Identification of pigments related to allergic tattoo reactions in 104 human skin biopsies.

BACKGROUND: Red tattoos are prone to allergic reactions. The identity of the allergen(s) is mostly unknown. OBJECTIVES: Chemical analysis of human skin biopsies from chronic allergic reactions in red tattoos to identify culprit pigment(s) and metals. MATERIAL AND METHODS: One hundred four dermatome biopsies were analyzed by matrix-assisted laser desorption/ionization tandem mass spectrometry (MALDI-MS/MS) for identification of commonly used organic pigments. Metal concentrations were assessed by inductively coupled plasma (ICP)-MS and x-ray fluorescence (XRF). Fourteen patients had cross-reactions in other red tattoos. RESULTS: In total, the identified pigments were mainly azo Pigment Red (P.R.) 22 (35%), P.R. 210 (24%), P.R. 170 (12%), P.R. 5 (0.9%), P.R. 112 (0.9%), and Pigment Orange (P.O.) 13 (11%). P.R. 122 (0.9%) and Pigment Violet (P.V.) 23 (8%) were also common. P.R. 22, P.R. 170, and P.R. 210 also dominated in patients with cross-reactions. In 22% of the biopsies, no red pigment was detected. Element analysis indicated the presence of the sensitizers nickel and chromium. CONCLUSIONS: P.R. 22, P.R. 170, and P.R. 210 were identified as the prevailing pigments behind chronic allergic reactions in red tattoos. The epitope causing the reaction might be a pigment-degradation product. Metal contamination may derive from different sources, and its role in red tattoo allergy cannot be ascertained.

Tattoo pigment agglomerates measured in commercial ink stock products by computerised light microscopy.

BACKGROUND: The incidence of clinical complications such as granuloma formation and sarcoidosis is often seen in black tattoos and may be associated with agglomeration of black pigment. AIM: To measure count and dimensions of agglomerates in black tattoo inks vs red inks and to compare old inks and new inks of identical brands. METHOD: Examination was performed by light microscopy (Olympus BX51™ ) with magnification 40X, immersion oil. Photographs (Jenoptik Gryphax RGB camera) were taken of each ink sample and analysed by ImageJ software; count, area, width, height, circumference and circularity index were measured. Agglomerates were defined as width and height of objects above 800 nm. Twenty-one new unopened black inks and 17 new unopened red inks were compared. Furthermore, five old black inks and five old red inks, that had been opened and stocked for over 2 years, were compared with new products of the same brands. RESULTS: Black agglomerates were area wise and with respect to width, height and circumference significantly larger compared with red agglomerates and more circularly shaped. Count of agglomerates was lower in black inks than in red inks, in accordance with bigger dimensions of black agglomerates. Comparison of old and new inks indicated old inks have larger agglomerates but variable bottle size and storage conditions may have confounded results. CONCLUSION: Pigment agglomerates in black tattoo ink stock products were sized larger than agglomerates in red inks. Agglomerates found directly in black inks may predispose to granuloma formation in black tattoos causing sarcoid reaction.

Tattooist-Associated Tattoo Complications: "Overworked Tattoo," "Pigment Overload" and Infections Producing Early and Late Adverse Events.

BACKGROUND: Tattooist-related technical failures of tattooing were hitherto unstudied and related to clinical complications. Tattooing requires talent, training and experience. Amateurism is a challenge in popular tattoo industry with no formal education and certification of the tattooists. OBJECTIVE: To study technical tattoo failures causing disease in a consecutive hospital material of tattoo complications. MATERIAL: 574 patients with 702 tattoo complications referred to the "Tattoo Clinic" (a subspecialised dermatological clinic) were enrolled. Patients were examined clinically and classified with respect to the cause of complication. RESULTS: 147 (21%) tattooist and tattoo studio-related complications were recorded, i.e. excessive pigment installed in the dermis with "pigment overload" in 64 (9%), tattoo "needle trauma" with "overworked tattoos" in 43 (6%), contaminated ink causing infection in 20 (3%), and other sources of infections related to tattooing in 20 (3%). Pain and discomfort were particularly common as well as long-term complications including scarring induced by "needle trauma." "Pigment overload" with black pigment carried a special risk of granulomatous inflammation and sarcoid granuloma and was observed in 12/35 (34%) of punch biopsies taken from tattoos with "pigment overload." Keratoacanthoma associated with trauma was observed in 1 case. 82% of complications were related to professional tattooists working in a tattoo studio and 18% to amateurs. CONCLUSION: Technical failures of tattooing are associated with medical tattoo complications. "Needle trauma" with major skin damage, e.g. "overworked tattoo," and installation of excessive pigment, e.g. "pigment overload," and (re)use of contaminated tattoo ink bottles are identified failures calling for preventive intervention.

