska M, Krecisz B, Swierczynska-Machura D (2008) Allergy to p-phenylenediamine from a black transferable picture tattoo - hypopigmentation and sensitization to clothing dyes in a little girl. Contact Dermatitis 58(3):174–175 102. Rastogi SC, Johansen JD (2005) Colourants in transferable picture tattoos for the skin. Contact Dermatitis 53(4): 207–210 103. Fischer T, Bohlin S, Edling C et al (1995) Skin disease and contact sensitivity in house painters using water-based paints, glues and putties. Contact Dermatitis 32(1): 39–45 104. Frick M, Björkner B, Hamnerius N et al (2003) Allergic contact dermatitis from dicyclohexylmethane-4, 4’-diisocyanate. Contact Dermatitis 48(6):305–309

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105. Gruvberger B, Bruze M, Almgren G (1998) Occupational dermatoses in a plant producing binders for paints and glues. Contact Dermatitis 38(2):71–77 106. Isaksson M, Gruvberger B, Bruze M (2004) Occupational contact allergy and dermatitis from methylisothiazolinone after contact with wallcovering glue and after a chemical burn from a biocide. Dermatitis 15(4):201–205 107. Jolanki R (1991) Occupational skin diseases from epoxy compounds. Epoxy resin compounds, epoxy acrylates and 2,3-epoxypropyl trimethyl ammonium chloride. Acta Derm Venereol Suppl (Stockh) 159:1–80 108. Kanerva L, Jolanki R, Leino T et al (1995) Occupational allergic contact dermatitis from 2-hydroxyethyl methacrylate and ethylene glycol dimethacrylate in a modified acrylic structural adhesive. Contact Dermatitis 33(2): 84–89

89 109. Tarvainen K (1995) Analysis of patients with allergic patch test reactions to a plastics and glues series. Contact Dermatitis 32(6):346–351 110. Bergendorff O, Hansson C (2000) Activation and crossreactivity pattern of a new allergen in adhesive plaster. Contact Dermatitis 42(1):11–17 111. O’Donnell BF, Hodgson C (1993) Allergic contact dermatitis due to lanolin in an adhesive plaster. Contact Dermatitis 28(3):191–192 112. Rademaker M (2004) Allergic contact dermatitis to a sanitary pad. Australas J Dermatol 45(4):234–235 113. Sjöborg S, Fregert S (1984) Allergic contact dermatitis from a colophony derivative in a tape skin closure. Contact Dermatitis 10(2):114–115

7

Techniques and Devices Used for Tattoo Removal Evelien Verhaeghe

Core Messages

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The treatment of choice for tattoo removal nowadays is a specific treatment with Q-switched lasers; however, multiple treatments are normally required and may vary between 5 and 20 or more. Excellent results can be obtained with Q-switched lasers but complete clearance of tattoos is rare and there is no guarantee that any treatment will restore the skin to its original condition. Side effects and complications can occur. In some indications, adjunctive topical therapy and nonspecific treatment with surgery or ablative lasers can be necessary, more particularly, tattoo granulomas or tattoos with an allergic response. Other indications are resistant tattoos after multiple Q-switched laser treatment sessions and some cosmetic tattoos.

7.1 Introduction/History Over the centuries, different nonspecific methods for tattoo removal have been tried out. The earliest report of attempted tattoo removal was from Aetius, a Greek physician who described salabrasion in 543 CE [1]. During the reign of the Emperor Claudius, garlic, excrement of pigeons, decomposed urine, pepper and

lime, mother’s milk, strong vinegar, sulphuric acid, and cantharides were used to remove unwanted tattoos. Agents producing superficial burns such as phenol, nitric acid, and carbon dioxide have also been popular [2]. Other techniques of tattoo removal used over the centuries are surgical, mechanical, and thermal treatment modalities. These techniques destruct or remove the outer skin layers. By damaging the epidermis, the pigment is able to migrate transdermally through the denuded skin. An additional inflammatory response promotes macrophage activity, with increased phagocytosis enabling additional pigment loss during the healing phase [3]. Today tattoo removal is generally performed with Q-switched lasers which involve targeted destruction of tattoo pigment. These lasers create the possibility to remove tattoo pigment particles by a very specific method, using the principle of selective photothermolysis, and causing only minimal collateral damage to the surrounding skin. Despite the availability of laser tattoo removal, some nonspecific methods of tattoo removal remain a useful tool in specific conditions of tattoo removal.

7.2 Nonspecific Methods of Tattoo Removal 7.2.1 Mechanical Methods 7.2.1.1 Salabrasion

E. Verhaeghe Ghent University Hospital Department of Dermatology, De Pintelaan 185, 9000, Gent, Belgium e-mail: [email protected]

Salabrasion involves abrading the superficial dermis with coarse granules of common table salt and a moist gauze pad. Salt is applied to the wound surface and left

C. de Cuyper, M. L. Pérez-Cotapos S. (eds.), Dermatologic Complications with Body Art, DOI: 10.1007/978-3-642-03292-9_7, © Springer-Verlag Berlin Heidelberg 2010

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under the surgical dressing for 24 h or longer to remove additional pigment by an osmotic effect. This procedure is very painful and requires local anesthesia. Although some authors were enthusiastic about this procedure for removal of amateur tattoos, this technique is now rarely used due to the associated risk of scarring, and residual tattoo pigment after wound healing.

E. Verhaeghe

is still used today and can be an advantage in circumscribed multicolored tattoos causing medical problems. It also offers a solution for small tattoos located in an area with a good degree of skin laxity resulting in a cosmetically acceptable scar. All surgical procedures will result in the formation of scars so the size of the tattoos is a critical issue in surgical treatment of tattoos. Tattoos in larger body parts or whole-body tattoos do not qualify as a target for surgical removal.

7.2.1.2 Dermabrasion During dermabrasion, a rapidly spinning diamond fraise wheel or a wire brush abrades the skin that is usually prepared with a skin refrigerant to produce a hard surface. The procedure tends to be bloody, and tissue and blood are aerosolized into the operation room. This may transmit infections to the treating physician and the staff members of the operation room. Removing tissue only to the depth of the papillary dermis minimizes scarring but will leave significant residual tattoo pigment. To remove professional and deeper tattoos, multiple procedures will be necessary. This will lead to increased risk of scarring (Fig. 7.1). To enhance the efficacy, gentian violet, tannic acid, and silver nitrate are applied to the superficially abraded surface and will prolong the exudative phase of the wound healing [3]. In this way, more pigment will migrate to the wound surface and can be removed from the skin by curettage.

