Marie Leger, MD, PhD, on Managing Dermatologic Complications of Tattoos

Tattoos have become increasingly common in the United States over the past several decades, with the proportion of Americans with tattoos reaching 4 in 10 in 2017.¹

Although tattoo knowledge and technology have advanced considerably over the years, much remains to be learned about managing dermatologic complications–such as allergies, infections, and sarcoidosis–that can occur as a result of a tattoo.

Consultant360 reached out to board-certified dermatologist Marie Leger, MD, PhD, from Metro Dermatology in New York City, to discuss the topic further.

Consultant360: How did you become interested in the field of dermatologic complications of tattoos?

Dr Leger: Through giving talks about tattoos, questions from colleagues, and participating in our specialty's online forums, I have gotten to learn a lot about how dermatologists in the United States think about tattoos. One of the reasons I love this field so much is because although tattoos are incredibly common, there are a lot of knowledge gaps about managing complications, and there is still so much to learn about them.

Over the last 10 years, a few tattoo clinics have been established in Europe – specifically, in Copenhagen, Amsterdam, and Helsinki. These larger clinics with registers of hundreds of patients are producing a lot of research about the kinds of complications that can happen and how to manage them. It is fun to discuss this research and some of the pearls I have learned from my European colleagues with US physicians. 

C360: What are some common knowledge gaps when it comes to identifying and managing dermatologic complications of tattoos, and how can dermatologists appropriately counsel patients who express interest in getting a tattoo?

Dr Leger: I think many dermatologists are relatively conservative in their willingness to give advice on tattoos. They are certainly conservative about saying "okay, go for it." It is important to consider the whole patient when discussing potential risks, and tattoos can be very meaningful for patients, especially those with conditions like psoriasis and eczema that can have a significant impact on body image. For example, while Koebnerization can happen when patients with psoriasis get a tattoo (one small study reports almost 30%)³, research also suggests that tattoos may help these patients to feel positively about their skin and to have something they can control after so much unpredictability with their condition.

Furthermore, although patients who are immunosuppressed may have a higher infection risk, many tattoos – such as tattoos of the nipples after breast cancer, tattoos over certain kinds of scars, or eyebrow microblading in patients with alopecia areata – can  be a very helpful part of the healing process in this patient population.

A recent thought piece published on this topic by leaders in the field concludes that the only absolute contraindication is pregnancy.⁴

C360: What are some key symptoms dermatologists should look for when assessing potential dermatologic complications from a tattoo? For potential allergic reactions, is patch testing warranted?

Dr Leger: The question about patch testing is a very good one. However, patch testing does not seem to be very helpful in its current iteration in helping to evaluate patients with tattoo allergies. A published series of 90 patients from the Copenhagen clinic showed that patch testing was not usually positive in patients with diagnosed tattoo allergies, even when patients were tested with their own inks. This led the authors to conclude that the allergen is not in the ink bottle, but more likely a metabolite of the ink and possibly photo-derived, which can make allergy prediction difficult.⁵ Tattoo artists are sometimes asked to do screening tests, during which an ink to be used is tested intradermally or topically beforehand, but allergies to tattoo inks can occur weeks, months, or even years after exposure.

Additionally, repeated exposures can increase the risk of allergy. Some patients with tattoo allergies and surgical implants have positive patch tests to metals such as nickel, aluminum, titanium, and chromium. I attended the European Congress on Tattoo and Pigment Research meeting in Switzerland recently, and a big topic of discussion was recent endeavors by chemists, regulatory bodies, and physicians geared toward more precisely determining the ink breakdown products that can problematic, as well as developing patch testing series that may be more relevant to tattooed patients. Stay tuned!

Key elements of evaluating a tattoo complication include asking when a tattoo was placed, if it was professionally done, when the symptoms started, any associated sensations such as pain or itch, aggravating and alleviating factors (sunlight is a common one), and whether the complication involves all the ink of a certain color, more than one color, the surrounding skin, or just portions of the tattoo within one or more colors.

C360: How should dermatologic tattoo complications be treated?