Tattoo pigment agglomerates measured in skin biopsies by computerised light microscopy: Study of 161 patients with adverse reactions in black and red tattoos.

BACKGROUND: Black tattoo reactions are suggested to be foreign body reactions manifested as papulo-nodular inflammation that is associated with active sarcoidosis. AIM: To study the morphology of black and red pigment agglomerates in skin biopsies from tattoo reactions, referenced to clinical diagnoses. METHOD: Agglomerate count, area, width, height, circumference and circularity were measured in 161 patients by light microscopy (Olympus BX51™); 161 unstained skin biopsies from 64 black tattoo reactions and 97 reactions in red tattoos with allergy. Images (Jenoptic Gryphax RGB camera) were taken through a 40× objective using immersion oil. Computerised analysis of agglomerates was performed using ImageJ software. Student t test, chi-square test, Fisher Exact test, ANOVA and Bonferroni tests were applied. RESULTS: Comparison of black and red pigment agglomerates showed no overall differences in count, area, width, height or circumference. However, in black tattoo reactions, the count of agglomerates was higher in patients with sarcoidosis (P = .009) vs no sarcoidosis. Black agglomerates were more circular shaped as compared to red, P = .023. In red tattoo reactions, agglomerates in patients with allergic cross-reactivity were slightly more circular (P = .036) vs patients with milder allergy. The count of red agglomerates was lower in patients clinically typed excessive hyperkeratosis (P = .041) compared with other clinical types of allergy. CONCLUSION: Patients with reactions in black tattoos associated with sarcoidosis have increased count of pigment agglomerates vs those without associated sarcoidosis indicating that black pigment agglomeration is one among a number of factors triggering sarcoid tattoo complication. Circular shape of agglomerates may code for bioactivity.

Search for Internal Cancers in Mice Tattooed with Inks of High Contents of Potential Carcinogens: A One-Year Autopsy Study of Red and Black Tattoo Inks Banned in the Market.

BACKGROUND AND OBJECTIVE: Tattoo ink stock products often contain potential carcinogens, which on large-scale population exposure may be clinically relevant. The aim of this autopsy study in mice was to screen major organs for clinical and subclinical cancers. METHODS: Mice were tattooed on their backs. In total, 48 mice were included and divided into 4 groups; 11 mice tattooed black, 10 tattooed red, and 5 mice serving as untreated controls. A group of 22 mice with black tattoos and exposed to ultraviolet radiation (UVR) were also studied. The black and red inks were both stock products banned on the Danish market due to the measured contents of potential carcinogens; benzo(a)pyrene and 2-anisidine, respectively. The mice were housed for 1 year after tattooing, and autopsy study on internal organs was performed. Tissue samples were systematically taken from major organs for screening of subclinical changes, not detected by visual examination. Any observed deviation from normal structure was subject to biopsy and light microscopy. RESULTS: All mice survived the 1-year observation period. Autopsy revealed no macroscopic signs of cancer. Microscopic search of internal organs showed no subclinical or clinical cancer. CONCLUSION: Despite extensive tattoos with 2 banned inks, the long-term observation in mice showed no internal cancers nor was the combination of carcinogen and UVR associated with cancer. Lack of observed malignancy might be explained by the fact that tattooing is only a single dose exposure. Registered data on carcinogens relies on repeated or chronic exposures. The study does not support the hypothesis that tattooing causes cancer.

Laser Surgeon, Client Education, and Satisfaction with Tattoo Removal.

Studies of satisfaction with tattoo removal outcomes by laser, rated by clients themselves, including qualitative aspects, are sparse. We studied long-term results and client satisfaction with tattoo removal by Q-switched YAG laser. Client satisfaction is influenced by numerous factors: pretreatment expectations, objective observations, pretreatment information, laser treatment procedures, and outcome, including subjective experiences such as pain. Client-surgeon interaction during the full laser treatment course is a major determinant of client satisfaction. The client is in a dynamic state of mind and undergoes a change of opinion during a laser treatment course as a result of his/her experiences. In this continuous process of learning, expectations are changed from a state of high expectation before treatment to a more realistic state with acceptance of outcome. The laser surgeon shall be aware of his/her role as a tutor and prepare the client for a situation, where outcomes can be acceptable albeit not ideal.

Classification of Tattoo Complications in a Hospital Material of 493 Adverse Events.