7.2.1.3 Surgical Excision Surgical treatment of tattoos remains a useful tool for complete removal [4]. This technique of tattoo removal

Fig. 7.1 Scar formation due to tattoo removal by dermabrasion (Courtesy of Dr. De Cuyper, Bruges, Belgium)

General Information The surgical procedures are in accordance with the standard dermatosurgery used in esthetic and oncologic therapies. Before starting a surgical treatment of tattoo removal, patients need extensive information about the risks and options of tattoo removal. Scarring is not avoidable in surgery and pigment changes may also happen in darker skin types. Patients should also be informed about the possible side effects and complications of the planned surgical procedure. An informed consent is advisable.

Surgical Techniques The depth of surgery is defined by the deepest layer of skin that contains color particles. Very small tattoos, in particular remnants of posttraumatic tattoos or first attempts at self-tattooing may be removed by a punch biopsy closed by a single suture. Smaller tattoos can be removed via an excision of an elliptical piece of skin and closed by sutures. In some cases, depending on the geometrics of the tattoo, flaps may be more suitable. Larger tattoos on limbs and trunk can be removed by split thickness tangential excision and dressing. Healing in these cases is obtained by second intention. Split-thickness excisions can also be covered by skin grafting to improve the outcome. For larger tattoos of various geometrics a multistep removal or the use of tissue expanders may be the best surgical option. A new developed technique is the use of a self-filling osmotic tissue expander, which is made of a hydrogel not requiring external filling. The final volume is reached within 6–8 weeks. The risk of infection is avoided and the filling is less painful [4].

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Techniques and Devices Used for Tattoo Removal

7.2.2 Chemical Methods Tannic acid and silver nitrate are used in chemical tissue destruction methods. The technique known as the French method, first described by Variot in 1988, involves disruption of the skin surface with punctures and incisions, followed by the application of caustic chemicals. An eschar forms in the subsequent 2–3 weeks, leading to elimination of the pigment [1]. Phenol solutions, trichloroacetic acid in a 95% solution also remove tattoos chemically but result in hypopigmented scars. Repeated application is hazardous and can result in a full thickness burn that requires skin grafting. Phenol solutions have to be used with caution. The resorption of phenol can lead to toxically systemic effects as it is a cardiotoxic product. The Rejuvi Tattoo removal system is a new chemical extraction method designed for facial cosmetic tattoos and body tattoos. It consists of a tattoo removal paste containing zinc oxide, magnesium oxide, calcium oxide, isopropanol, triethanolamine, and benzoic acid that is delivered into the skin via a puncture technique using needles, similar to regular tattooing. The paste is then reapplied over the tattoo and left in place for 6–8 days. The website indicates that several treatments may be required at no less than 4 weeks apart. Although the manufacturer claims a low rate of adverse events, there have been reports of adverse events such as hypertrophic scarring after this procedure, as mentioned in the literature [5].

7.2.3 Thermal Methods

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lamp has preset pulses triggered by an electronic timer. The energy source is a tungsten halogen light that emits light with wavelengths of 400–2,700 nm and a maximum emission near the infrared range at 900– 960 nm. At this wavelength, the primary tissue chromophores are water and oxygenated hemoglobin however when exogenous black and blue tattoo pigments predominate as target chromophores a nonspecific thermal burn occurs from heat absorption. The infrared radiation penetrates to a predetermined depth in the treated tissue were light energy is converted into heat and this heat results in coagulation of the dermis. The advantage over an electrocoagulator is that the depth of injury is more predictable. Scarring is common in both the electrocoagulator and the infrared coagulator and more significant than in tattoos removed by Q-switched lasers. This is due to an important collateral damage of the surrounding skin structures.

7.2.3.2 Thermal Tissue Destruction Methods with Nonspecific Laser Treatment Argon Laser The argon laser was the first laser used to remove tattoo pigment. Although the initial choice of the argon laser was based on selective absorption of energy from its 488 and 514 nm wavelength by complementary tattoo pigment colors its clinical usefulness was limited. This was due to important melanin and hemoglobin absorption resulting in unwanted thermal damage. As the pulse duration of the laser was 50–200 ms, this allowed an extensive diffusion of heat from the absorbing chromophores resulting in nonselective thermal destruction.

7.2.3.1 Thermal Tissue Destruction Methods Without Laser Treatment Carbon Dioxide Laser (CO2laser) Hot coals, fire, and cigarettes have been used for centuries in an attempt to remove unwanted tattoos. In most of the cases, these techniques resulted into significant scarring. Electrocoagulation has also been used for centuries leading to the same significant scars. Twenty years ago the infrared coagulator was developed in West Germany. This device shares some properties with an infrared laser but differs by virtue of its noncoherent, multispectral light source [6]. The

A CO2 laser operates with a wavelength of 10,600 nm: this wavelength in the near-infrared spectrum ablates all water containing tissue. The original objective in using this laser in tattoo removal was to vaporize tissue by using visual control to remove all the tattoo pigment in one session. The great enthusiasm to use these lasers was mainly due to the fact that all the different tattoo colors could be treated and that the complete tattoo removal could be accomplished in one session.

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In spite of the extraordinary precision of the CO2 laser, removing all pigment in one session did result in a variable range of wound depth reaching often up to the deeper dermis or even subcutis. This led to thick scars. Later on patients were treated in more than one session with less deep ablation per session. However, this approach also gave unsatisfying cosmetic results as residual tattoo pigment and scars in shape of the original tattoo. This is due to direct vaporization of dermal tissue and thermal necrosis of dermal tissue. Dermal tissue will be reconstituted by fibrosis and scar formation [3]. Today the CO2 laser is used for some very specific indications:

a tattoo results in successful removal of the tattoo in an animal model. However, this acute-phase tattoo removal was associated with fibrosis and loss of dermal appendages [9].The use of 5% imiquimod cream as an adjuvant to laser removal of mature tattoos in an animal model appeared also to be useful [10]. However, these positive results in animal models could not be confirmed in a case–control study involving 40 tattoos in humans. Laser-assisted tattoo removal with topical 5% imiquimod cream was shown to be ineffective and resulted in a significant higher incidence of adverse effects when compared to placebo [11].

• The removal of tattoo granulomas. • The removal of tattoos in which an allergic response has been elicited when using Q-switched lasers. • Treatment of resistant tattoos after multiple Q-switched laser treatment sessions. In this case, the CO2 laser will be used to remove the epidermis prior to Q-switched laser treatment. • CO2 laser can also provide precise removal of facial cosmetic tattoo pigment in delicate areas as eyelids, lip liners, and eyebrows. It is best to avoid Q-switched lasers in removing flesh toned facial cosmetic tattoos due to the risk of paradoxic ink darkening. The resulting gray–black tattoo may prove difficult to remove and is certainly more visible than the flesh tone. This pigment darkening can be permanent and disfiguring [7]. Mafong et al. [8] describe the successful removal of a pinkish-red cosmetic lip-liner tattoo. The pulsed CO2 laser laser with a computer pattern generator was used at 10,600 nm, 300 mJ, and 60 W in a linear scan pattern with a scan density of six. The entire tattoo was resurfaced in one pass. After 4 days the treated area was completely healed. The procedure was repeated at 1-month intervals. After six sessions the tattoo was essentially removed without scarring or pigment change.

