Tattooing in adolescents and young adults

INTRODUCTION — The epidemiology and health hazards associated with tattooing will be reviewed here. Body piercing and issues related to tattooing in pregnancy are discussed separately. (See "Body piercing in adolescents and young adults" and "Maternal adaptations to pregnancy: Skin and related structures", section on 'Tattoos and piercing'.)

For the purposes of this topic, "tattooing" generally refers to permanent tattoos. However, some sections discuss temporary (eg, henna) tattoos.

EPIDEMIOLOGY — Tattooing is increasingly common among adolescents and young adults [1-6].

Although there are few data regarding the prevalence of tattooing in adolescents, small surveys of college students (18 to 25 years of age) in the United States consistently indicate that 20 to 25 percent have tattoos [1,5,7]. The prevalence is slightly higher in larger surveys of adults (18 to 35 years of age) in the United States, ranging from 22 to 47 percent, depending upon the age groupings [6,8,9].

Surveys evaluating the association between tattooing and high-risk behaviors (eg, tobacco use, drug use, sexual activity) in adolescents and young adults have inconsistent results [3,10-19].

Little information is available about tattoo removal in adolescents and young adults. In one survey of college students, 6 of 149 tattoos (4 percent) had been removed [1]. In a 2015 survey of 2225 adults, 23 percent of those with tattoos reported having had regrets [6]. Common reasons for regret included being too young when they got it, the tattoo no longer reflects their lifestyle, the tattoo was poorly done, and the tattoo is not meaningful. (See 'Tattoo removal' below.)

COUNSELING PATIENTS ABOUT TATTOOS — Clinicians and school nurses may be the first and perhaps the only source of credible information about tattooing for children and adolescents [20]. Adolescent and young adult patients are more likely to discuss body art if the clinician is not judgmental. If patients perceive negative judgment from the clinician, they may seek information from other sources (eg, friends, commercial tattoo artists) [20].

Regulations about the age of consent for tattooing differ from state to state [21]. (See 'The tattooing process' below.)

●Proactive counseling – Proactive counseling can begin as early as first grade [20,22]. Such counseling does not address tattoos directly but highlights internal empowerment and self-esteem, which can bolster self-worth, decision making, and confidence, which in turn may foster healthy decision-making skills about tattoos and other decisions with long-term consequences. Similarly, for older children and adolescents, proactive counseling focuses on positive physical and psychosocial development rather than pros and cons of tattoos.

●Patients contemplating tattoos – When counseling patients who are thinking about tattooing but have not yet made up their mind, clinicians can [23-25]:

•Encourage them to talk with others who have been tattooed and/or had tattoos removed.

•Remind them that tattoos are permanent; suggest that they obtain a henna tattoo to see what it is like to have a tattoo.

•Urge them not to make the decision under pressure, in haste, or while intoxicated.

•Provide education and resources (table 1) to help them make informed decision.

•Educate them about the difficulty, expense, and potential incompleteness of tattoo removal. (See 'Tattoo removal' below.)

•Discuss the motivational factors (ie, perceived benefits), costs, and potential risks; potential motivations for obtaining tattoos in adolescents and young adults include [6,7,14,15,20,26]:

-To redefine themselves

-To take control of their bodies and identities

-To be like their friends

-To feel unique

-Permanent makeup (eg, eye liner, eyebrow, coverage for scars, etc)

Costs and potential risks of tattooing include [6,27]:

-The cost of the tattoo placement

-Negative response from others (eg, caregivers, teachers, employers)

-Pain (no topical anesthetic is used for tattoo placement)

-Infectious and noninfectious complications, including the potential for prolonged bleeding in patients with bleeding disorders or receiving anticoagulant therapy (see 'Health risks' below and 'Other considerations' below)

-The meaningfulness of the tattoo may change over time; they may regret obtaining the tattoo later in life

-Complete removal may not be possible if they subsequently decide to have the tattoo removed

-The cost and pain of tattoo removal if they subsequently decide to have the tattoo removed (see 'Tattoo removal' below)

●Relative contraindications to obtaining a tattoo – Relative contraindications to obtaining a tattoo include [28]:

•Oral isotretinoin therapy for acne (may impair healing time) [29]

•History of keloid formation (keloids could develop within the tattoo) [30]

•Moles or melanocytic nevi (the tattoo could make it difficult to monitor for changes suggestive of melanoma); tattoos should not be placed on scars from melanoma resection or lymph node dissection

•Skin conditions associated with the Koebner phenomenon (development of skin lesions at sites of skin trauma); these conditions include psoriasis, lichen planus, vitiligo, and discoid lupus

•Immune compromise, whether due to infection, medication, or other conditions [31]

In addition, we consider having a bleeding disorder or receiving anticoagulation therapy to be a relative contraindication to obtaining a tattoo. Consultation with the patient's hematologist or specialist managing anticoagulation therapy is recommended before obtaining a tattoo.

