Are you among those who share a love for tattoos like me? Tattooing has become more than a decorative art; it is a symbolic art of self-expression. But did you know there are potential risks associated with it?. This popular body modification can lead to infections if proper care is not taken. Let us learn about the different types of infections arising from tattoos and their complications. 

How is a tattoo done?

The history of tattoos goes back to when they were first found on the Iceman and ancient Egyptians. It gained popularity in Western culture around the 18th century and became a sign of rebellion in the 19th and 20th centuries when it was associated with sailors and bikers. Fast forward to today, every other celebrity and countless everyday people have them. So, how exactly is tattooing done?. It is essentially done in the following steps:

1. Choosing the design and body part
2. Preparing the stencil
3. Sterilizing the tools(needles) and preparing the skin
4. Tattooing with the tools
5. Aftercare and healing

With the use of tools such as needles in tattooing, it is necessary to ensure proper sterilization and hygiene. Contaminated needles, improper aftercare, or allergic reactions contribute to developing infections and complications. 

Causes and symptoms of tattoo infections

Possible reasons for tattoo infections can be any of the following:

1. Unclean skin— It is necessary to clean your skin before and after the process
2. Non-sterile water— If the water used to prepare the ink is not clean, it can cause infection
3. Dirty tools— Proper sanitization of the needles and equipment should be done in a manner 
4. Contaminated tattoo ink— Sometimes water is mixed with ink to obtain the desired color, and this water should be clean
5. Ink ingredients— The ink ingredients can be harmful, such as synthetic pigments used in textiles, metal salts, chemicals, etc.A significant number of pigments used in tattoo ink remain unregulated by authorities
6. Lack of proper aftercare— To ensure healing after tattooing, it should not be exposed to sunlight and should be moisturized often
7. Immune system— Being immunocompromised due to diseases or taking immunosuppressants can increase your susceptibility to infections

A recent study found that unhygienic practices were the most common cause of tattoo infections, followed by contaminated tattoo ink and inadequate healing process.¹

The symptoms of tattoo infections are generally seen around the tattooed skin, such as:

1. Redness and swelling in the area
2. Pain or tenderness
3. Itching sensation and hotness
4. Bumps on or under the skin with or without pus
5. Fever and chills
6. Soreness, sweat, and fatigue

Complications 

Tattooing breaches the skin barrier creating a risk of infection. There is a normal course of the healing process, which may include a little itching, soreness, or swelling. But if it leads to the unusual symptoms listed above, even after recovery, this could be a sign of infection. Colored inks such as red, blue, and green tend to be associated with more infections compared to black ink. Prompt recognition and management are essential to prevent such infections as they can occur in days, weeks, or months after tattooing. One of the research studies reported that around 1-5% of people experience tattoo-related infections.² They may range from mild dermal infections to more serious systemic complications.

Localized skin issues

One of the most common infections related to tattoos is abscess formation, which can lead to swelling and pain. Skin rashes or ulcers can also develop due to infection. These are open sores that may cause scarring. Keloids are raised scars, accompanied by itching and sometimes mild pain. When an injury occurs, the fibroblast cells rush to the site forming scar tissue to heal the wound. Sometimes, extra cells and tissue grow, leading to keloid formation. It can spread to surrounding areas, making it large even masking the tattoo. 

Systemic infections

Systemic infections are those that affect more than one organ or the whole body. Sarcoidosis is one of the most common conditions, which primarily affects the lungs and thoracic lymph nodes, but skin is involved in almost 20-30% of cases.⁴ Sarcoidosis can be divided into specific or non-specific lesions. The components of the ink used in tattooing, specifically the metal content, may be the reason for sarcoidosis. Rare complications such as uveitis and vasculitis are also reported, sometimes along with sarcoidosis. 