7.2.4.2 Fractional Ablative Laser Treatment In the literature, we could not find any reports about the use of fractional ablative and/or nonablative photothermolysis in tattoo removal. Some operators mention in their personal experiences good results when using the fractional nonablative photothermolysis devices in treating leukoderma after tattoo removal.

7.2.5 Summary The nonspecific methods of tattoo removal may be less expensive and time-consuming than the specific tattoo removal techniques mentioned later; however, the high risk of scarring, hypertrophic scarring, and residual tattoo pigment makes them less attractive. Only in specific indications they can replace the Q-switched lasers that are nowadays the treatment of choice in removing tattoo pigment. The experimental nonspecific methods of tattoo removal sounds promising but their efficacy has to be proven first as well as the absence of significant side effects.

7.3 Specific Methods of Tattoo Removal 7.2.4 Experimental Nonspecific Methods of Tattoo Removal

7.3.1 General Principles of Tattoo Removal by Q-Switched Laser

7.2.4.1 Topical Imiquimod It has been shown that topical application of 5% imiquimod cream within the first 24–72 h of placement of

Anderson and Parrish’s principle of selective photothermolysis (1983) revolutionized the use of lasers in dermatology and therefore the treatment of tattoos.

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This principle proposes that if the used wavelength is well absorbed by the target and the pulse width is equal to or shorter than the target’s thermal relaxation time, the heat generated will be confined to the target [12].

The target chromophores for laser treatment of tattoos are the tattoo pigment ink particles. Tattoo pigments consist of insoluble, submicrometers-sized particles that are phagocytosed by dermal cells. They react almost in the same way as melanosomes. The tattoo pigment particles sometimes grouped in granules and packed into vacuoles from 0.1 to 10 mm are endocytosed by fibroblasts as well as macrophages in the dermis and sometimes in the subcutis [13]. To selectively destroy these particles, the optimal wavelength has to be chosen to achieve maximal and selective absorption for each color, while minimizing the nonspecific thermal effects through absorption by the endogenous chromophores as hemoglobin and melanin. Table 7.1 (adapted from Beute et al. [14]) and Fig. 7.2 show the most frequently used tattoo colors and their absorption spectrum peaks that can be used to remove that specific color. Knowing that many tattoo inks are mixtures of colors with a wide range of tint (blue, green, violet, orange) it is sometimes difficult to predict the response of a tattoo pigment to a specific type of laser. Also the volume of pigment particles may play a role in response of a tattoo to the treatment. When comparing a low total pigment volume vs. a high volume of the same pigment, clearance will be achieved in a fewer number of sessions in the first case.

Table 7.1 Absorption spectrum peaks by tattoo pigment color measured in the spectrum of visible light from 404 to 820 nm (adapted from Beute et al. [14]) Color Maximum Comment absorption (nm) 600–800

Blue–green Permanent green Red Orange Yellow

656–808 570–800 500–570 420–540 470–485

Absorption over the entire spectrum with no true peak – – – – –

KTP 532nm

NetYAG 1064nm

655nm

60% Absorption

7.3.1.1 The Target

Black

Tattoo Ink Absorption 80%

40%

20%

400

500

600

700 800 900 Wavelength (nm)

1000 1100

Fig. 7.2 Tattoo ink absorption curve (Source, Palomar Medical Technologies, Inc.)

7.3.1.2 The Wavelength Today, the four most common wavelengths available in different Q-switched laser devices are 532, 694, 755, and 1,064 nm as mentioned in Table 7.2. These wavelengths have been originally chosen for the good absorption of the most current tattoo pigment colors. 7.3.1.3 The Pulse Duration and the Thermal Relaxation Time In 1983, Parrish et al. [15] defined the thermal relaxation time for a spherical target by the following formula: Tr = d²/27 k, where Tr is the thermal relaxation time, k is the thermal diffusivity, and d is the target’s diameter. According to the principle of selective photothermolysis, the pulse duration of the used laser has to be equal

Table 7.2 Four most common wavelengths available in Q-switched lasers Wavelength Laser Used to treat (nm) 532 694

Frequency doubled Nd-Yag laser Ruby laser

755 1,064

Alexandrite laser Nd-Yag laser

Red, (orange) Black, blue black, green Black, blue, green Black

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or shorter than the thermal relaxation time of the target to minimize the risk of collateral thermal damage. As mentioned the target in tattoo removal consists of small submicrometer-sized particles of tattoo ink. These tattoo particles, like melanosomes, are small targets with a thermal relaxation time around 10–6 s [13]. Lasers with very short pulses of light are needed to target and remove tattoo pigment without damaging the surrounding skin. Already in 1965, Goldman et al. [16] published the earliest report of tattoo pigment interaction with short-pulsed lasers. When he compared the reaction of a dark blue tattoo to a Q-switched ruby laser (QSRL) with nanosecond pulses vs. a microsecond pulsed ruby laser, he found that microsecond pulses led to nonspecific thermal necrosis and that nanosecond impacts only produced transient erythema accompanied with a whitening of the impact area. No thermal necrosis was observed but due to tattoo pigment retention in the dermis this modality was originally interpreted as a failure. Despite these results, Goldman followed the patients’ progress and noted continued fading of the treated area [3]. In the nineties, the first Q-switched lasers with pulse durations in the nanosecond range were commercialized for tattoo removal. Today, these Q-switched lasers are the treatment of choice for tattoo removal. They have been shown to provide efficacious removal of tattoos with minimal side effects. The Q-switched lasers used to remove tattoos are as follows: QSRL (694 nm); Q-switched Neodymium-YAG laser (Nd:YAG laser) (532 and 106 4nm); and the Q-switched Alexandrite laser (755 nm).

7.3.2 Different Q-Switched Laser Systems At present, no single Q-switched laser system can treat optimally all multicolored tattoos. Wavelength, pulse duration, and spot size of the different commercialized laser systems will determinate the specific benefits and limitations of the device.

7.3.2.1 Q-Switched Ruby Laser (QSRL) The Ruby laser is the first developed Q-switched laser and operates with a wavelength of 694 nm and a pulse width of 28–40 ns [17].

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This laser is as effective as other Q-switched lasers for the removal of black inks, and is one of the better lasers to remove green and blue inks; however, it is ineffective for the removal of red or yellow inks [17]. This 694 nm wavelength is well absorbed by melanin also leading to competitive absorption of the laser light by melanosomes and to vacuolization of melanocytes and keratinocytes with hypopigmentation noted in 39(low fluencies)–46% (higher fluencies) of patients [18]. This hypopigmentation is in most of the cases transient but occasionally, small areas of confetti-like hypopigmentation persists. The absorption of the 694 nm wavelength of the QSRL by melanin has to be taken into account when treating tattoos in darker skinned patients.

