To Tattoo or Not to Tattoo…

By Gopinathan K. Menon
December 15, 2017

image of a woman with a tattoo

Every time I walk into the gym, it is rather common to observe an impressive collage of tattoos over bulging muscles of men, and toned limbs of women.1 Often they cover an entire limb, the neck, or even part of the face. Tattoos are so prevalent these days that you see them wherever you go, be it a swimming pool, airport, or supermarket. It reminds me of New York City subway station walls of the late 1970s, which were covered with so much graffiti that it was considered an urban crisis.2 During that period, tattoos on hands and faces were not very evident. In the last several decades, the surface for urban art shifted from inanimate objects to the living canvass of our bodies. Is this a new urban (and suburban) crisis?

What is a Tattoo?
Tattooing is a process of implantation of insoluble pigment granules in the dermal layer about 1/16th of an inch below the skin surface. As the dermal layer turn over is a very slow process (compared to that of the constantly renewing epidermis), the tattooed designs or patterns of the insoluble pigments are nearly permanent, although some fading may be observed in older tattoos. The term tattoo has its origin from "tattau", a Tahitian word which means to mark. Tattoos are created intentionally for cosmetic (decorative tattoos and permanent makeup) or therapeutic purposes (medical tattoos), and even to cover areas of the skin affected by vitiligo or scars.

While Tattooing has a long history in human cultures—from the Eskimos, Maori and some Asian cultures—it was probably never a universal phenomenon as it is today, with millions of young people getting tattoos (ranging from multiple small tattoos to very large ones) often covering an entire limb, the back, or even the face and scalp. The increased popularity of tattoos is unquestionable. A Harris Poll in 2016 demonstrated that three out of every ten Americans have at least one tattoo, and most do not just stop at one.3 Indeed, tattoos have left behind the derogatory " tramp stamp" image to attain a cult status among today’s youth.4

Much has been written about the psychological relevance of tattoos as well, such as a feeling of power or control over oneself and reflecting self-concept.5 Contrast this with an older study involving about one hundred tattooed and seventy non-tattooed inmates of a U.S. prison by Howell and colleagues, who found that the tattooed group had significantly more psychological pain, family discord, self-degradation, social deviancy, impulsiveness, and depression than their non-tattooed counterparts.6 They imply that the tattooed population demonstrated significantly more impulsive and sensation-seeking behavior than the non-tattooed population. Stereotypes of tattooed individuals have also included being unsuccessful in school, having an unhappy childhood, coming from broken homes, etc.6 Were these conclusions and perceptions colored by the existing social norms of nearly half a century ago? I leave it for the readers to be the jury on that matter.

Social and Corporate Attitudes
Social and corporate attitudes towards tattooed persons have definitely changed in the last couple of decades. However, tattoos still may influence social attitudes toward women and minorities, as suggested by Houghton et al. and Brown et al., but these studies focused on sexism and racism, rather than a general attitude towards tattoos.4,7 A good article tracing the social origins of tattooing in Western civilization (criminals being marked by ancient Greeks and Romans) and the evolving cultural aspects was written by Jill Fisher.8 Corporate cultures of today are slowly becoming somewhat tolerant to tattooed employees.9

Skin and Health Implications
Coming from a biology background, I have covered the socio- and psycho-aspect about tattoos as much as possible. Now, let's move onto the less exciting, but vital health implications of this wonderful art form. I believe it was in the 1980’s that dermatologists were almost unanimously advocating tattoo removal for health reasons. However, if today’s resurgence of popularity for tattoos is any indication, the frequency of health problems are neither widely known or recognized.

Skin Problems from Tattoos
Tattoos affect proper functioning of sweat glands, impacting the important role of body temperature regulation. Tattooed skin generates less sweat and contains a higher sodium concentration in sweat than non-tattooed skin.10 Such a phenomenon indicates that heavily tattooed athletes have decreased ability for both evaporative cooling of the body and for reabsorption of sodium ions, both which will affect their performance. A web based survey by a group of researchers at University of Regensburg in Regensburg, Germany, demonstrated that after tattooing, 67.5% of individuals had skin problems and 6.6% reported systemic responses.11 Millions of people had either transient or persistent health problems that lasted for a lifetime. Many of the colorants in tattoo preparations are metals, such as aluminum, barium, cadium, cobalt, chromium, copper, iron, mercury, manganese, nickel, lead, antimony, strontium, and vanadium.12 Their concentrations vary depending on the commercial source of inks. Toxic metals, such as cadmium, manganese, lead, antimony, and vanadium were over 1 µg/g in a few cases, while Hg was found in trace amounts.