●Patients who have decided to get a tattoo – If the patient decides to proceed with tattooing, the clinician can help them make informed decisions about [25]:

•The site and design of the tattoo – The site may affect the ability to control who is able to see the tattoo [27]. The design may affect the likelihood of negative response.

•The tattoo artist and studio – Patients may be better able to choose a tattoo artist/studio if they visit several studios to observe placement of a tattoo before making a decision. This allows the patient to see if the artist is certified by the Alliance of Professional Tattooists, uses sterile technique (eg, uses disposable gloves and disposable or adequately sterilized needles, cleans the site with an antimicrobial solution), and provides appropriate aftercare instructions. (See 'Prevention of infection' below and 'Studio tattoos' below.)

Individuals who are considering a noncertified setting for their tattoo should inquire about the equipment and pigment that are being used. Amateur artists are more likely to use discarded or defective equipment.

The clinician can also provide anticipatory guidance about complications and indications for medical care. (See 'Health risks' below.)

THE TATTOOING PROCESS

Studio tattoos

●Tattoo studios and artists – Most tattooing is performed in commercial studios, although studio artists may establish temporary locations (eg, flea markets, concerts).

Regulations for tattoo artists and studios vary geographically [25]. Clinicians should become familiar with the regulations in their cities, counties, and states. In the United States, a compendium of state laws, statutes, and regulations is available from the National Conference of State Legislatures.

Tattoo artists routinely learn their trade either by self-teaching or by observing others; few complete apprenticeships. A standardized procedural curriculum is lacking. Tattoo artists are not required to complete any formal training, even in states that require examinations [32]. The Alliance of Professional Tattooists (APT) is a nonprofit educational organization that promotes safety and provides information to tattoo artists, clients, and legislators. Artists must have a minimum of three years' experience with appropriate references to become APT certified [33].

Few states require examinations and continuing education about anatomy, universal precautions, disease transmission, skin diseases, sterilization procedures, sanitation, personal hygiene, or aftercare instructions [21,32].

A 2011 review of state tattooing regulations in the United States found that sanitation was effectively regulated in 36 states, infection control in 26, and training in 15 [21]. However, only 14 states effectively regulated all three.

●Tattoo design – The client chooses a design from illustrations on display at the studio or provides the artist with an illustration.

●Procedure – The skin should be cleaned with an alcohol and iodine solution. The tattoo design is then drawn on the skin by hand or with a stenciling machine. Ink is applied to the design with needles that have been dipped in ink that has been poured into disposable ink cups.

Most commercial tattoo artists apply the ink using a handheld, electric-powered machine (picture 1). This device is held several centimeters away from the skin and has a needle bar that moves up and down between 50 to 3000 times per minute [34]. Several needles may be attached to the end of the needle bar and are responsible for inserting the pigment into the skin. The number of needles produces the desired effect: A single needle creates a fine line; increasing numbers of needles create thicker lines, shading, or solid color.

The skin is repeatedly punctured using solid bore needles to allow the tattoo pigment to leach into the dermis, where it is taken up by macrophages [35,36]. The depth of the puncture varies from 1 to 4 mm [34]. During the tattooing process, blood and serosanguineous fluid seep onto the skin and are wiped away by the artist [35].

●Tattoo ink/coloring agents – The coloring agents of tattoo ink include inorganic metallic salts, different types of organic molecules, and organic dyes [37,38]. Auxiliary ingredients may be added to make the ink more suitable for tattooing [39]. The composition of inks has changed over time; aluminum, oxygen, titanium, and carbon are more common than metallic salts such as mercury, cadmium, and cobalt, but metallic salts continue to be used [38,40,41]. Allergenic metals (eg, chromium, nickel, and cobalt) may exceed safe allergologic limits [41]. Most of the commercially available tattoo compounds are azo pigments or polycyclic compounds, some of which are carcinogenic. (See 'Cancer' below.)