Fluence and Treatment Sessions When selecting the energy level for treatment with a QSRL, immediate tissue whitening with minimal or no bleeding should be observed. The required energy density varies depending on the used spot size and the amount as well as the color of pigment in the tattoo [17]. The number of treatment sessions can vary between 4 and 20 sessions or more. Amateur tattoos usually require 4–6 treatment sessions and professional tattoos may require 6–10 sessions; however, in some patients as many as 20 treatment sessions are needed. Several trends are noted: professional, distally located, recently acquired or deeply placed tattoos may be difficult to remove, requiring more treatment sessions to eradicate them. Acceptable clearing varies greatly from patient to patient and some individuals accept some residual pigment [3].

7.3.2.2 Q-Switched Alexandrite Laser In the nineties, this laser was often sold in tandem with a 510 pigmented lesion dye laser (510 nm). The Q-switched Alexandrite laser has a wavelength of 755 nm and a pulse width of 50–100 ns. This laser is effective in removing black, blue and most of the green inks, but less effective in removing red and yellow inks [17]. Transient hypopigmentation after treatment is common (occurs in 10% of patients) but is often not

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apparent until after 5–7 treatment sessions and usually resolves gradually over 1–12 months. Transient surface textural changes resolve usually and are seen in approximately 10% of the patients. Hyperpigmentation depends on the skin type and can get cleared most of the time through the use of hydroquinone and sunscreen.

Fluence and Treatment Sessions The clinical endpoint of the Q-switched Alexandrite laser is the same as the endpoint of the QSRL: tissue whitening without tissue splatter (Figs. 7.3 and 7.4). The starting fluence depends on the spot size however 5.0–6.5 J/cm² is mostly used. Approximately 4–10 treatments performed at 1–2 month interval usually clear the tattoo without scarring. However, the treatment range can vary between 4 and 16 treatments (Fig. 7.5–7.7).

Fig. 7.4 Clinical endpoint of Q-switched Alexandrite laser treatment: immediate tissue whitening without tissue splatter (Source, Department of Dermatology, Ghent University Hospital, Ghent, Belgium)

Fig. 7.3 Black amateur tattoo (Source, Department of Dermatology, Ghent University Hospital, Ghent, Belgium)

Fig. 7.5 Multicolored professional tattoo (Source, Department of Dermatology, Ghent University Hospital, Ghent, Belgium)

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7.3.2.3 Q-Switched Neodymium-YAG Laser (Nd-YAG Laser)

Fig. 7.6 Multicolored professional tattoo after four treatment sessions with Q-switched Alexandrite laser and 510 nm pulsed dye laser (Source, Department of Dermatology, Ghent University Hospital, Ghent, Belgium)

The Q-switched Nd-Yag laser was explored with the expectation that its longer wavelength (1,064 nm) would increase dermal penetration and decrease melanin absorption. The increased dermal penetration was used to improve the response of QSRL-resistant tattoos. The ability of the Q-switched Nd-YAG laser to remove pigment in the QSRL-resistant tattoos was shown in a study of 28 tattoos showing more than 50% lightening of residual tattoo ink within the first treatment, with the greatest improvement seen with higher fluences. The laser offers a great advantage when treating patients with a darker skin type. Grevelink et al. [19] demonstrated minimal hypopigmentation or hyperpigmentation in dark-skinned patients. This is a significant advantage for darker skinned patients in whom melanin absorption is a hindrance. This laser is effective in removal of black and blue– black pigments.

Fluence and Treatment Sessions The treatment at higher fluences seems to be more effective than at lower fluences. This laser is very effective in removing black ink, creating rare textural changes and almost no hypopigmentation. This is due to its longer wavelength, higher fluence and very short pulses. In comparison with the other Q-switched lasers, the Q-switched Nd-Yag brings more bleeding and tissue splatter during treatment making the treatment more cumbersome. Because of the 1,064 nm absorption by melanin and hemoglobin, blistering and purpura frequently occur. The primary disadvantage of this laser is the limited color range, which is basically restricted to black and dark blue/black tattoo pigment. However, a frequencydoubling crystal is a feature of this laser that provides a 532 nm wavelength to effectively treat red ink.

7.3.2.4 Recent Laser Developments

Fig. 7.7 Multicolored professional tattoo: result after 12 treatment sessions with Q-switched Alexandrite laser and 510 nm pulsed dye laser (Source, Department of Dermatology, Ghent University Hospital, Ghent, Belgium)

Nowadays there are different Q-switched laser devices on the market with multiple wavelength possibilities in the nanosecond domain in one device. A Q-switched Alexandrite laser is commercialized with the addition of 1,064 and 532 nm laser pumped

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Techniques and Devices Used for Tattoo Removal

solid-state hand pieces. Three wavelengths are combined in one device. There are also Q-switched Nd:Yag devices with hand pieces that can convert the 532 nm wavelength to both 585 and 650 nm with pulses in the nanosecond domain. The 585 nm hand piece is used to treat sky-blue pigment and the 650 nm hand piece to remove green inks. The recent development of lasers like the titanium:sapphire laser with shorter pulse durations than the Q-switched lasers (in the picosecond range) offer the potential to further reducing unwanted injury and simultaneously improving the results. Although this is still a current area of active research these devices may ultimately prove superior to Q-switched lasers [20]. Important to note, intense pulsed light (IPL) sources are not developed to remove tattoos as there pulse durations are to long (millisecond domain). Treating tattoos by IPL devices will lead to important scarring due to unwanted aspecific thermal damage of the surrounding skin.

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Amateur tattoos are typically less dense and are often made up of carbon-based ink that responds more readily to Q-switched laser treatment [17] (Figs. 7.8 and 7.9). Traumatic tattoos usually have minimal and superficial pigment deposition and mostly need only a few treatment sessions with good results.

Fig. 7.8 Ritual tattoo before start of laser treatment (Source, Department of Dermatology, Ghent University Hospital, Ghent, Belgium)

7.3.3 Clinical Aspects of Q-Switched Laser Treatment of Tattoos 7.3.3.1 Patient Selection and Expected Benefits Although Q-switched lasers are the treatment of choice for tattoo removal they are by far not able to remove all tattoos. The number of treatment sessions to remove a tattoo can vary between 1 and 20 sessions or more. The amount of treatment sessions depend on the tattoo and laser linked parameters:

Tattoo Linked Parameters Clinical experience and trials teach us that treatment results depend on different tattoo linked parameters as ink color, ink pigment mix, density of the ink placed in the skin, and depth of location of the ink into the dermis. Tattoos placed with a professional or homemade tattoo gun contain more ink and, therefore, usually require more treatment sessions before clearing. Densely pigmented tattoos with a variety of colored, metallic pigments (e.g., cadmium, mercury, cobalt, and copper) may be particularly difficult to remove, requiring more than ten treatment sessions.