BACKGROUND/AIMS: Tattooing is a global trend. Clinical knowledge of complications is based on case reports collected over a century. Larger cohorts reflecting complications associated with contemporary trends are lacking. METHODS: The study was a retrospective review of a consecutive cohort of patients with tattoo complications diagnosed in the "Tattoo Clinic" of Bispebjerg University Hospital in Copenhagen, Denmark, from 2008 to 2015, based on patient history and systematic clinical examination. RESULTS: A total of 493 tattoo complications in 405 patients were studied. Overall, 184 (37%) presented allergic reactions with plaque elevation in 32.2%, excessive hyperkeratosis in 3.7%, and ulceration in 1.4%, predominantly observed in red tattoos and nuances of red; 66 (13%) presented papulo-nodular reactions, mainly observed in black tattoos (considered non-allergic) and due to pigment agglomeration; 53 (11%) had bacterial infections; 46 (9%) were psycho-social complications; 144 (30%) belonged to several specific diagnostic entities, including photosensitivity, pain syndrome, and lymphopathy. We found no cases of cutaneous or other malignancies. Sarcoidosis was primarily seen in black tattoos and was a common associated disease, found in 23 reactions (5%), compared to the background population. CONCLUSION: The study introduces a new concept of classification of tattoo complications based on simple tools such as patient history and objective findings supplemented with histology. The study reflects complications originating from presently used tattoo inks, often with organic pigments. The introduced classification has been submitted to the World Health Organisation (WHO) as a proposal to the 11th revision of the International Classification of Diseases.

Papulo-Nodular Reactions in Black Tattoos as Markers of Sarcoidosis: Study of 92 Tattoo Reactions from a Hospital Material.

BACKGROUND/AIMS: Sarcoidosis is, from historical data, suggested to be more prevalent among patients with tattoo reactions. We aimed to evaluate this association in a systematic study. METHODS: This is a consecutive study of patients with tattoo complications, diagnosed in the "Tattoo Clinic" at Bispebjerg University Hospital in Copenhagen, Denmark, from 2008 to 2015, based on clinical assessment and histology. From the overall group of 494 tattoo complications in 406 patients, 92 reactions in 72 patients showed a papulo-nodular pattern studied for local and systemic sarcoidosis, since sarcoidosis is expected to be nodular. RESULTS: Of the 92 reactions with a papulo-nodular pattern, 27 (29%) reactions in 19 patients were diagnosed as cutaneous or systemic sarcoidosis, supported by histology; 65 (71%) were diagnosed as non-sarcoidosis due to histology and no clinical sarcoid manifestations. "Rush phenomenon" with concomitant reaction in many other black tattoos, triggered by a recent tattoo with a papulo-nodular reaction, was observed in 70% in the sarcoidosis group and 28% in the non-sarcoidosis group, indicating a predisposing factor which may be autoimmune and linked with sarcoidosis. Agglomerates of black pigment forming foreign bodies may in the predisposed individual trigger widespread reaction in the skin and internal organs. CONCLUSION: Black tattoos with papulo-nodular reactions should be seen as markers of sarcoidosis. Papulo-nodular reactions may, as triggers, induce widespread reactions in other black tattoos - a "rush phenomenon" - depending on individual predisposition. Sarcoidosis is estimated to be 500-fold increased in papulo-nodular reactions compared to the prevalence in the general population, and the association with black tattoos is strong.

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.

BACKGROUND: Tattoo reactions, especially in red tattoos, are often suggested as allergic in nature, however, systematic evaluation by patch testing has not performed in the past. OBJECTIVE: To report the results of patch testing in 90 patients with non-infectious chronic tattoo reactions. MATERIALS/METHODS: From 2009 to 2013 at the 'Tattoo Clinic', Department of Dermatology, Bispebjerg University Hospital, 90 patients were patch tested with batteries of baseline allergens, disperse dyes/textile allergens, and a selection of tattoo ink stock products, which, according to case observations, were problematic, supplemented with individual culprit inks when accessible. RESULTS: Patients with reactions to the tattoo colour red, the most predominant colour associated with skin reactions, showed negative patch test results with common allergens. Outcomes were also negative in patients who had experienced concomitant reactions in another hitherto tolerated tattoo of the same colour as the problematic tattoo. DISCUSSION/CONCLUSION: The allergen or allergens responsible for tattoo reactions are not present directly in tattoo ink stock products. This is despite the fact that clinical histories suggest that the vast majority of clinical reactions, especially reactions to red and red nuances, are likely to be allergic events caused by the injected inks. We suggest that the responsible allergen results from a complicated and slow process of haptenization, which may even include photochemical cleavage of red azo pigment.