TATTOO REACTIONS
Dr Clare D’Alberto, (from R. Dawkins, “The Greatest Show on Earth”, Bantam Press, 2009)
Once principally the preserve of rough and ready males of the armed forces and, more often than not, of somewhat lower intelligence than the average, tattoos in the 21st century now adorn the bodies of both sexes, of all walks of life. Indeed they can now be seen even within the highest intellectual circles, Dr Clare D’Alberto, who poses with her tattoo in Richard Dawkin’s, “The Greatest Show on Earth”, being a case in point. Dr D’Alberto is a Melbourne graduate zoologist whose, as Dawkins aptly puts it, “interest in the diversity of life is more than just skin deep”.
One of the most profoundly interesting observations of life on Earth is its universal “cousinship”. Every living organism from the archaea to human is ultimately related to all other life forms if you trace back the family trees far enough into deep geological time - geological time scales that are measured in billions of years. How fascinating it would be to see laid out before you the entire family tree of all life on Earth, to be able to trace the lineages of any life form back through the eons of time to see how it is related to other life forms, and indeed to ourselves. One such attempt exists in the form of the Hillis plot, constructed by David Hillis and colleagues. Hillis, whose brother Danny Hillis was a pioneer of one of the first supercomputers, constructed a circular plot, instead of the usual traditional format of the laid out linear arrangement, in order to compact far more information into a visually comprehendible scale. The tiny feathered points at the periphery of the circle show individual species, including the relative position of humans, yet so vast is the tree of life, this plot only represents a mere 3000 species. Some estimates currently put the number of species on Earth at over 10 million! The sampling in the Hillis plot is so necessarily contracted to appreciate an overview of all life, that the closet relatives of Homo sapiens on the plot are rats and mice! Dr D’Alberto’s tattoo represents one of the highest intellectual pursuits in biology today, it is a scaled down version of the Hillis plot, “tree of life”. Her tattoo shows a small sample of 88 species, (the number of terminal twigs). The gap in the circular plot can now be seen at this scale and imagined opened out into the more traditional linear representation. The smaller peripheral images represent a sampling of the major groups of life, chosen from the bacteria, protozoa, plants, fungi, and four animal phyla.
In previous times the decision to have a tattoo would involve a calculated risk between adornment and infectious disease. A risk that not many of higher intellectual faculties were willing to indulge. Today however, in the proper hands, this risk is far less and those of far greater intellectual capacity are now more than comfortable to take it. It should be noted however, that while the risk of infectious disease is extremely low in the right hands, there remains a small and unpredictable risk of hypersensitivity skin reaction.Tattoos perhaps show a universal cousinhood of the human psyche, all walks of life and both sexes seem to share a desire for them now that the risks of bygone times are very much reduced. Tattoos are known to have existed in all cultures as far back as Neolithic times. The particular images chosen on the other hand are very much a matter of individual taste –whilst the desire for adornment appears to be universal, beauty on the other hand is in the eye of the beholder! Ms D’Alberto’s tattoo shows an arresting beauty of both form and of mind.
TATTOO REACTIONS
Introduction
Tattoos are an ancient body art form with origins that trace back as far as the Stone Age.
In more recent times permanent injected tattoos weretraditionally seen in males, in particular in those of the armed forces.
Today however they are increasingly popular in young people from all walks of life and of both sexes.
The infectious complications of tattoos are fortunately less common than seen previously due to improved awareness of infectious complications and higher standards in general among tattooists.
Nonetheless the introduction of foreign chemicals into the skin can result in toxic or immunologic reactions and because of the recent increased popularity of tattoos these reactions are now being seen more often.
Temporary painted on tattoos, can also produce a contact dermatitis depending on what chemicals are used. These reactions are usually much less severe than those seen with permanent injected tattoos.
Pathology
Chemical composition of pigments:
The composition of tattoo pigment colors is as follows:
Black: Carbon (India ink), iron oxide, logwood
Blue:Cobalt aluminate
Brown:Ferric oxide
Green: Chromic oxide, lead chromate, phthalocyanine dyes
Purple: Manganese, aluminum
Red:Mercuric sulfide (cinnabar), sienna (ferric hydrate), sandalwood, brazilwood, organic pigments (aromatic azo compounds)
White: Titanium oxide, zinc oxide
Yellow:Cadmium sulfide
Complications:
Tattoos can result in a number of complications including:
1.Infectious:
●Pyogenic infections
●Hepatitis B
●Hepatitis C
●HIV
●Human papilloma virus, (warts)
2.Acute inflammatory reactions:
●This is a normal reaction to the injection of foreign chemicals and metals into the skin, and the usually resolve within 2-3 weeks.
3.Allergic hypersensitivity reactions:
●Once the normal acute inflammatory changes have resolved, the most frequent reaction observed with tattoos is an allergic hypersensitivity to one of its pigments which presents as an eczematous type skin reaction.