Fig. 7.9 Result after four treatment sessions with Q-switched Alexandrite laser for removal of a ritual tattoo (Source, Department of Dermatology, Ghent University Hospital, Ghent, Belgium)

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Laser Linked Parameters Current Q-switched lasers have pulse durations in the nanosecond domain, wavelengths well absorbed by most tattoo inks and very high peak powers, respecting the criteria for selective photothermolysis of ink particles [18]. The ability of a particular wavelength of light to remove colored ink particles can often be predicted by the ink’s absorption spectra. So the selection of the laser to treat a tattoo depends mainly on the color of the tattoo pigment (see Table 7.2). Appropriate wavelength selection allows the most efficient treatment with the fewest side effects. It is very important to establish realistic expectations to every patient before starting the laser treatment to achieve finally a result with which the patient will be satisfied. Prior to the start of the treatment, the following information should be given to the patient: • It must be emphasized that multiple treatment sessions are normally required and may vary anywhere between 5 and as many as 20. • Complete clearance of all treated tattoos is rare. Even after numerous treatments some tattoo pigment may still remain (Fig. 7.10). • There is no guarantee that any treatment will restore the skin to its original condition.

Fig. 7.10 Residual pigment and textural changes after ten Q-switched Alexandrite laser sessions of a multicolored tattoo (Source, Department of Dermatology, Ghent University Hospital, Ghent, Belgium)

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• Even when removal is complete or nearly complete there is often a slight “ghost-like” color change of the skin that may resemble the original shape of the tattoo. • Information about the costs: There is a wide variety in the cost of removing a tattoo with laser. The purchase price of the laser, the size of the tattoo, and the number of treatments will all play a role. In most of the cases, the cost of tattoo removal is not covered by health insurances. This has to be clearly explained to the patient before starting the treatment. • Information about the risk factors and complications should be provided (see Sect. 7.2.3.3).

7.3.3.2 Treatment Strategy Before starting the treatment of the informed patient, it is important to rule out or to define: • Skin tan: it is necessary to ensure that the patient is not tanned. Epidermal melanin produced by UV may interfere with laser treatment and increase the risk of pigment alterations and scarring. If a tan is present treatment should be delayed until the tan has faded in the treatment area. • An active HSV infection in or near the treatment area: if there is an active HSV infection the appointment should be canceled until the area is properly healed. If there is a history of recurrent HSV infection near or in the area, which will be treated, oral antiviral prophylaxis should be considered. • Use of oral retinoids within the past year can increase the risk of scarring. • History of keloid or easy scarring: These patients can be prone to develop scarring after the treatment. • The presence of white ink in the tattoo: this can lead to paradoxal darkening after the treatment. • The type of tattoo: amateur, professional, cosmetic and medical: this can be important when you inform the patient about the possible results and treatment numbers. • Was there a treatment before? Depending on the experience of the laser surgeon and the type of tattoo one would advise to perform a test spot and evaluate the test within 4–8 weeks. After the treatment with a Q-switched laser the area will appear somewhat abraded in most of the cases. There is no

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consensus about the postoperative wound care. Most laser surgeons will apply an antiseptic dressing for a few days. To minimize postinflammatory hyperpigmentation it is recommended to avoid sun exposure and to use a UVA/UVB sunblock.

7.3.3.3 Adverse Events and Complications Q-switched laser treatment can lead to different complications as mentioned in Table 7.3.

Primarily Epidermal Adverse Events Crusting and blistering are transient side effects due to epidermal thermal damage. These side effects are expected in most cases. They are linked to excessive laser fluence or inadvertent absorption of laser energy attributable to the tattoo pigment. Although Q-switched lasers are the most appropriate devices for selective removal of tattoo particles in the skin there is always a possibility for pigment alterations. As described, hypopigmentation is a common side effect with all types of Q-switched lasers. This is often transient but can become permanent after repeated treatments. Hypopigmentation (Fig. 7.11) is difficult to treat but the use of UVB treatment or sun exposure can induce repigmentation. Hyperpigmentation following laser treatment of a tattoo is largely related to the skin type. Use of the 1,064 nm wavelength is preferable by patients prone to hyperpigmentation but transient hyperpigmentation is still common. Hyperpigmentation usually improves over time but the recovery time varies widely among patients. Treatment with hydroquinone containing cream and broad spectrum sunscreens can resolve the

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problem within a few months, although in some patients resolution can be prolonged [3].

Primarily Dermal Adverse Events Purpura and pinpoint bleeding are transient adverse events due to photoacoustic shattering of dermal capillary walls as a result of a high peak of laser energy, promoting extravasation of heated blood into the surrounding tissue. This phenomenon lasts approximately 7–14 days. Transient textural changes are often noted but usually resolve within 1–2 months. Permanent textural changes and scarring following Q-switched laser treatment of tattoos are very rare when the appropriate treatment parameters are used and the proper treatment guidelines are followed. Of course, laser energy can cause thermal damage to the dermis that can result in atrophic or hypertrophic scarring as can postoperative wound infection [21]. Be

Fig. 7.11 Hypopigmentation after Q-switched laser treatment of a professional tattoo (Source, Department of Dermatology, Ghent University Hospital, Ghent, Belgium)

Table 7.3 Q-switched laser treatment: different complications Primarily epidermal adverse events Primarily dermal adverse events Postoperative blistering Postoperative crusting Hyperpigmentation Hypopigmentation –

Purpura Pinpoint bleeding Scarring/textural change – –

– –

– –

Other complications Wound infection Oxidative darkening of pigment Allergic reactions after laser treatment Chrysiasis after laser treatment Scarring after Q-switched laser treatment of traumatic gunpowder tattoos Transient immunoreactivity Carcinogenic potential of molecules

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aware that the initial placement of the tattoo can also cause minimal scarring which will be more visible after removal of the tattoo ink. To prevent textural changes after treatment good wound care after tattoo removal laser treatment is necessary. In people prone to scarring and textural changes longer treatment intervals are recommended. The intermittent use of a topical steroid can reduce the development of hypertrophic scars in individuals at risk.

