Adverse reactions to tattoos.

Sir,

I imagine Dr Wollina's ears are burning. Indeed, I have been spreading nothing but good words about Dr Wollina's superb retrospective analysis of “severe and adverse events related to tattooing.”[1] Such an area of dermatology simply does not receive the glitz it deserves. With the estimated incidence of 0.02%, this makes for a significant caseload at the population level. As tattoos become more commonplace amongst Western culture the number of complications is set to rise. Certainly I learn much about my patients from their tattoos, which are often only revealed on the operating table and, during the recent years, I have noticed a marked increase in the prevalence of tattoos.

I propose that dermatology heads must seriously consider setting up databases of adverse reactions to tattoos to aid prospective study. Knowledge of the conditions under which the tattoo was created as well as patient factors is invaluable to further our understanding of adverse reactions. Only with a sufficiently powered prospective observational study will we be able to identify any specific factors predisposing to such a fascinating casemix. With so many variables including the type of ink used, equipment used to apply it and the conditions under which it is done we can only postulate mechanisms. Large-scale observational studies will help to elude the mechanisms and, more importantly, culprits.

I believe the pigments would be the offenders in many of the reactions described.[23] However, regulatory bodies may not have as much control over the situation of inks as much as we would hope. For example, in the United States, tattoo inks are considered to be cosmetics; consequently, the Food and Drugs Authority does not have the authority to exert stringent regulation.[4] Earlier this year, in the United States, there were reports of a breakout of non-tuberculosis mycobacterial skin infection stemming from a single ink company.[5] It is the responsibility of tattoo parlours to warn about potential adverse affects following tattoo art. Indeed, I suspect, although tattoo artists will be aware of the infective complications of tattoos, fewer will be aware of the more florid reactions that present to the medical profession.[6] Ultimately, close work between dermatological associations and tattoo parlours will be warranted to facilitate feedback of adverse reactions and reduce their incidence. As India and the rest of the East becomes more Westernised, we can expect an increase in reports of these adverse reactions due to the increase in variety of inks used. We must stay ahead whilst we can by being vigilant.