Modern tattoos cause high concentrations of hazardous pigments in skin

Background:  Modern tattoo colourants frequently consist of azo pigments that not only contain multiple impurities but also are originally produced for car paint and the dyeing of consumer goods.
Objective:  In order to be able to assess the health risk of tattoos, it is important to determine the pigment concentration in human skin.
Methods:  We tattooed excised pigskin and human skin with a common tattoo pigment (Pigment Red 22) under various conditions. After tattooing, we quantitatively extracted the pigment in order to determine the pigment concentration in skin.
Results:  The concentration of pigments ranged from about 0.60 to 9.42 mg/cm² of tattooed skin (mean value 2.53 mg/cm²) depending upon the size of the pigment crystals, the pigment concentration applied to the skin surface, and the respective procedure of tattooing.
Conclusion:  In conclusion, high concentrations of colourants are injected into the skin during tattooing and based upon this quantification, a risk assessment of tattooing ought to be carried out.     

Optische Kohärenztomographie

Optical coherence tomography (OCT) is a high-resolution imaging method for in vivo investigation of the human skin. In cross-sectional images of several millimeters length with a penetration depth of the light signal into deeper parts of the dermis, architectural details of the upper skin layers can be assessed and monitored non-invasively over time. The resolution is not high enough to visualize cellular details. Several studies have been performed using OCT to assess its significance as a diagnostic tool for dermatology. The actual technical configuration of OCT is suitable to assess therapeutic effects objectively and to observe skin changes over time.     

In vivo optical coherence tomography of basal cell carcinoma

BACKGROUND: Optical coherence tomography (OCT) is a promising non-invasive imaging technique that has not systematically been studied in skin cancer such as basal cell carcinoma (BCC). OBJECTIVE: We aimed, first, to describe the in vivo histologic features of BCC by using OCT, and second, to find out whether it is possible to differentiate BCC subtypes by means of OCT. METHODS: Prior to the excision, the BCCs (n=43) as well as adjacent non-lesional skin sites were assessed by OCT in vivo. The lesional area of interest was marked prior to OCT and tattooed after excision, respectively, in order to enable topographical concordance between the cross-sectional OCT images and the histologic sections. RESULTS: Compared to non-lesional skin, a loss of normal skin architecture and disarrangement of the epidermis and upper dermis was observed in the OCT images of BCCs. Features that were frequently identified by OCT and correlated with histology included large plug-like signal-intense structures, honeycomb-like signal-free structures, and prominent signal free cavities in the upper dermis. With regard to the aforementioned OCT features, no statistically significant (P<0.05) difference was found between nodular, multifocal superficial, and infiltrative BCCs, respectively. CONCLUSIONS: OCT is capable to visualize altered skin architecture and histopathological correlates of BCC. However, there is not at this time sufficient data supporting the clinical use of OCT for the differentiation of BCC subtypes.     

Advances in optical coherence tomography imaging for dermatology

Optical coherence tomography (OCT) is a non-invasive imaging technique, which has previously demonstrated potential for use in dermatology. The purpose of this study is to demonstrate how improvements in image quality, speed, and functionality enable qualitative and quantitative information to be obtained from in vivo human skin. We developed a portable fiber-optic based OCT imaging device that requires only 1 second to simultaneously provide high-resolution images of skin structure, collagen birefringence, and blood flow. Images of normal human skin were acquired in vivo, and features compared with clinical and histologic observations. The layered structure and appendages of skin were apparent in conventional OCT images, and correlated well with corresponding histology. Polarization-sensitive OCT images simultaneously revealed birefringent regions within the dermis corresponding to the location of collagen fibers, as confirmed with polarized light microscopy. Properties of collagen-rich tissues including tendon and scar tissues were quantified. Location of blood flow was also displayed alongside structural and polarization-sensitive images. Significant improvements in OCT technology have been made since its early application in dermatology. In particular, combining the previously described structural and Doppler imaging functions with polarization-sensitive imaging increases the utility of the technique for rapid, non-invasive investigations in the skin.     