Other Complications Wound Infection Wound infections are rare and can be prevented by a good postoperative wound care. Bacterial infections are typically caused by Staphylococcus epidermidis or S. aureus and Candida infections are also possible. Herpes simplex can be reactivated when there is a history of repeated infections in or near the treated area. Oxidative Darkening of Pigment An important adverse effect seen especially with laser treatment of cosmetic tattoos is laser-induced immediate darkening of the tattoo inks. Red, brown, white, or flesh-colored inks, colors mainly used for cosmetic tattoos are at high risk for this type of reaction (Fig. 7.12). Therefore, cosmetic tattoos should be approached with extreme caution while attempting to remove them by any high-energy pulsed lasers, meaning with wavelengths in the visible trough near infrared region.

Fig. 7.12 Oxidative darkening of a cosmetic tattoo of the lip after 1064 nm Nd-Yag laser treatment (Courtesy of Dr. De Cuyper, Bruges, Belgium)

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The exact chemical mechanism of paradoxical tattoo ink darkening remains unknown but it is highly likely that the conversion of ferric oxide (Fe2O3) to ferrous oxide (FeO) and/or other iron components is involved. Many cosmetic tattoo inks contain iron oxide in the ferric form, which is “rust” or “rouge.” In contrast, FeO is black and can be derived from Fe2O3 by reduction. Every patient should be warned of the potential of cosmetic tattoo darkening. Also, test spot treatment should be performed initially. As the darkening reaction may temporarily be masked by the immediate whitening action after the laser treatment, the test site should be evaluated about 10 min after exposure. If darkening occurs in the test site, dark colors can be treated with a QS laser with another wavelength. This approach can sometimes offer a good result (see Chap. 5). Other options are conventional treatment options such as excision, dermabrasion, CO2 laser vaporization, make-up or no further treatment can be proposed. When these options are not acceptable retreatment can be proposed on a monthly base to assess whether the darkened ink can be removed [7]. However, even if a test area shows a good result there is no guarantee that complete clearing of the tattoo will be obtained [7]. Allergic Reactions After Laser Treatment (See Chap. 6) Localized and general allergic reactions (including anaphylaxis) are unusual complications following tattoo removal but have been reported with Q-switched laser treatment of tattoos (Fig. 7.13). De Cuyper observed an eczematous reaction in a patient with a black tattoo occurring 24 h after the third treatment with QS Nd-Yag laser 1,064 (Personal communication) (Fig. 7.14). A patch test with laser black ink evoked a positive reaction. These reactions are thought to be caused by altered antigenicity of the tattoo pigment by the laser. Systemic reactions following Q-switched laser treatment are more prevalent in patients exhibiting a localized allergic reaction at the tattoo site. In patients experiencing such reactions, an alternative treatment should probably be implemented, as it cannot be predicted when a more severe systemic reaction might occur [22]. These allergic reactions responded well to treatment with antihistamines and topical and/or systemic antibiotics.

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Chrysiasis The development of localized chrysiasis is a risk in any patient with a history of gold therapy who is exposed to Q-switched lasers or UV therapy. Chrysiasis presents as blue–gray pigmentation on the UV or laser-exposed areas and may develop many years after gold therapy is discontinued. Figure 7.15 shows a gray–blue pigmentation typical for chrysiasis in the face of a patient treated for lentigines with a laser or flashlamp (unknown type). The patient was treated with gold salts 20 year before for arthritis. The pathophysiology of chrysiasis is not entirely understood. The Q-switched laser impact results in structural alteration of the gold deposits, which is similar to what happens after UV-exposure. Treatment may be attempted with low-irradiance long pulsed lasers. It is wise to screen all patients treated with lasers

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routinely for previous gold therapy, even gold therapy that may be discontinued years earlier [23].

Scarring After Laser Treatment of Traumatic Tattoos Containing Gunpowder or Firework Debris In the literature, there are reports of the development of pox-like scars after Q-switched laser therapy of traumatic tattoos from patients who had dermal inclusions of gunpowder [24]. These pox-like scars are only reported if the tattoo resulted from gunpowder or firework debris being shot at a short distance from the skin. If a traumatic tattoo is suspected to contain gunpowder or firework debris treatment must be done prudently. A test should be performed and treatment must not be started if an abnormal reaction with sparking and transepidermal pitting occurs above the test area. Transient Immunoreactivity In the literature, two cases were reported with regional lymphadenopathy spatially and temporally related to laser tattoo removal [25]. The reactions resolved without any complications but should be recognized by laser surgeons. The exact mechanism of such immunoreactivity is unclear and should be examined more thoroughly in prospective studies.

Fig. 7.13 Local allergic reaction after Q-switched laser treatment of a red-pigmented tattoo probably containing mercury (Source, Department of Dermatology, Ghent University Hospital, Ghent, Belgium)

Fig. 7.14 Allergy with blistering after 1064 nm Nd-Yag laser treatment (Courtesy of Dr. De Cuyper, Bruges, Belgium)

Fig. 7.15 Chrysiasis developed after laser or flashlamp treatment in a patient treated with gold salts 20 years before (Courtesy of Dr. De Cuyper, Bruges, Belgium)

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Carcinogenic Potential of Molecules In the past, coloring agents were inorganic pigments. In recent years, azo dyes have become popular substances in tattoo inks. Since tattoo compounds are not officially controlled, in comparison to cosmetics, the origin and chemical structure of these coloring agents are hardly known. Consequently, neither the tattoo artist nor the tattooed person has any information about the compounds punctured into the skin. Treating this tattoo compounds with Q-switched laser molecules can break up resulting in decomposition products or molecular structure change. Because of fragmentation of the tattoo particles, unknown decomposition products and newly generated chemical compounds may then be removed from the skin via the lymphatic system. Recently experiments of laser-induced cleavage of tattoo pigment were performed by the department of dermatology and the institute of organic chemistry (University of Regensburg) [26]. Two widely used azo compounds were irradiated in suspension with laser and subsequently analyzed. The high laser intensities cleaved the azo compounds, leading to an increase of decomposition products such as 2-methyl-5-nitroanaline, 2, 5-dichloroaniline and 4-nitro-toluene which are toxic and even carcinogenic compounds. In order to quantify and judge the problems and health risks of tattoo and laser treatment further research is necessary to analyze and quantify laser-induced decomposition products in vitro and in vivo.

7.3.4 Conclusion Q-switched laser systems have improved the results of tattoo removal enormously over the last 15 years and have become the treatment of choice for tattoo removal nowadays. Although Q-switched laser treatment is a wonderful technique, no single Q-switched laser system can at present treat optimally all multicolored tattoos. Multiple treatments are normally required and may vary between 5 and 20 or more depending on the characteristics of the tattoo and the Q-switched laser device used. The complete clearance of laser treated tattoos is rare and there is no guarantee that the treatment will restore the skin to its original condition. Side effects and complications are possible. The most common side

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effects are hypopigmentation, hyperpigmentation, and textural changes. Another complication is laser induced immediate oxidative darkening of the tattoo inks. Mainly, cosmetic tattoos are prone to this darkening reaction. Adjunctive topical therapy and nonspecific treatment with surgery or ablative lasers can be necessary in some indications such as for tattoos with an allergic response, tattoo granulomas, and some cosmetic tattoos. As tattooing is becoming more popular there is an increasing amount of people requesting tattoo removal. Unfortunately the new flashy inks make tattoo removal with Q-switched lasers often disappointing due to complications and pigment resistance. The development of pigments that can be safely placed in the skin and removed, with or without lasers, and without causing any adverse reaction will be the challenge for the future.