Mycobacterium, Streptococcus, and Staphylococcus sp. are common bacteria involved in bacterial infections. They were found to be involved in almost 30 outbreaks, affecting around 344 individuals.¹ Streptococcus pyogenes causes impetigo, erysipelas, and septicemia, while Staphylococcus aureus causes cellulitis and the rare toxic shock syndrome. In rare cases, Streptococcus can also cause necrotizing fasciitis, a life-threatening, flesh-eating disease. Another rare but possible complication due to bacterial infection is endocarditis, which compromises the efficiency of the heart, causing a stroke or organ failure. There have been cases of syphilis caused by Treponema pallidum and leprosy caused by Mycobacterium leprae in the past. 

When compared to bacterial infections, viral infections are fewer and less common. The viruses involved are human papillomavirus (HPV), molluscum contagiosum, herpes simplex virus (HSV), rubella, and vaccinia, among which human papillomavirus and molluscum contagiosum are the most frequently reported. Viruses that spread through blood, such as those involved in hepatitis and human immunodeficiency virus (HIV), have also been reported.⁵

Another risk is that large tattoos might hide or conceal possible signs of skin cancer. Although concerns over links between tattoos and skin cancer have been raised, there is no strong evidence to suggest the same to date. 

How can you identify the infection? 

To identify a tattoo infection, an allergic reaction, or flare-up should first be ruled out. This is where diagnosis by the healthcare provider comes in. Diagnosis is often difficult and requires a structured approach, as symptoms often overlap with many existing conditions. They may start with patient history and a routine examination of the affected area, assessing the evident symptoms. Clinical tests and microbiological tests, sometimes along with ultrasound scanning and clinical photography follow. Punch biopsy is an important tool for confirming tattoo infections. The chemical pigments in the tattoo ink can be analyzed by sophisticated machinery such as electron microscopy, mass spectroscopy, etc. 

Treatment

Infected tattoos are treated based on the type and severity of the infection. It is necessary to consult with your healthcare provider and follow their instructions for a fast recovery. The treatment options can broadly be categorized into:

1. Abscess can be treated by incision and drainage, along with antibiotics
2. Topical antibiotics in the case of minor infections
3. Oral antibiotics if the infection is more significant, with pus and inflammation. The duration may depend on the type and severity of the infection 
4. Sometimes, intravenous (IV) antibiotics are provided in cases of severe infections
5. Anti-viral and fungal medications are prescribed based on the source of infection
6. Over-the-counter medications such as NSAIDs can help with pain and inflammation in mild infections
7. In rare complications such as necrotizing fasciitis, where the tissue is dead, surgery may be necessary
8. Other options, such as corticosteroid injections, radiation, laser therapy, and cryotherapy, are also used for treatment whenever necessary

Is prevention possible?

Yes, very much! Though getting a supercute tattoo on yourself is alluring, you need to make sure to prioritize your safety first. This can be done by following some simple tips below:

1. Make informed decisions— Do thorough research and choose reputable tattoo facilities with licensed tattoo artists. Also, check with your healthcare provider in advance for any existing health issues before getting a tattoo
2. Retrieve as much information— Get to know your tattoo facility and artist by asking them about the equipment used, its cleaning, and handling procedures. You can also enquire about hygiene, the inks used in tattoos, and their regulations
3. Maintain personal hygiene— Always wash your hands with soap before and after handling your tattoo and pat dry with a tissue or towel
4. Follow proper aftercare— Make sure to stick to the set of care instructions provided. Keep the area moisturized enough, and do not go out in bright sunlight or into the pools or oceans
5. Seek medical care— Always watch for any signs of infection and get help at the earliest

Summary

The realm of tattoos is fascinating, but we need to understand the risks and infections associated with it. Tattoo infections can be as mild as an itchy scar, which is resolved in a few days, to life-threatening diseases such as necrotizing fasciitis. Complications of tattoo infections can be exhausting and sometimes lifelong. Improper aftercare and toxic components in tattoo ink are the most common reasons for infections. With proper awareness and informed decisions, we can ensure that this beautiful body-modification art has only good tales to tell.