Tattoos: risks and complications, clinical and histopathological approach

Abstract

Background: Skin modification through tattoos is as old as humanity itself. However, this trend is on the rise, and with the use of different types of pigments and application practices, both cutaneous and systemic complications can arise. Adverse reactions can be grouped into five classes: inflammatory, infectious, neoplastic, aesthetic, and miscellaneous. On histopathology, inflammatory reactions can exhibit a lichenoid pattern or present as spongiotic dermatitis, granulomatous reactions, pseudolymphoma, pseudoepitheliomatous hyperplasia, or scleroderma/morphea-like changes. This article reviews tattoo complications, including their clinical and histopathological characteristics.

Methods: An open search was conducted on PubMed using the terms "tattoo", "complications", and "skin". No limits were set for period, language, or publication type of the articles.

Results: Reactions to tattoos are reported in up to 67% of people who get tattooed, with papulonodular and granulomatous reactions being the most common. Some neoplastic complications have been described, but their causality is still debated. Any pigment can cause adverse reactions, although red ink is more frequently associated with them. Patients with pre-existing dermatoses may experience exacerbation or complications of their diseases when getting tattoos; therefore, this procedure is not recommended for this patient group.

Conclusions: Dermatological consultation is recommended before getting a tattoo, as well as a histopathological examination in case of complications. In patients who develop cutaneous inflammatory reactions following tattooing, additional studies are recommended to investigate systemic diseases such as sarcoidosis, pyoderma gangrenosum, atopic dermatitis, and neoplasms. It is important for physicians to be trained in providing appropriate care in case of complications.

Keywords: Complications; Inks; Punctures; Skin; Tattooing.

Figure 1

Papulonodular lesions following cosmetic eyebrow tattooing. The final diagnosis was sarcoidosis. Photographic archive of the Dermatology Service at the University of Antioquia.

Figure 2

Papulonodular lesions over a black and red tattoo in the lower lumbar region. The histopathological diagnosis was pseudolymphoma. Photographic archive of the Dermatology Service at the University of Antioquia.

Figure 3

Lichenoid pattern. Epidermal hyperplasia, orthokeratosis, Malpighian layer with spongiosis and scattered dyskeratocytes. Vacuolar damage of the basal layer. In the dermis, there is an inflammatory infiltrate in a band-like pattern with some cytoid bodies containing black pigment, (Hematoxylin & eosin, [A] ×100, [B] ×400). Photographic archive of the Dermatopathology Laboratory, Dermatology Section, University of Antioquia.

Figure 4

Spongiotic dermatitis. Preserved thickness of the epidermis with marked spongiosis and some dyskeratocytes. Basal vacuolar damage. Black ink pigment is identified in the dermis, (Hematoxylin & eosin, [A] ×100, [B] ×400). Photographic archive of the Dermatopathology Laboratory, Dermatology Section, University of Antioquia.

Figure 5

Granulomatous inflammation of a sarcoid type. (A) Papulonodular lesions in a tattoo on the right scapular region. (B) Granulomatous infiltrate of sarcoid type associated with black ink pigment (Hematoxylin & eosin, ×400). Systemic studies revealed sarcoidosis. Photographic archive of the Dermatopathology Laboratory, Dermatology Section, University of Antioquia.

Figure 6

Sclerodermiform/morphea-like pattern. The epidermis appears unaltered in thickness. In the dermis, fibrosis with effacement of cutaneous appendages is observed, associated with deposition of black ink pigment, (Hematoxylin & eosin, [A] ×100, [B] ×400). Photographic archive of the Dermatopathology Laboratory, Dermatology Section, University of Antioquia.

Figure 7

Dermatofibroma. Dermis with non-encapsulated neoplasm of spindle cells with mild cytological atypia, surrounded by black ink pigment. The epidermis shows pseudoepitheliomatous hyperplasia, (Hematoxylin & eosin, [A] ×40, [B] ×100). Photographic archive of the Dermatopathology Laboratory, Dermatology Section, University of Antioquia.