References 1. Burris K, Kim K (2007) Tattoo removal. Clin Dermatol 25:388–392 2. Strong AM, Jackson IT (1979) The removal of amateur tattoos by salabrasion. Br J Dermatol 101(6):693–696 3. Kilmer S, Fitzpatrick R (2008) Tattoo lasers. http://www. emedicine.com/derm/topic563.html. Retrieved 25 Jun 2008 4. Wollina U, Köstler E (2007) Tattoos: surgical removal. Clin Dermatol 25:393–397 5. Saini R, Winhoven SM, Kaufman J (2008) Hypertrophic scar after chemical tattoo removal. Dermatol Surg 34: 1599–1602 6. Colver G (1989) The infrared coagulator in dermatology. Dermatol Clin 7:155–167 7. Anderson RR, Geronimus R, Kilmer SL et al (1993) Cosmetic tattoo ink darkening. A complication of Q-switched and pulsed laser treatment. Arch Dermatol 129:1010–1014 8. Mafong EA, Kauvar ANB, Geronemus RG (2003) Surgical pearl: removal of cosmetic lip liner tattoo with the pulsed carbon dioxide laser. J Am Acad Dermatol 48:271–272 9. Solis RR, Diven DG, Colome-Grimmer MI et al (2002) Experimental nonsurgical tattoo removal in a guinea pig model with topical imiquimod and tretinoin. Dermatol Surg 28:83–87 10. Ramirez M, Magee N, Diven D et al (2007) Topical imiquimod as an adjuvant to laser removal of mature tattoos in an animal model. Dermatol Surg 33:319–325 11. Ricotti CA, Colaco SM, Shamma HN et al (2007) Laser assisted tattoo removal with topical 5% imiquimod cream. Dermatol Surg 33:1082–1091 12. Anderson RR, Parrish JA (1983) Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 220(4596):524–527 13. Adatto MA (2004) Laser tattoo removal: benefits and caveats. Med Laser Appl 19:175–185

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14. Beute TC, Miller CH, Timko AL et al (2008) In vitro spectral analysis of tattoo pigments. Dermatol Surg 34: 508–516 15. Parrish JA, Anderson RR, Harrist T et al (1983) Selective thermal effects with pulsed irradiation from lasers: from organ to organelle. J Invest Dermatol 80:075S–080S 16. Goldman L, Wilson RG, Hornby P et al (1965) Radiation from a Q-switched ruby laser. Effect of repeated impacts of power output of 10 megawatts on a tattoo of man. J Invest Dermatol 44:69–71 17. Sl K (2002) Laser eradication of pigmented lesions and tattoos. Dermatol Clin 20(1):37–53 18. Talor CR, Gange RW, Dover JS et al (1990) Laser treatment of tattoos by Q-switched ruby laser. A dose-response study. Arch Dermatol 126(7):893–899 19. Grevelink JM, Duke D, van Leeuwen RL et al (1996) Laser treatment of tattoos in darkly pigmented patients: efficacy and side effects. J Am Acad Dermatol 34(4):653–656 20. Herd RM, Alora MB, Smoller B et al (1999) A clinical and histological prospective and controlled comparative study of the picosecond titanium: sapphire (795 nm) laser versus the

105 Q-switched alexandrite laser (752 nm) laser for removing of tattoo pigment. J Am Acad Dermatol 40:603–606 21. Zelickson BD, Mehregan DA, Zarrin AA et al (1994) Clinical, histologic and ultrastructural evaluation of tattoos treated with three laser systems. Lasers Surg Med 15:364 22. Ashinoff R, Levine VJ, Soter NA (1995) Allergic reactions to tattoo pigment after laser treatment. Dermatol Surg 21: 291–294 23. Geist DE, Philips TJ (2006) Development of chrysiasis after Q-switched ruby laser treatment of solar lentigines. J Am Acad Dermatol 55(2):S59–S60 24. Fousade T, Toubel G, Grognard C et al (2001) Treatment of gunpowder traumatic tattoo by Q-switched Nd:YAG laser: an unusual adverse effect. Dermatol Surg 26(11): 1057–1059 25. Izikson L, Avram M, Anderson RR (2008) Transient immunoreactivity after laser tattoo removal: report of two cases. Lasers Surg Med 40:231–232 26. Vasold R, Naarmann N, Ulrich H et al (2004) Tattoo pigments are cleaved by laser light. The chemical analysis in vitro provides evidence for hazardous compounds. Photochem Photobiol 80:185–190

Index

A Acrylonitrile butadienestyrene-plastic, 19 Additives, 19 Allergic contact-granuloma type, 65 Allergy, 32 dermatitis, 37 eczematous, 32 granulomatous, 32 lichenoid, 32 morphea, 35 Pseudoepitheliomatous hyperplasia, 33 pseudolymphoma, 32 vasculitis, 32 Allopurinol, 74 Aluminium, 64 American Association of Blood Banks, 10 Amputation, 39 Angiofibroma, 49 Angioneurotic oedema, 78 Aromatic amines, 21 Association of Professional Piercers, 10, 47 Auschwitz, 3 Azo dyes, 21 B Baal, 1 Bioflex, 14, 45 Bleomycin, 55 Blood donation, 10, 48 Body painting, 38 Branding, 5, 38 Breast feeding, 45, 50 Breast implant infection, 50 C Cadmium chloride, 67 Cadmium sulphide, 20 Cambodia, 4 Capri Jean Baptiste, 3 Captain Cook, 3 Carbon black, 19 Certification, 9 China, 2 Chinese ink, 19

4-Chloro-o-toluidine, 26 Chrome, 20 Chrysiasis, 103 Cobalt, 20 Colorants, 19 Condylomata accuminata, 48 Corset piercing, 44 Council of Europe, 18 Curcumine, 21 Cutting, 38 D Dental damage, 49 Dermabrasion, 74 Dermatography, 30, 54 3,3’-Dichlorobenzidine, 21, 26 Dimethylgloxime test, 14 Dye, 19 E Ear pointing, 39 Egyptian mummies, 1 Embedding, 5, 44 Endocarditis, 48 Erythema multiforme, 78 European Union Nickel Directive, 17, 46 Excision, 74 F Face painting, 38 Firework, 103 Flesh tunnels, 44 G Gingival damage, 49 Glass, 14 Glomerulonephritis, 48 Glycerin, 71 Gold, 14 Gold-allergy, 63 Granulomatous mastitis, 50 Gunpowder, 103