Dr Leger: I will talk about 3 common complications. Bacterial infections, which usually occur days to weeks after obtaining tattoos, are red, painful, swollen, and sometimes ulcerated. For suspected bacterial infections, a swab (or if persistent or severe, a biopsy and tissue culture) should be obtained to determine the pathogen. Tattoos can become infected for a variety of reasons, including contaminated ink, poor aftercare, technique, contaminated water used to dilute the ink, etc., and the artist can help determine the source and help prevent future infections. The ink bottle used in the affected tattoo should also be obtained and cultured.

For tattoo allergies, mild reactions such as scale, pruritus, and mild inflammation can be treated with topical or intralesional steroids. For more elevated or symptomatic allergies, I have seen many dermatologists (including myself in the past) refer to plastic surgery for removal. This usually yields poor cosmetic outcomes. Scarring can be severe when tattoos are excised to the depth of the fat without respecting tattoo contours, and also when skin grafts are used. Instead, ablative lasers can be successfully used. Clinicians could also use a recently published technique called "dermatome shaving," in which the tattoo is removed with a dermablade a few millimeters at a time until ink is no longer observed, and is left to heal by secondary intention.⁶ These techniques yield much better outcomes than surgery. I have seen patients tattoo over the area after it has been treated and is no longer symptomatic with a different color with good results. Patients should avoid future tattoos with the affected color. 

Tattoo sarcoidosis can present very subtly, often just as small papules and nodules associated with the tattoo ink and sometimes surrounding skin. Sarcoidosis occurs most often in black ink, though other colors can be affected. A recent case series from Copenhagen shows that these patients seem to be at a high risk for systemic sarcoidosis and can have associated uveitis, pulmonary findings, and erythema nodosum.⁷ It is important to perform a complete review of systems and physical exam and to monitor these patients closely, as one would for other cutaneous sarcoidosis patients.

C360: What key takeaways would you like to leave with dermatologists and related clinicians about tattoo complications?

Dr Leger: A few take home points to remember are:

• Examine your patients’ tattoos carefully when you perform skin checks. They will often not point out any problems to you, and many complications (especially sarcoidosis) can have very subtle findings.
• Contact the patient’s tattoo artist if any problems arise. Most of the artists I have worked with are very professional, take their craft very seriously, and are important partners in evaluating and avoiding complications. 
• Try to treat severe or recalcitrant tattoo allergies with ablative lasers or dermatome shaving. The results I have seen are so much better than with cruder surgical excision!
   

—Christina Vogt

Published in partnership with the American Academy of Dermatology.

References:

1. Armstrong, M. 4 in 10 US adults have a tattoo. Statista. June 2017. https://www.statista.com/chart/9980/us-adults-with-a-tattoo/. Accessed on April 15, 2019.

2. Tattoo complications may warrant a trip to the doctor [press release]. Washington, DC: American Academy of Dermatology; March 2019. https://www.aad.org/media/news-releases/tattoo-complications. Accessed on April 15, 2019.

3. Kluger N, Estève E, Fouéré S, et al. Tattoing and psoriasis: a case series and review of the literature. In J Dermatol. 2017; 56(8):822-827. doi:10.1111/ijd.13646.

4. Kluger N, De Cuyper C. A practical guide about tattooing in patients with chronic skin disorders and other medical conditions. Am J Clin Dermatol. 2018;19(2):167-180. https://doi.org/10.1007/s40257-017-0326-5.

5. Serup J, Hutton Carlsen K. Patch test study of 90 patients with tattoo reactions: Negative outcome of allergy patch test to baseline batteries and culprit inks suggests allergen(s) are generated in the skin through haptenization. Contact Dermatitis. 2014;71(5). https://doi.org/10.1111/cod.12271.

6. Sepehri M, Jørgensen B, Serup J. Introduction of dermatome shaving as first line treatment of chronic tattoo reactions. J Dermatol Treat. 2015;26(5):451-455. doi:10.3109/09546634.2014.999021.

7. Serup J, Sepehri M, Hutton Carlsen K. Classification of Tattoo complications in a hospital material of 493 adverse events. Dermatology. 2016;232:668-678. https://doi.org/10.1159/000452148.