High incidence of photosensitivity was also reported among young people tattooed with carbon black and organic pigments, especially red, which limits their outdoor activities in the Sun and at the beach—a place to showcase the art work!13 Other medical risks of tattooing are the transmission of infectious disease agents, such as the hepatitis B virus, human immunodeficiency virus, Treponema pallidum, papillomavirus, Mycobacterium tuberculosis, and hepatitis C virus.14,15 Although this is more of a concern with amateur tattoo artists, and not with professional tattoo studios with good hygienic conditions, the risk of infections remain, as Hogsberg and coworkers reported that even some unopened bottles of commercially available inks were contaminated with bacteria.16 In addition, allergic reactions, photodermatitis, granulomatous reactions, and lichenoid reactions may occur after tattooing. Skin diseases localized on the tattooed area, such as eczema, psoriasis, lichen planus, and morphea may also be occasionally seen.17

More seriously, there has been a global increase in pseudolymphoma and allergic reactions caused by the introduction of an exogenous pigments into the dermis.18 The black ink consists of soot products like carbon black or polycyclic aromatic hydrocarbons, a genotoxic substance, where significant quantities of it are transported to other sites, like the regional lymph nodes, where the body’s immune cells are produced. Lehner and colleagues, who extracted and quantified the amount of polycyclic aromatic hydrocarbons in black tattooed skin and lymph nodes in a dozen samples, concluded that the polycyclic aromatic hydrocarbons concentration ranged from 0.1-0.6 µg/cm2 in tattooed skin, and 0.1-11.8 µg/g in the lymph nodes.19

Buyer’s regret?
Our great consumer culture encourages impulse buying, followed by buyer’s regret, which usually comes with the condition of easy return of the purchased item. Does this apply to post-tattoo regret, and is the return an easy option? Apparently not! In spite dermatologists' procedure with Q-switched lasers (the safest method), tattoo removal can be a prolonged tedious procedure for professional tattoo artists, which are difficult to erase as compared to amateur tattoos. Several acute complications might result from tatto removal, which may include pain, blistering, crusting, and pinpoint hemorrhage. In addition, delayed complications such as pigmentary changes, hypopigmentation, and hyperpigmentation as well as allergic reactions can also result from tattoo removal. Irreversible complications, such as scarring and textural changes, may also result from tattoo removal. Thus, "stop and think before you ink" is indeed a valid piece of advice.17

Tattooing: Is Big Brother Watching?
This is an aspect of cyber culture, which most of our tattooed youngsters may not be aware. The government is using tattoos to identify people.20 Research by the Electronic Frontier Foundation show that the FBI has teamed up with government scientists to work on a technology system to track tattoos. The imaging wing of the National Institute of Standards and Technology (NIST) has a Tattoo Recognition Technology, Challenge (Tatt-C), sponsored by the FBI’s Biometric Center for Excellence.21 Several academic and commercial sector groups are working on creating algorithms that scan the information (from a database on prisoners with tattoos) for "making identification of people easier, based on their body art." Their interest is due to the view that tattoos indicate affiliation to gangs, sub-cultures, religious or ritualistic beliefs, or political ideology. In short, tattoos may contain intelligence, messages, meaning, and motivation. The Electronic Frontier Foundation is concerned about implications on "free expression, religious freedom, and the right to associate".22 Reason enough for the society at large to be concerned as well…

Concluding Remarks
On a lighter note, as I watch those rippling muscles move the artwork of a fierce looking bald eagle, I mentally visualize the same image forty years later. It is not a pleasant sight. Will the sagging canvass show the once fierce bird as a mere road kill? Maybe "stopping and thinking before you ink" is not such a bad idea.

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2. J. Austin, Taking the Train: How Graffiti Art Became an Urban Crisis in New York City, Columbia University Press: New York, 2001.
3. The Harris Poll, Tattoo takeover: three in ten Americans have tattoos, and most don’t stop at just one, February 10, 2016;
4. S.J. Houghton, K. Durkin, E. Parry, Y. Turbett, and P. Odgers, Amateur tattooing practices and beliefs among high school adolescents, J. Adolesc. Health, 19, 420-425 (1996).
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20. C. Thompson, The government is ramping up the effort to use tattoos to identify people, Business Insider, June 13, 2015;
21. A.K. Jain, J.-E. Lee, and J. Rong, Tattoo-ID: automatic tattoo image retrieval for suspect and victim identification In Advances in Multimedia Information Processing – PCM 2007, Eds. H.H.S. Ip, O.C. Au, H. Leung, M.T Sun, W.Y. Ma, and S.M. Hu, Proceedings 8th Pacific Rim Conference on Multimedia, Hong Kong, China, December 11-14, 2007, Vol. 4810. Springer-Verlag: Berlin (2007).
22. B. Heater, The FBI is working on a tattoo tracking system that has privacy groups up in arms, TechCrunch, June 5, 2016;