Lichenoid red tattoo reaction: histological and immunological perspectives

As tattooing practices increase, delayed-type inflammatory reactions represent an uncommon adverse event to tattoo pigments. Different reaction patterns, such as eczematous, lichenoid, granulomatous and pseudolymphomatous reactions, have been previously reported, especially in association with metals contained in red tattoo pigments. We report a lichenoid papular reaction to an organic red tattoo ink, characterized by an intense mononuclear infiltrate dominated by CD8(+) T cells and CD56(+) lymphocytes and distributed in the superficial dermis around the red pigment and in the epidermis. Cytofluorimetric analysis of the lesional skin infiltrate confirmed the high frequency of cytotoxic CD8(+ )T cells and CD56(+)CD16(-) lymphocytes, most of which release type 1 cytokines. Chemical analysis of the red tattoo pigment confirmed its organic nature and the presence of intermediate reactive compounds. The lichenoid tissue reaction to red organic tattoo pigment showed the prototypical features of a cytotoxic inflammatory response to foreign substances (xenobiotics). The chemically unstable and reactive nature of modern tattoo pigments has to be taken into account by the clinician as well by the tattoo recipients.     

In vivo imaging of intradermal tattoos by confocal scanning laser microscopy

BACKGROUND/AIMS: In vivo confocal laser scanning microscopy (CLSM) is a new method for high-resolution imaging of intact skin in situ. Horizontal mapping of the outer skin is provided (magnification x 1000). OBJECTIVES: Tattooing is popular all over the world; however, tattooed skin has not been studied in using CLSM. RESULTS: Tattoos in two volunteers were studied using the Vivascope1500 of Lucid Inc. Subepidermal massive deposits of dense, clustered pigment granules up to about 3 mum in size corresponding to black tattoos, and more scarce and diffuse deposits, corresponding to red, blue and green tattoos, were observed. Diffuse pigment granules tended to accumulate in the outer dermis underneath the level of the basement membrane zone. CONCLUSIONS: Dermal pigments from tattoos can be imaged in vivo using CLSM. This application of CLSM has an important future potential for pre-evaluation of tattoos before laser removal, predicting good or poor outcome of laser removal.     

Optical coherence tomography (OCT) of collagen in normal skin and skin fibrosis

Optical coherence tomography (OCT) is a non-invasive imaging modality that is transforming clinical diagnosis in dermatology and other medical fields. OCT provides a cross-sectional evaluation of the epidermis and dermis and allows in vivo imaging of skin collagen. Upregulated collagen content is a key feature of fibrotic skin diseases. These diseases are often managed by the practitioner’s subjective assessment of disease severity and response to therapies. The purpose of this review is to provide an overview of the principles of OCT and present available evidence on the ability of OCT to image skin collagen in vivo for the diagnosis and management of diseases characterized by skin fibrosis. We review OCT studies that characterize the collagen content in normal skin and fibrotic skin diseases including systemic sclerosis and hypertrophic scars secondary to burn, trauma, and other injury. We also highlight several limitations of OCT and suggest enhancements to improve OCT imaging of skin fibrosis. We conclude that OCT imaging has the potential to serve as an objective, non-invasive measure of collagen’s status and disease progression for use in both research trials and clinical practice. The future use of OCT imaging as a quantitative imaging biomarker of fibrosis will help identify fibrosis and facilitate clinical examination in monitoring response to treatment longitudinally without relying on serial biopsies. The use of OCT technology for quantification of fibrosis is in the formative stages and we foresee tremendous growth potential, similar to the ultrasound development paradigm that evolved over the past 30 years.     

Optical coherence tomography in dermatology: technical and clinical aspects

Optical coherence tomography (OCT), a fairly new non-invasive optical real-time imaging modality, is an emergent in vivo technique, based on the interference (Michelson interferometry) of infrared radiation and living tissues, that allows high-resolution, 2- or 3-dimensional, cross-sectional visualisation of microstructural morphology of tissues. OCT provides depth-resolved images of tissues with resolution up to a few micrometers and depth up to several millimetres depending on tissue type. The investigations using OCT to assess skin structure in clinical settings started in the past decade and consequently proved that this imaging method is useful in visualizing subsurface structures of normal skin, including the epidermis, dermoepidermal junction, dermis, hair follicles, blood vessels and sweat ducts. An increasing number of papers brought evidence of the utility and the precision of OCT technology, in its different technical variants, in diagnosing and monitoring skin disorders, including malignancies and inflammatory conditions, respectively. The present comprehensive review describes and illustrates technical aspects and clinical applications of OCT methods in dermatology.     

