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Photo: Mateo Matthias Nielsen
Disease and treatment

More and more people need hospital treatment for tattoos

For the first time globally, Danish researchers have clinically classified the allergies, infections and lump growths resulting from the tattooing trend. The numbers are considered the tip of the iceberg and suggest that the tattoo trade today is an unregulated cowboy industry.

As many as 600,000 Danes have decorated their skin with tattoos, but these beautiful inked works of art are increasingly ending up requiring painful hospital treatment. For the first time globally, Danish researchers have clinically classified the allergies, infections and lump growths resulting from the tattooing trend. The numbers are considered the tip of the iceberg and suggest that the tattoo trade today is an unregulated cowboy industry.

The doctor slowly scrapes off the top blood-red skin layer with two extremely sharp razor blades. The blood slowly trickles out again from the skin underneath and rebuilds what were once the colours of a beautifully tattooed Danish flag. Yet another shaving operation is over, and Majken Jensen is on the way to being free of the complications to which a growing number of tattoos lead.

“It began with the tattoo never healing properly, and when it finally did, I could not let it get wet or go outside in the summer. So I went to the doctor and they found out that I had blood poisoning and infections. I was admitted to hospital and given penicillin. So this has not been fun at all,” explains Majken Jensen.

“A few years ago we performed one shaving operation a month, but now there is a waiting list for our weekly shaving operations, and no evidence suggests that fewer people will require treatment in the coming years,” explains Mitra Sepehri, a doctor and PhD student at the Copenhagen Wound Healing Center of Bispebjerg University Hospital in Copenhagen and an author of an article describing the first systematic classification of the complications of tattooing.

RED AND BLACK INKS ARE THE MAJOR CAUSES

The study covered the 492 severe complications of tattooing treated by the Tattoo Clinic (Department of Dermatology) at Bispebjerg University Hospital from 2008 to 2015. About one third of the complications were allergic reactions; 13% arose from agglomeration of the pigment; 11% resulted from bacterial infections such as Staphylococcus caused by contaminated ink; and 9% were psychosocial complications. Other people also had problems with sensitivity to sunlight and pain.

“The red pigment used in tattoos is the major cause and triggered the most allergic reactions and the most severe ones. In the very severe cases, we have to remove the tattoo surgically: removing the top layer of skin, which is like scraping the skin away.”

Sarcoidosis is one of the most severe complications, affecting 5% of those with complications. This disease creates abnormal collections of inflammatory cells that form lumps in the lungs, skin or lymph nodes. Sarcoidosis is a serious inflammatory condition that often disappears over 2–5 years, but about 2% of the people who have it become chronically ill. The cause in this situation is the black pigment because, for unknown reasons, it clumps together in the skin and causes inflammation.

“The problem is that some tattooists put far too much pigment under the skin so the skin is overfilled. Severe complications arise because the excess pigment cannot escape. We can often solve this by shaving: scraping off the top layer of skin – the epidermis and most of the dermis – to allow the pigment to escape. However, in more severe cases, the pigment penetrates more deeply into the dermis or into the subcutis. This means that we have to shave deeper, with a greater risk of major scarring, infections or slower healing.”

THE WORLD’S BEST TATTOO CLINIC

Bispebjerg University Hospital established the Tattoo Clinic led by Jørgen Serup in 2008 in response to the growing number of severe tattoo complications, and this enabled the new classification study. Today, the Tattoo Clinic is a global leader, and this new study demonstrates a completely new system for classifying tattoo complications, which the researchers have sent to the World Health Organization to be included in the 11th revision of the International Classification of Diseases.

“It is horrible to witness this growth in the number of people with tattoo complications. Nevertheless, it is great that the people who previously had to seek help randomly can now come to one place and be examined, offered proper treatment and followed up,” explains Jørgen Serup.