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108 H Hawaii, 3 Henna tattoos, 27, 36, 77 Black henna, 27, 77 Blue henna, 27, 77 complications, 37 Henna tattoos, complications, 37 contact dermatitis, 37 Hyperpigmentation, 37 Hypertrichosis, 38 Hypopigmentation, 37 Hepatitis, 9, 48 Hildebrandt Martin, 3 Hindu, 4 HIV, 48 Hyperprolactinemia, 50 I Imiquimod, 74, 94 Implantation, 44 Implants, 39 India, 4 Indigo, 20, 27, 37 Infection, 25 bacterial, 33 cellulitis, 33 endocarditis, 33 erysipelas, 33 gangrene, 33 leishmaniasis, 34 sepsis, 33 spinal abcesses, 33 Syphilis, 34 mycoses, 35 Candida endophtalmitis, 35 sporotrichosis, 35 zygomycosis, 35 viral, 34 Condylomata accuminata, 48 hepatitis, 34 herpes simplex, 34 HIV, 34 Mollusca contagiosa, 34 Warts, 34 Initiation ceremony, 4 Ink, 19 Inuit, 2 Iron oxide, 20, 67 Isaiah, 1 J Japan, 2 JewelEye, 44 K Kama sutra, 4 Karnavedha, 4 Keloids, 35, 48

Index L Laser Argon, 93 CO2, 93 fractional ablative laser, 94 Q-switched lasers Alexandrite, 96 Neodymium-YAG, 98 Ruby, 96 selective photothermolysis, 94 Laser irradiation, 26 Laser therapy, 74 complications, 101 Lawsonia inermis, 27, 36, 77 Leviticus, 1 Lichenoid, 76 Lichen planus, 35 Listerine, 45 Ludwigs angina, 48 Lupus discoid, 35 Lymphadenopathy, 103 M Magnetic Resonance Imaging, 35 Malady, 74 Malignancy, 26, 35 Manganese, 20 Medical procedures, 49 Mehndi, 36 Melanoma malignant, 35 Mercury, 20 Metallic oxides, 19 Metallic silver, 64 Metal salts, 67 Micropigmentation, 53 Mineral pigments, 19 Moko, 3 Morphea, 35 Mycobacterium, 50 N National Center for Toxicological Research, 10 Natural pigments, 21, 67 New Guinea, 4 New Zealand, 3, 7 Nickel allergy, 62 Nickel spot test, 14 Niobium, 14 Non-Hodgkin primary lymphoma, 35 O o-anisidine, 26 Omai, 3 O’Reilly Samuel, 3 Organic colorants, 68 Otzi, 1 Oxidative darkening, 102 P Palladium, 65 Palladium body-piercing ornaments, 65

Index Paraphenylenediamine (PPD), 27, 37, 77 Pentamonogalloylglucose, 55 Permanent make-up, 17, 75 complications, 56 allergic reaction, 56 infections, 56 legislation, 18 paradoxical darkening, 59, 102 Permanent tattoos, 17 legislation, 18 Photodecomposition, 26 Photothermolysis, selective, 26, 94 Piercing, 62 complications, 47 infections, 47 epidemiology, 4 history, 1 infections, 47 leprosy, 48 tetanus, 48 tuberculosis, 48 legislation in Europe, 17, 47 legislation in the US, 1 materials, 10, 13, 44 colours, 46 designs, 46 different types, 46 prevalence, 5, 7 (table 1.2) Australia, 7 Brazil, 7 Canada, 7 England, 7 Finland, 7 Germany, 7 Italy, 7 New Zealand, 7 Switzerland, 7 USA, 7 procedure, 44 types cheek, 4 ear, 4, 5 genital, 5, 49 lip, 4, 10 nipple, 4, 8 (fig 1.5), 45 umbilical, 5 Piercing retainers, 45 Pigment, 1, 4, 10, 19 carcinogenic potential, 10, 21, 26 Plastics, 14 Pneumonia, 48 Pocketting, 44 Poll, Harris, 5 Polycyclic amines, 21 Polytetrafluorethylene (PTFE), 14, 45 Pregnancy, 50 Prince Albert, 4 Prison, 4, 5, 9 (fig 1.7) Pseudolymphoma, 49, 70 Pseudolymphomatous and granulomatous inflammation, 76 Pseudo tattoos, 38

109 Psoriasis, 35 Purity, 21 Pyogenic granuloma, 48 R Reconstructive surgery, 55 Regulation, 9 Removal techniques, 74 Rockwell Norman, 3 Rush, 29 S Salt dermabrasion, 74 Santalin, 21 Sarcoidal tissue reaction to piercing with gold earrings, 65 Sarcoid-like granuloma, 49 Sarcoidosis, 35, 70 Scalping, 38 Scarification, 38 Scarring, 38 Scars atrophic, 48 hypertrophic, 35, 48 Sepsis, 48 Siberia, 2 Splitting the tongue, 5, 39 Stainless steel, 14 Stapling, 44 Sterilization of instruments, 9, 15 Steroids intralesional, 73 systemic, 73 topical, 73 Stretching, 4 Sunlight, 26 Sun tattoos, 38 T Tahiti, 3 Tatau, 3 Tattoo glues, 83 Tattoo Induced Immunologic Reaction (TIIR), 70 Tattooing amateur, 31 procedure, 31 professional, 31 Tattoo ink chemical analysis, 22 composition, 19 evolution, 19 ingredients, 25 removable, 24 test methods, 18 Tattoo pigments, 67 Tattoo removal, 91 chemical, 93 dermabrasion, 92 salabrasion, 91 Surgical excision, 92 thermal, 93

110 Tattoos complications, 25 epidemiology, 4 history, 1 instruments, 1, 10 tattoo machine, 3 legislation in Europe, 17, 47 legislation in the US, 1 materials, 10, 13 prevalence, 5, 6 (table 1.1) Australia, 6 Brazil, 6 Canada, 6 Germany, 6 Italy, 6 USA, 6 procedure, 31 amateur tattooing, 31 professional tattooing, 31 types amateur, 31 blood type, 4 cosmetic, 30, 53 cultural, 30 ethnic, 30

Index gang, 4 identification, 30 medical, 30, 53 ornamental, 31 professional, 31 traditional, 3 traumatic, 30 tribal, 30 Tattoo stickers, 67, 83 Temporary tattoos, 27 Thaipoosam, 4 Titanium, 14, 64, 67 Toxic shock syndrome, 48 Transfer tattoos, 38 Tretinoin, 74 U Urticaria, 78 V Vanadium, 64 W Waters Percy, 3 Wetting, 19