The decrease of pigment concentration in red tattooed skin years after tattooing

Background Tattooing entails the injection of high amounts of colourants into skin. Excepting black inks, red azo pigments are the most frequent colourant used. Part of the pigment is transported away via lymphatic system. Another part can be decomposed in skin, which might be responsible for many known adverse skin reactions. Objective The aim of this study was to estimate the extent of decomposition and transportation by measuring the decrease of pigment concentration in human skin under in vivo conditions. Methods Red pigments were extracted from nine tattooed skin specimen and attempted quantification by using HPLC technology. To optimize quantification, we synthesized five common red azo pigments with purity at 98% and used them as HPLC reference substances. Results In five of the nine skin specimens, we were able to identify and subsequently to quantify the red tattoo pigments such as Pigment Red 22 or Pigment Red 112. The mean pigment concentration in skin was 0.077 ± 0.046 mg/cm². As the pigment concentration in skin ranges from 0.60 to 9.42 mg/cm² (mean: 2.53) directly after tattooing, we estimate a decrease of 87 to 99% of pigment concentration in skin after tattooing. Conclusion Millions of people have many and large tattoos, whereas a single tattoo frequently covers a skin area of more than 300 cm². Thus, the major part of more than 760 mg of azo pigments either decomposes in skin or migrates in the body. That may pose a health risk on tattooed individuals, in particular may cause severe skin reactions.     

Non‐invasive imaging of mid‐dermal elastolysis

Mid‐dermal elastolysis (MDE) is a rare disease that is characterized histopathologically by selective loss of elastic tissue in the mid dermis. We aimed to assess MDE using noninvasive skin imaging techniques in vivo. We examined both the lesional and adjacent healthy skin of a woman with the reticular variant of MDE, using confocal scanning laser microscopy, optical coherence tomography (OCT) and high‐frequency ultrasound (HFUS). The median diameter of blood vessels at the top of dermal papillae was significantly increased in erythematous lesional skin compared with healthy skin. The mid‐dermal signal intensity detected by OCT was higher in healthy skin than in lesional skin. With HFUS, mid‐dermal density values were significantly higher in healthy skin than in lesional skin. Our preliminary findings indicate that noninvasive skin imaging methods such as OCT and HFUS might be suitable techniques for the evaluation and monitoring of elastolytic skin disorders such as MDE.     

Red tattoo reactions

Considering the ever increasing popularity of tattoos, significant reactions remain unusual. Red pigments are the commonest cause of delayed tattoo reactions. Histology typically shows extensive lichenoid basal damage, well away from the dermal pigment. We report two cases of lichenoid reactions to red tattoo pigment and review the literature on the subject.     

Massive pseudoepitheliomatous hyperplasia: an unusual reaction to a tattoo

We document an unusual tattoo reaction presenting as verrucous plaques, which on histopathologic examination showed marked pseudoepitheliomatous epidermal hyperplasia. The patient is a 27-year-old female who presented to her dermatologist complaining of itchy overgrowth of her tattoo. Her symptoms began 2 months after tattoo placement approximately 1 year ago. Physical examination revealed verrucous plaques in the purple areas of the tattoo, suggesting a clinical diagnosis of a granulomatous tattoo reaction. A superficial biopsy showed epidermal hyperplasia somewhat reminiscent of a regressing keratoacanthoma. No tattoo was identified. A repeat shave biopsy demonstrated marked epidermal hyperplasia with focal keratin filled cystic dilatations, and local mild reactive keratinocytic atypia. In the surrounding dermis, there was dense chronic inflammation, fibrosis, and granules of dark red pigment. These findings suggest marked pseudoepitheliomatous hyperplasia secondary to the tattoo. Different reaction patterns have been described in association with tattoos, such as granulomatous and/or perivascular lymphocytic inflammation. However, there have been few cases reported of pseudoepitheliomatous hyperplasia arising at a tattoo site. Therefore, we encourage physicians to consider massive epidermal hyperplasia in the differential diagnosis of a verrucous tattoo reaction.     

Skin from various ethnic origins and aging: an in vivo cross-sectional multimodality imaging study

Background: Ethnic differences in skin structural features have not been thoroughly investigated, and the few reported studies are contradictory. Thus, we have carried out a set of in vivo measurements on the skin of about 400 volunteers from various ethnic origins living in the same environment.
Methods: Female subjects were distributed into four ethnic groups: African Americans, Mexicans, Caucasians, and Chinese. Inter- and intra-ethnic skin structural differences, according to age and anatomic site, were investigated using three non-invasive skin-imaging methods: ultrasound (US) at 25 and 150 MHz, and optical coherence tomography (OCT).
Results: The thickness of the skin is higher on the cheek compared with the dorsal and ventral forearm, with no ethnic or age-related specificity. We confirm that the sub-epidermal non-echogenic band is a sensitive marker of skin aging, and reveal for the first time that it is less pronounced in African Americans. From OCT images, we bring out evidence that the thickness of the dermal–epidermal junction (DEJ) decreased with age, and was higher in African Americans than in Caucasians. Finally, by comparing US images at 150 MHz with OCT images, we show that papillary dermis thickness can be measured and appears to be quite constant irrespective of age or ethnic group.
Conclusion: Our study confirms that skin imaging is very attractive to further our knowledge of the morphology of skin from various ethnic origins. Regarding age effects, quantitative parameters have shown that they would be delayed in African Americans compared with all other ethnic populations.     

