Self-expression takes many forms, one of which is through tattoos. But underneath beautiful designs and people’s personal stories lies a side that people often look past- breaking the body’s first line of defense against infection.¹ Although most heal without complications or infections, understanding the risk factors for tattoo infections is important as it could be the difference between showing your friends and family your new tattoo, or going to the hospital unexpectedly. 

What exactly is a tattoo infection?

When you get a tattoo, the needle constantly punctures your skin whilst depositing ink into the dermis,² the second layer of your skin. This causes thousands of tiny wounds on your skin, which can lead to the attraction of unwanted microorganisms, causing an infection. 

Symptoms and signs of tattoo infections

When a tattoo infection occurs, microorganisms like bacteria and viruses can enter these tiny wounds during or after the tattooing process, leading to infections. This can be mild or severe and can result in multiple typical symptoms:³

• Fever
• Redness
• Swelling
• Chills
• Itchiness
• Bumps /nodules on skin
• Pain
• Inflammation 
• Pus
• Soreness around the tattoo 

These symptoms can happen as a result of the whole tattoo or just an aspect of the tattoo, such as a particular ink that was used or the colour.³

Complications that can arise from tattoo infections

Why should you care? Beyond the discomfort and physical signs, untreated tattoo infections can cause more serious complications like cellulitis. Therefore, it is particularly important to recognise and get medical attention as it can result in various complications such as:

• Endocarditis^3,4
• Septic shock ^3,4
• Organ failure³
• Cellulitis⁴
• Necrotising fasciitis⁴
• Abscesses⁴

Risk factors for tattoo infections

It is known that there are 4 main sources of tattoo infections: the tattoo artist, lack of hygiene practices, contamination of tattoo ink, and lack of aftercare and proper healing⁵ but of course, there are also others.

• Tattoo artists can transmit infections from sources such as saliva
• Pre-existing medical conditions, such as diabetes, can impair blood flow to the tattooed area, which can slow healing and enable bacteria to thrive, therefore exacerbating the infection. Using immunosuppressive medications also makes it difficult for the body to fight infections
• Skin conditions- if you have psoriasis, acne or eczema within the area to be tattooed, you run the risk of increasing infection risk. Moreover, getting a tattoo can lead to keloids, which occur as a result of scar tissue overgrowing, making the area raised like a bump⁶
• Aftercare- if you do not take care of your tattoo properly as advised by your tattooist, this will lead to tattoo infections. Make sure not to:
  • Touch the tattoo with unwashed hands
  • Use non-sterile ointments
  • Cover the tattoo with non-breathable materials
  • Pick at the scabs or peeling skin
  • Swim in pools or other bodies of water before complete healing
• Allergic reactions- if you have an allergic reaction to the ink within your tattoo, especially red pigments (however, you can get an allergic reaction to any coloured pigments), it can mimic the symptoms of an infection, which can increase vulnerability to actual infections such as oedema (fluid filled swelling)⁷

Figure: allergic reaction to ink causing localised edema.⁷

• Although it is rare, you can have skin reactions on your tattoo if you have a magnetic resonance imaging (MRI) scan. This can lead to a burning sensation⁶ 
• Contamination with the needle- if your tattooist does not have a good sterilisation protocol that is followed in between each customer, you can get diseases that can spread if the needle is contaminated with blood. For example, hepatitis A/B and methicillin-resistant Staphylococcus aureus (MRSA).³ Therefore, make sure you are vaccinated for these conditions before getting a tattoo to prevent the occurrence of an infection

Prevention of tattoo infections

To ensure you get your tattoo done safely and you follow all regulations to prevent the occurrence of an infection, always make sure to ask yourself the following questions prior to getting one:

Who is your tattoo artist?

Make sure to do your research and go to a parlour that has artists who are trained properly and have the right qualifications. Check the regulations of your country and city, and check if they follow the regulations. Make sure to never do your own tattoo unless you have the training to do so. 

Is my tattoo artist wearing gloves?

Make sure your artist follows correct hygiene protocols and washes their hands and wears new disposable gloves after every tattoo to prevent the spread of germs.

Is the parlour using sterile equipment?

Make sure to do your research and be aware of whether the artist you will be getting a tattoo from:

• Uses needles and tubes from sealed packages to prevent any contamination of the equipment. 
• Places the inks within new disposable cups 
• Ensures other equipment is sterilised and disinfected after every client. 
• Does not use any expired products 
• Does not improperly store inks 
• Dilutes ink with non-sterile water

Will I be able to take care of my tattoo?

It will take roughly 2 weeks for your tattoo to heal and to ensure you do not get an infection and you heal properly you will need to make sure you use moisturizers multiple times throughout the day, avoid sun exposure to your tattoo, you need to wash the tattoo with soap two times a day with water and during showers you will need to avoid getting water on it as much as possible. If water does get on the tattoo, as it is inevitably will, just pat the area dry. Do not rub! Moreover, although it does seem tempting, you cannot go swimming! Any body of water, such as hot tubs, rivers, pools, or showers, you will need to ensure you do not go into them ⁶

FAQs

If I think my tattoo is infected? What should I do?

Do not panic, but don't ignore it either. Firstly, clean the area properly using mild soap and water. And then make sure to visit the doctors. You will usually be prescribed an antibiotic. You may require one or multiple, depending on how bad the infection is. These can take the shape of pills, or in severe cases, an intravenous (IV) antibiotic may be used. And if your body does not respond to both of these, you may need surgery to remove all the infected skin.³ Make sure not to take any home remedies or over-the-counter medication without guidance from a healthcare professional first. 

What is the prognosis?

It depends on the individual however, usually people make a full recovery. At times, it can be easy to treat and have a quick recovery (roughly two weeks), but in mild to moderate cases of infection however, it will take you multiple months.³

Do people with diabetes get tattoos safely?

Yes! You can still get a tattoo if you have diabetes! But make sure to take extra precautions. If you have well-controlled diabetes, you can get a tattoo, but make sure to consult a healthcare professional first. Then ensure you take all the preventative measures. However, if you have poor control of your diabetes, you may face a higher infection risk and heal slowly. 

Can I remove my tattoo after an infection?

While you might consider seeking removal of the tattoo, you should avoid this as much as possible! Neither laser nor chemical removal of the tattoo is recommended as they could potentially aggravate the existing infection and lead to serious scarring, which can be disfiguring. 

Summary 

• Tattoos break the skin's protective layer-skin, therefore causes an increase in infection risk
• Infections occur when microorganisms enter the tiny puncture wounds caused by the needle
• Common symptoms: fever, redness, swelling, pain, pus and inflammation
• Serious complications include cellulitis, septic shock, etc
• Main risk factors: tattoo artists, poor hygiene, contaminated ink and inadequate aftercare

Prevention measures include:

• Having trained tattoo artists
• Having correct hygiene protocols
• Using needles and inks safely
• Following the correct aftercare instructions and ensuring it is followed properly
• Avoiding swimming and exposure to other bodies of water during healing