Thinking Before Inking: A Public Health Perspective

Tattooing originated over 5,000 years ago and is now a global phenomenon. Today, various motives exist for obtaining a tattoo, including cosmetic and medical. In the past decade, an exponential increase in decorative tattooing has occurred in adolescents and young adults (1). Furthermore, cosmetic tattoos (also referred to as permanent makeup) have increased in popularity since the early 1980s. Cosmetic tattooing may serve as an adjunct to reconstructive surgery (ex. breast reconstruction), temporary makeup replacement (ex. lip-liner), and camouflage for conditions such as vitiligo (pigment loss from skin) or alopecia (hair loss due to an inappropriate immune response, including in children and women). The permanence of a tattoo is achieved by injecting pigment granules into the second layer of the skin (the dermis). An assortment of professionals and non-professionals perform these procedures – each varying in artistic ability, observance of sterility procedures, and use of anesthesia (2).

Despite the growing number of individuals with tattoos, there are currently very few safety regulations (3), and those that do exist are sometimes not followed. The pigments in tattoo inks contain color additives – defined as any material that imparts color to drugs, food, the human body, medical devices, or cosmetics. Approved color additives are listed in the United States Code of Federal Regulations, but no such approval exists for injected use into skin. This means that currently no tattoo pigments are approved for use in the United States (2). In Italy, tattoo ink labeling is not mandatory, and their composition is not regulated. Very often, no information on expiration, standard warnings, conditions of use, or sterility are found (4). Unsurprisingly, a rise in complications from tattooing has been reported around the world but is hidden from the public (2).

Tattooing involves several medical risks, including superficial and deep local infections, systemic whole-body infections, granulomatous inflammatory reactions, lichenoid skin reactions, immune-mediated reactions, and photodermatitis (allergic skin reaction to the sun). Although declining in number, there have been numerous reports of infectious diseases transmitted during tattooing, including human immunodeficiency virus (HIV) and hepatitis (5). Additionally,  patient dissatisfaction, general regrets, and other desires for tattoo removal have been rising (6).

Due to the increasing popularity of tattoos, the public (particularly adolescents and young adults), tattoo artists, and health care professionals must be better educated about the potential short- and long-term complications of tattooing. Epidemiological studies regarding the use of tattoo inks may significantly improve the understanding of health effects, enhance consumer safety, and help establish guidelines that regulate tattoo ink. Along with better regulation, national and international standardization of inks and processes are crucial for public safety. It is essential for the public, and individuals considering a tattoo, to understand that while an aspect of art, tattoos involve significant health risks and a lifetime of exposure to chemicals that have not been sufficiently studied (7). Additionally, health officials should raise awareness of the potential harms of tattoos, and encourage longitudinal studies to determine if these practices are correlated with adverse health consequences. Findings from these studies should be considered by policymakers and guide tattoo regulations. Ultimately, public health practitioners have a duty to play a much larger role in “thinking before inking” than they previously played in the past.


1)    DeMello M. 2000. Bodies of inscription: a cultural history of the modern tattoo community. Durham, NC: Duke University Press.

2)    Ortiz AE, Alster TS, et al. Rising concern over cosmetic tattoos. Dermatol Surg 2012 (38): 424–9.

3)    Bassi A, et al. Tattoo-Associated Skin Reaction: The Importance of an Early Diagnosis and Proper Treatment. BioMed Research International 2014 (2014).

4)    Lehner K, Santarelli F, Vasold R. Black tattoo inks are a source of problematic substances such as dibutyl phthalate. Contact Dermatitis 2011 (65): 4: 231–238.

5)    Long GE, Riackman LS. Infectious Complications of Tattoos. Clin Inf Dis 1994 (18): 610–619.

6)    Khunger N, Molpariya A, Khunger A. Complications of Tattoos and Tattoo Removal: Stop and Think Before You ink. Journal of Cutaneous and Aesthetic Surgery 2015 (8): 1: 30–36.

7)    Laux, Peter et al. A Medical-Toxicological View of Tattooing. The Lancet 2016 (387): 10016: 395–402.


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