Granulomatous tattoo reaction induced by intense pulse light treatment

Cosmetic tattooing involves implantation of pigments into the dermis in order to create a permanent makeup. Here, we report a case of sarcoidal granulomatous reaction to old cosmetic tattoos after an intense pulsed light (IPL) treatment for facial skin rejuvenation. We consider this case as a peculiar example of photo-induced reaction to tattoo. In addition, we hypothesize that an underlying immune dysfunction was present, and acted as a predisposing factor for this unusual response, as the patient had suffered from an episode of acute pulmonary sarcoidosis 15 years before. Overall, our observation suggests that IPL treatment should be used cautiously in patients with tattoos, especially when a history of autoimmune disease is present.     

Laser Removal of Tattoos

Tattoos are placed for different reasons. A technique for tattoo removal which produces selective removal of each tattoo pigment, with minimal risk of scarring, is needed. Nonspecific methods have a high incidence of scarring, textural, and pigmentary alterations compared with the use of Q-switched lasers. With new advances in Q-switched laser technology, tattoo removal can be achieved with minimal risk of scarring and permanent pigmentary alteration. There are five types of tattoos: amateur, professional, cosmetic, medicinal, and traumatic. Amateur tattoos require less treatment sessions than professional multicolored tattoos. Other factors to consider when evaluating tattoos for removal are: location, age and the skin type of the patient. Treatment should begin by obtaining a pre-operative history. Since treatment with the Q-switched lasers is painful, use of a local injection with lidocaine or topical anaesthesia cream may be used prior to laser treatment. Topical broad-spectrum antibacterial ointment is applied immediately following the procedure. Three types of lasers are currently used for tattoo removal: Q-switched ruby laser (694nm), Q-switched Nd:YAG laser (532nm, 1064nm), and Q-switched alexandrite laser (755nm). The Q-switched ruby and alexandrite lasers are useful for removing black, blue and green pigments. The Q-switched 532nm Nd:YAG laser can be used to remove red pigments and the 1064nm Nd:YAG laser is used for removal of black and blue pigments. The most common adverse effects following laser tattoo treatment with the Q-switched ruby laser include textural change, scarring, and pigmentary alteration. Transient hypopigmentation and textural changes have been reported in up to 50 and 12%, respectively, of patients treated with the Q-switched alexandrite laser. Hyperpigmentation and textural changes are infrequent adverse effects of the Q-switched Nd:YAG laser and the incidence of hypopigmentary changes is much lower than with the ruby laser. The development of localized and generalized allergic reactions is an unusual complication following tattoo removal with the Q-switched ruby and Nd:YAG lasers. Since many wavelengths are needed to treat multicolored tattoos, not one laser system can be used alone to remove all the available inks and combination of inks. While laser tattoo removal is not perfect, we have come a long way since the advent of Q-switched lasers. Current research is focusing on newer picosecond lasers, which may be more successful than the Q-switched lasers in the removal of the new vibrant tattoo inks.     

Akkumulation von Tatoo-Pigment im Sentinellymphknoten

A 22-year-old woman presented with a superficial spreading melanoma on her right thigh (tumor thickness 1.0 mm, Clark-Level III). She also had decorative tattoos on her right ankle, right groin and coccyx. The staging results gave no indication for metastases. Intra-operatively, we observed a black pigmented lymph node highly suspicious for metastatic disease, but histological examination excluded metastatic spread and detected the accumulation of black pigment within the lymph node. Clinical differentiation between tattoo pigments and metastatic disease within lymph nodes is not possible. Histological confirmation of an enlarged pigmented lymph node is therefore essential before radical surgery is performed. Hence, accumulation of tattoo pigment within enlarged and pigmented lymph nodes needs to be included into the differential diagnosis and the documentation of decorative tattoos is important during skin cancer screening as well as during the follow-up of melanoma patients.     