The Tattoo Clinic thoroughly investigates people’s tattoo complications and prepares a treatment plan. Luckily, most people with complications can be treated with hormone (steroid) cream and antihistamines. However, for serious complications, the Clinic can refer patients directly for surgery at the Copenhagen Wound Healing Center, which is located next to the Tattoo Clinic at Bispebjerg University Hospital.

“Previously, patients wandered around the healthcare system or ended up at tattooists, who removed tattoos using such things as lactic acid, resulting in severe acid burns. From the start, we have systematically registered and followed up on all types of complications and the effects of shaving surgery after 3, 6 and 12 months. This enables us to both provide the right treatment and also tell others about it.”

A COWBOY INDUSTRY WITHOUT THE SHERIFF

How many of the estimated 600,000 tattooed Danes have complications is not known, but the number of people attending the Tattoo Clinic is presumably only the tip of the iceberg.

“Many people with tattoos have severe complications and discomfort that strongly influence their daily lives and their quality of life, but they rarely consult a doctor about them. Although more and more doctors refer patients to our Clinic, most are still treated by general practitioners and dermatologists. The strain on the public healthcare system is massive and probably underreported.”

According to the researchers, however, the greatest challenge is the lack of certification of tattooists in the trade and legislation on the types of tattooing ink permitted.

“This is a cowboy industry; neither Danish nor EU legislation regulates the tattoo trade. Strict legislation regulates pharmaceuticals, requiring thorough testing before marketing. Cosmetics and make-up are also extremely strictly regulated; all materials must be tested and approved for skin contact. However, paradoxically, no legislation governs tattoo pigment, even though this is injected under the skin.”

The researchers estimate that 80% of all tattooing ink is far from sterile and can therefore be full of bacteria and other unwanted substances. In addition, previous experimental studies on animals have shown that many inks contain carcinogens. The researchers are therefore carrying out experiments on mice in which they examine the extent to which the pigment disperses throughout the body and the long-term effects this might have for the health of people with tattoos.

Majken Jensen’s red tattoos have ruined the past two years of her life: blood poisoning, severe allergies, hospitalization and constant treatment with penicillin. She therefore hopes that other people can avoid this.

“I had not been told that many people cannot tolerate the red pigments. I really wish that I had known this because I would probably not have chosen the red colours and might not have ended up here,” concludes Majken Jensen.

Classification of tattoo complications in a hospital material of 493 adverse events” has been published in Dermatology. In 2015, the Novo Nordisk Foundation awarded a grant to Jørgen Serup, Tattoo Clinic, Bispebjerg University Hospital, for the project Pigment Aggregations in Black Tattoos and the Development of Granuloma and Sarcoidosis Studied Using Polarized Light Microscopy. An introduction to shaving surgery can be found here.

Inspired by Copenhagen, Amsterdam is the second city in the world to have opened a tattoo clinic, at VU University Medical Center Amsterdam. The 3rd European Congress on Tattoo and Pigment Research is being held in Regensburg, Germany on 28– 30 March 2016. The 1st European Congress was held at Bispebjerg Hospital in Copenhagen in 2013.

FACTS ABOUT TATTOOS

About 600,000 adults in Denmark (13%) have a tattoo – with an equal number of men and women. Two thirds experience severe skin problems after tattooing, with bleeding, scabs, itching and swelling in the following weeks. About one third develop chronic or periodic itching or swelling triggered by sun exposure. Tattooing can result in severe bloodborne viral or bacterial infections such as HIV, chronic hepatitis or blood poisoning (sepsis). Strong allergic reactions, mostly from red tattoos, such as chronic itching and swelling, can result in deep wounds. Black pigment can trigger pain and itching that can be incapacitating. Thirteen percent of those tattooed regret it because they fear being considered vulgar and with poor taste because they have chosen a type of tattoo that is no longer popular.

Source: Tatovering – helbred, risici og kultur [Tattooing – health, risks and culture], Council on Health and Disease Prevention, April 2015 (in Danish with an English summary)