New colors – new problems

New colors – new problems. Both from our own experience and from numerous reports from colleagues, we know that some new tattoo colors (REACH) are increasingly causing complications in the healing process. The bright colors are particularly affected, less so the black/grey tones. We would like to tell you here what this is all about and how serious these complications can be.

Because with the new REACH regulation, there are also new tattoo inks with new formulations. And it turned out exactly as feared: Proven ingredients often had to be replaced by untested but REACH-approved alternatives. This included the use of substances that have actually long been banned under the German Colorants Ordinance. This may explain why various new paints, although REACH-compliant, are still not offered by the major German suppliers. The result is an increase in allergic reactions and even serious immune complications, so-called granulomas.

In view of the forthcoming changes to the color formulas (Blue 15, Green 7) and the possible ban on titanium peroxide (white), it is to be feared that this problem will be with us for some time to come.

We had the opportunity to interview an expert in this field. For many younger members of the industry, such health problems may still be completely new territory. They are correspondingly unsettled when they are suddenly confronted with them. What is comparatively harmless and what requires urgent medical attention?

Interview with Katharina Herberger, dermatologist at Hamburg University Hospital

About herself and her work

Katharina Herberger is a dermatologist and head of the laser department at the University Medical Center Hamburg-Eppendorf. In addition to treatment with the various laser systems, since 2019 she has also been building up a research department on tattoo and skin, among other things, a practical field of research that investigates what actually happens to the tattoo colors in the skin. A multi-photon tomograph (a so-called 5D laser) is used for this purpose, which makes it possible to look into the skin and metabolic processes without having to perform a biopsy.

In everyday practice, however, she also deals with acute skin conditions that require specialist treatment, including tattoo removal, whereby the majority are unwanted designs/tattoos. Real problem cases do not occur very frequently, around 2-4 per month, which is not a particularly large number given the large catchment area. Despite the growing popularity of tattoos, there has been no recent increase in the number of cases. It remains to be seen to what extent this will change.

“As a rule, we only see a negative selection of the tattoos that are out there, i.e. those that should never have been done in the first place. We hardly ever see really well-made tattoos, which speaks volumes for the industry.”

Into which areas can problem cases be divided?

“Based on the practical experience of our department at Hamburg University Hospital, these cases can be divided into

1. Inflammatory reactions (bacteria, viruses)
   These occur shortly after tattooing and are due to bacteria entering the open wound. This is not necessarily due to an unclean working environment on the part of the tattoo artist, but can also be due to a weakened immune system, for example.
2. Mycobacterial infections
   In recent years, there have been increasing reports of infections with so-called waterborne pathogens, atypical mycobacteria, which lead to nodular inflammation. These infections can also occur several weeks after tattooing and are usually due to contamination in the drinking water used. These are harmless for consumption, but can cause problems if introduced into fresh wounds.
3. Granulomas / Dermal sarcoidosis
   This inflammatory disease is a multisystemic disease in which granulomas can form on the skin, among other things. The body is affected by certain foreign substances and builds up a wall of immune cells around them. These can be recognized as papules or raised areas of skin, are often accompanied by itching and can also become inflamed. These can also appear many years after tattooing. It is important that those affected should be examined by a doctor for involvement of other organs!
4. Allergic reactions
   These can also only occur after many years (e.g. chemical change due to UV radiation or photoallergic reaction, i.e. only in connection with UV radiation). There are also various theories as to the causes. In principle, you can develop allergies to all substances.
   
5. Tumors
   Such very rare cases (a total of 50 cases have been described in the last 50 years) usually end up in the dermatology clinic when skin cancer is detected too late because it has developed in heavily tattooed areas of skin. It is not even necessary for a pigment change to have previously existed in the affected area.

For points 3 and 4, the affected parts of the skin must be removed if the problem is persistent, and for point 5 anyway.”

How often do which complications occur?

“Cases of needle trauma or pigment overload usually remain in the care of general practitioners and local dermatologists. An evaluation of two cohort analyses (evaluation of larger groups of tattooed patients) provides information on the frequency of these complications” (from “Tattoos – Heterogeneous spectrum of dermatological complications”, Aesthetic Dermatology & Cosmetology 01 2022):

• Bacterial infections 1 % (493) Serup et al. 2016 [45]
• Viral infections 1 % (493) Serup et al. 2016 [45]
• Mycotic infections rare Schwob and Kluger 2020 [31]
• Granulomas/sarcoidosis 6 % (493) Serup et al. 2016 [45]
• allergic reactions 37 % (493) Serup et al. 2016 [45]
• Skin tumors rare, causality unclear Kluger and Koljonen 2012 [42]
• Needle trauma 6 % (702) Hutton et al. 2020 [13]
• Pigment overload 9 % (702) Hutton et al. 2020 [13]

What preventive measures are recommended?

Not everything is within the tattoo artist’s sphere of influence and responsibility, but one or two things can be done.

1. Inflammatory reactions (bacteria, viruses)
   The applicable hygiene guidelines must be observed here. Ms. Herberger’s practical experience shows that professional studios already have a very good standard here.
2. Mycobacterial infections
   In your own practice, you use sterile water for wound care. Appropriate filter systems can be installed directly on the water pipe (e.g. under the washbasin).
3. Granulomas/sarcoidosis
   People with autoimmune diseases have a significantly increased risk here and should not be tattooed. The red pigments (in the past, iron/nickel oxide, today often azo pigments) are particularly conspicuous in connection with granulomas. Tattoo inks that completely avoid these substances are recommended.
4. Allergies
   The more pronounced a customer’s other allergies are, the higher the risk of allergic reactions to one of the many substances that are applied to the skin during tattooing. At this point, be careful with skin disinfectants: not all of them may be introduced into the skin via needles (keyword wound cavity in the instruction leaflet, e.g. Octenisept/Octenidin). Also be careful with aluminum hydroxychloride (often contained in Tattoo Finish), as this is a strong irritant.
5. Tumors
   Azo pigments should also be warned against at this point. These are aromatic amines and are known to be carcinogenic. The problem is that so far only certain azo pigments have been banned, but by no means all those on the market.
   From JDDG, article dated 17.8.2020 “Tattoos – more than just colored skin? Searching for tattoo allergens”: “However, another group, the azo pigments, are still most commonly used. They span the yellow to red color range and are composed of condensed aromatic amines, which are often carcinogens or sensitizers.”

The tried and tested rule of thumb is: the fewer ingredients a tattoo ink contains, the better it is for your health (as few as possible, as many as necessary).

Yours