Docs Corner

Risks of Tattooing
The practice of tattooing skin dates back thousands of years to ancient times. Since the 1970s, tattoos have become a mainstream part of global and Western fashion, common among both sexes, to all economic classes, and to age groups from the later teen years to middle age. For many young Americans, the tattoo has taken on a decidedly different meaning from previous generations. The tattoo has undergone dramatic redefinition and has shifted from a form of deviance to an acceptable form of expression. Although there is little data regarding the prevalence of tattooing, surveys in the US suggest the prevalence has increased to 25-40%, depending on age groupings. The growth in tattoo culture has seen an influx of new artists into the industry, many of whom have technical and fine arts training. This has been coupled with advancements in tattoo pigments and the ongoing refinement of the equipment used for tattooing and the quality of tattoos being produced.
The skin is now often thought of as just a “covering” of our body. Many, especially young people write on it, draw on it, pierce it, graffiti it and generally treat it as an “Oh, well”. Skin is the largest vital organ of our bodies. Our skin is actually made up of more than a trillion living cells with our unique DNA and 46 chromosomes containing more than 6 billion base pairs. These cells are very physiologically active and must replicate themselves with an exact copy every 7-15 days. Skin cells are influenced by their environment or exposure, as are all of our cells. Use of various soaps and deodorants can affect the skin. Excessive drying and exposure to radiation rays, i.e.. sun exposure, can have potential serious adverse effects. The skin reacts with varying inflammatory response to irritating and toxic exposures. What about the potential adverse effect of being injected with pigmented dyes?
How often do people stop to consider the potential short and long term adverse outcome effects of having their skin injected with dye to have a tattoo. Little information is available about the incidence of complications of tattooing because they are infrequently reported to state health departments or in the medical literature. Potential concerns for consumers include unsafe practices and the ink itself, said Dr. Linda Katz, director of the FDA’s Office of Cosmetics and Colors in an FDA health alert, May, 2017. Localized infections and skin reactions appear to be the most frequent complications; however, the release of serosanguineous fluid and blood during/after the tattooing procedure may result in blood-borne diseases. Hepatitis B and C can be transmitted during tattooing, particularly when tattoos are obtained in unregulated establishments, which may reuse or inadequately sterilize instruments. While you can get serious infections from unhygienic practices and equipment that isn’t sterile, infections can also result from ink that was contaminated with bacteria or mold. Using non-sterile water to dilute the pigments (ingredients that add color) is a common culprit, although not the only one. There is no foolproof way to tell if the ink is safe. An ink can be contaminated even if the container is sealed or the label says the product is sterile. Research shows that some tattoo inks contain pigments used in printer toner or in car paint. No pigments for injection into the skin for cosmetic purposes have FDA approval.
A number of reactions may occur after you get a tattoo. You might notice a rash— redness or bumps — in the area of your tattoo, and you could develop a fever. More aggressive infections may cause high fever with shaking, chills, and sweats. Treating such infections might require a variety of antibiotics— possibly for months — or even hospitalization and/or surgery. A rash could also mean you’re having an allergic reaction and because the inks are permanent, the reaction may persist for days, weeks months, and in rare cases, indefinitely. Other problems may show up later. After getting a tattoo, you may develop scar tissue including unsightly keloid formation reflecting an intense inflammatory reaction. The tattoo might lead to swelling and burning when you undergo an MRI (due to metal fragments in the ink), so be sure to disclose to your doctor prior to scheduling an MRI.
Tattoos are generally considered permanent. Tattoo pigments are not approved by the US Food and Drug Administration (FDA) for intradermal use and contain nonstandardized ingredients. Although we are aware that all tattoos invoke at least an acute inflammatory response by the cell, that varies considerably between individuals and with the various inks and injection techniques employed. We have less awareness of the body’s reaction to having a foreign substance injected that may remain in the body (not on the body) for 50-75 years. Most of the commercially available tattoo compounds are azo pigments or polycyclic compounds, some of which are potentially carcinogenic.
Little information is available about tattoo removal in adolescents and young adults. In one survey of college students, 6 of 149 tattoos (4 percent) had been removed. In a 2015 survey of 2225 adults, 23 percent of those with tattoos reported having had regrets. Common reasons for regret included being too young when they got it, the tattoo no longer reflects their lifestyle, the tattoo was poorly done, and the tattoo is no longer meaningful or has become embarrassing. Although laser techniques have been successfully employed to remove tattoos, this is never accomplished without residual scarring. All too often the residual scarring may have residual discomfort and be unsightly. Remember as well that although the original tattoo may have been relatively expensive, the removal effort will always cost more and will NEVER be completely satisfactory.
Prior to proceeding with a tattoo, consider the risks v. benefits. This is not a decision that should be made at the spur of the moment, with the intimidation of others or while intoxicated. All behavior has consequences. One can best influence the consequences before they occur.
Paul R. Block, MD, FACP, FCCP

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