Successful removal by ruby laser of darkened ink after ruby laser treatment of mismatched tattoos for acne scars

Cosmetic tattoos are becoming increasingly popular. Elimination of cosmetic tattoos is sought because of misplacement or migration of tattoo pigment, allergic reactions to the various pigments or dissatisfaction of the customer for various reasons. Removal of unwanted pigment is a domain of laser surgery using various Q-switched laser systems, such as the ruby, alexandrite, pulsed dye and Nd:YAG lasers. Dark colours are easily removed by these lasers, whereas red, pink and skin-toned pigment may turn black if exposed to Q-switched laser light. This ink-blackening occurs because Q-switched lasers heat up the pigments, which consist of ferric oxide, and reduce them into ferrous oxide, which is black. Laser-induced black ink is not always readily removed. A successful ruby laser-removal of laser-induced blackened cosmetic tattoos for acne scar camouflage is reported. The advantageous outcome in this case contrasts with other published cases where laser-darkened pigment had to be removed by other measures, or was permanent. Test site treatment can limit the problem to some degree but, in addition to test-treating, some kind of 'tattoo identification card' could help to prevent problems in this field and allow 'in vitro' test treatment.     

Necrotizing Black Tattoo Reaction

We report the rare case of an 18-year-old man who developed a necrotizing cutaneous reaction 5 days after having a permanent black tattoo on his left forearm spelling his name. Three cases of reactions to permanent black tattoos have been reported within the literature. These cases described the development of cellulitis of the skin adjacent to the tattoo but none reported florid necrotizing cutaneous reactions. The initial management with oral antibacterials failed to resolve the symptoms and use of intravenous antibacterials and topical corticosteroids was needed. Six weeks after presentation the tattoo lettering showed the presence of hyperpigmented skin. Subsequent patch testing confirmed that the patient had no allergy to black tattoo pigments suggesting that the necrotizing cutaneous reaction was secondary to infection. We show that successful treatment of this rare infective complication of permanent black tattoos involves the early institution of intravenous antibacterial agents and topical corticosteroids.     

The Q-switched neodymium: YAG laser and tattoos: a microscopic analysis of laser-tattoo interactions

The Nd:YAG laser effectively removes or lightens amateur and professional tattoos. The biomechanics of the removal of tattoo particles at the cellular level are incompletely understood. We examined biopsies obtained from 35 amateur and professional tattoos (including coloured tattoos), treated on three or more occassions with the Nd:YAG laser. Biopsies taken immediately after laser treatment showed vacuolation with complete clearance of tattoo particles in the most superficial layers of the dermis, as assessed by light and electron microscopy. We propose that the ‘disappearance’ of the tattoo particle arises from the formation of atomic species and gaseous products, which are rapidly dissolved in the extracellular fluid. Residual fragmented particles that are commonly found in the mid-and lower dermis are rephagocytosed. The interaction between the Nd:YAG laser and black tattoo particles at 1064nm, and red tattoo particles at 532nm, appears to be specific, as there was little evidence of thermal damage to adjacent cells or stromal collagen.     

Tattooing of skin results in transportation and light-induced decomposition of tattoo pigments – a first quantification in vivo using a mouse model

Abstract:  Millions of people are tattooed with inks that contain azo pigments. The pigments contained in tattoo inks are manufactured for other uses with no established history of safe use in humans and are injected into the skin at high densities (2.5 mg/cm²). Tattoo pigments disseminate after tattooing throughout the human body and although some may photodecompose at the injection site by solar or laser light exposure, the extent of transport or photodecomposition under in vivo conditions remains currently unknown. We investigated the transport and photodecomposition of the widely used tattoo Pigment Red 22 (PR 22) following tattooing into SKH-1 mice. The pigment was extracted quantitatively at different times after tattooing. One day after tattooing, the pigment concentration was 186 μg/cm² skin. After 42 days, the amount of PR 22 in the skin has decreased by about 32% of the initial value. Exposure of the tattooed skin, 42 days after tattooing, to laser light reduced the amount of PR 22 by about 51% as compared to skin not exposed to laser light. A part of this reduction is as a result of photodecomposition of PR 22 as shown by the detection of corresponding hazardous aromatic amines. Irradiation with solar radiation simulator for 32 days caused a pigment reduction of about 60% and we again assume pigment decomposition in the skin. This study is the first quantitative estimate of the amount of tattoo pigments transported from the skin into the body or decomposed by solar or laser radiation.