●Hypersensitivity to red pigments is most common, especially those containing mercuric sulfide (cinnabar).
●Allergic hypersensitivity reactions may also take more chronic glaucomatous or lichenoid forms
4.Photo-aggravated reactions:
●Inflammatory reactions may occur with some pigments on exposure to sunlight
●These reactions are most commonly caused by yellow (cadmium sulfide) tattoo pigments.
Clinical Assessment
Hypersensitivity Reactions to Permanent Injected Tattoos:
Hypersensitivity reactions to tattoos are characterized by:
1.Intense localized itching
●This may have its onset weeks to months after the tattoo.
2.Erythema
3.Localised edema
4.Eczematous type reactions, with desquamation of epidermis.
5.A reaction may be confined to a particular colour region within the tattoo. This implies a reaction to a particular chemical or metal component of the pigment
Severe chronic hypersensitivity reaction with intractable pruritus associated with the red pigments of this 40 year old’s tattoo. Symptoms had begun approximately 4 months after placement of the tattoo.1
Contact Dermatitis Reactions to Temporary Painted Tattoos
It should be noted that even temporary painted on tattoos (as opposed to the permanent injected sort), can result in a significant contact dermatitis depending on exactly what chemicals are being used, (see also Contact Dermatitis guidelines).
Temporary henna tattooing is a custom at weddings in much of the world, especially in the Indian subcontinent and the Middle East. Henna is a vegetable dye that can be brown, red or green, and it wears off in a matter of days.
However,tattoo henna is often mixed with paraphenylenediamine (PPD) to hasten drying anddarken the color. PPD is a common allergen that is also found in permanent hairdyes.The US Food and Drug Administration lists the only legal cosmetic use for PPD as a hair dying agent, (makes the hair jet black).PPDis a very commoncause of contact dermatitis.
Henna that has been mixed with PPD therefore is a common source of allergic reactions in temporary “paint on” tattoos, as demonstrated below:
Contact dermatitis ina nineteen year old Kuwaiti woman caused by a Henna tattoo that contained PPD. Burning and itching began 6 days after the tattoo which was then followed by a significant blistering reaction.The patient was treated with high-potency topical corticosteroids, and the lesions resolved, although with extensive post inflammatory hyperpigmentation.2
Investigation
Specific investigation will not usually be necessary, as the diagnosis of an allergic hypersensitivity reaction will most commonly be a clinical one.
The following may need to be considered in some cases:
Pyogenic infection:
If pyogenic infection is suspected, the following may be considered:
●FBE
●CRP
●U&Es/ glucose
●Swab for microscopy and culture of any discharging purulent material
Viral transmission:
If the tattoo was not done to high standards of sterile technique or by a reputable tattooist, then transmitted viral diseases may need to be ruled out:
●Hepatitis B serology
●Hepatitis C serology
●HIV serology
Biopsy:
Ultimately a biopsy of the inflamed region, may be required to establish the exact nature of the reaction.
Histologic sections of the resected skin of the lesion shown above revealed an intense, chronic inflammatory reaction to tattoo pigment, characterized by moderate, irregular epidermal hyperplasia, marked dermal fibrosis, and a dense, patchy infiltrate of lymphocytes and histiocytes surrounding the areas of granular, refractile red pigment (Panel B, arrows). Other areas, nearly devoid of inflammation and fibrosis, showed only granular black pigment between collagen bundles of the superficial dermis (Panel B, arrowhead).1
Management
Pyogenic infection is treated along conventional lines.
Contact dermatitis to painted tattoos
●These usually respond well to high potency topical steroids.
Hypersensitivity reactions to injected permanent tattoos
Hypersensitivity reactions to injected permanent tattoos are often unfortunately very difficult to treat and may require referral to a dermatologist or even on occasions a plastic surgeon.
Options include:
1.Antihistamines:
●These may give some relief of pruritic symptoms.
2.Steroids:
●Both topical and intra-dermal injections may be tried.
●In the case demonstrated above however neither of these treatments were effective
3.Laser therapy:
●Specialized laser phototherapies can be tried. These may even be able to target specific pigment-containing structures in the skin. In the case above however event this treatment was not effective.
4.Surgical excision:
●Excision and spilt skin grating may ultimately be necessary for severe and intractable chronic skin reactions that have not responded to other more conservative methods of treatment.
The Hillis Plot, this “‘tree of life” plots 3000 species, a very small representation of all life on Earth of - perhaps 10 million species? (from R. Dawkins, “The Greatest Show on Earth”, Bantam Press, 2009)
References
1.Cook J, and Metcalf J. Images in Clinical Medicine “Tattoo Allergy”, NEJM vol 361, July 2, 2009, e1.
2.Colby C. Evans and John D. Fleming. “Images in Clinical Medicine”, Allergic Contact Dermatitisfrom a Henna Tattoo, NEJM, August 7, 2008.
Dr J. Hayes
14 January 2010