Tattoo pigments are not routinely reviewed or regulated by the US Food and Drug Administration (FDA) for intradermal use and contain nonstandardized ingredients [38]. In one study, samples of 30 tattoo inks were chemically analyzed and results compared with the information supplied by the manufacturer [42]. Among the 30 pigment samples, the most commonly identified elements were aluminum (87 percent), oxygen (73 percent), titanium (67 percent), and carbon (67 percent). The elemental analysis was usually consistent with the information supplied by the manufacturer, but there were important exceptions. Further research indicates that some pigments are industrial-grade colors suitable for printers' ink or automobile paint [43,44]. Most tattoo pigment manufacturers do not provide a description of the ingredients used in tattoo pigments, but one state (California) requires that tattoo pigments provide an itemization of ingredients [32].

The FDA considers tattoo inks to be cosmetics and the pigments used in the inks to be color additives [45,46]. As color additives, the pigments used in the inks are subject to premarket approval under the Federal Food, Drug, and Cosmetic Act, but the FDA generally has not exercised its authority over tattoo pigments [45]. Outbreaks of skin infection related to pigment contamination have occurred [47-49]. (See 'Localized infection' below.)

Amateur tattoos — Amateur tattoos may be applied or placed by friends or acquaintances, often in an unsanitary setting. These tattoos often are placed using primitive instruments, such as pencils, pens, or other sharp objects. The pigments could be unconventional and may incorporate available materials, such as charcoal, ink, mascara, or discarded pigment and equipment from professional studios. Adolescents may obtain amateur tattoos because they cannot find a studio that will tattoo minors or because they cannot afford to pay for a studio tattoo [34].

Henna tattoos — Henna-based body art is performed by temporarily applying pigment to the surface of the skin. Henna tattoos last between days to one month, depending upon the time of henna exposure. The pigment is derived from dried powder of the plant Lawsonia inermis, which in its native form appears red and is commonly used for dying hair and skin in many cultures. Henna is usually applied as a paste via syringe or stylus, left on the skin or hair for 6 to 12 hours, and then washed off. Red henna is often mixed with black henna (paraphenylenediamine [PPD]) or other plant-based pigments to enhance the staining contrast [50]. The combination of red henna and PPD generally is referred to as "black henna," but also may be called "blue henna," "skin painting," or "pseudo-tattooing."

AFTERCARE INSTRUCTIONS — After the tattoo is applied, petroleum jelly or a similar ointment is applied to the skin to prevent oozing of serosanguineous fluid. The artist bandages the tattoo and should provide aftercare instructions, including recommending that the client cleanse the site twice daily with an antimicrobial soap and avoid contact with the site except for cleaning [34-36].

Tattoos take approximately two weeks to heal [25]. During this time, the risk of infection is increased. We advise patients to avoid swimming, soaking in water, and directing shower jets onto the site of the tattoo. We also advise them to avoid sun exposure, to use sunscreen if sun exposure cannot be avoided, and to wear loose clothing that will not stick to the tattoo site [51].

HEALTH RISKS — Little information is available about the incidence of complications of tattooing because they are infrequently reported to state health departments or in the medical literature [52]. Localized infections and skin reactions appear to be the most frequent complications; in addition, the release of serosanguineous fluid and blood during/after the tattooing procedure may result in blood-borne diseases [53].

Localized infection — Tattooing may be associated with localized skin infection due to Staphylococcus aureus (picture 2), Streptococcus pyogenes, and other bacterial organisms, including nontuberculous mycobacteria (eg, Mycobacterium chelonae, Mycobacterium haemophilum (picture 3), Mycobacterium abscessus) [36,47-49,53-57]. The risk of infection is greater within the first three weeks after tattoo placement [25] because of diminished skin integrity. Delayed-onset development of flat warts associated with human papillomavirus, activation of herpes simplex virus, and infection with Molluscum contagiosum virus have all been documented as complications within the sites of tattoos [57-60].

Although treatment of infected tattoos can be initiated empirically, we obtain bacterial culture of purulent drainage before empiric treatment in case there is failure of treatment [61]. (See "Nontuberculous mycobacterial skin and soft tissue infections in children" and "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis".)

Outbreaks of community-associated methicillin-resistant S. aureus (CA-MRSA) among tattoo recipients have been associated with lack of adherence to infection control measures in the tattoo studio (eg, changing gloves between clients, hand hygiene, skin antisepsis, disinfection of equipment and surfaces) [54] and recent incarceration of the tattoo artists. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Epidemiology", section on 'Community-associated MRSA infection'.)

Outbreaks and individual cases of tattoo inoculation with M. chelonae and other nontuberculous mycobacteria species have also been reported [47-49,62-67]. Many of the cases of M. chelonae infection shared several common features: lesions of varying morphology (eg, red papules, pustules, lichenoid papules and plaques) occurring predominantly in areas of gray pigment; onset within 10 days to 5 months of tattoo placement (usually within one to three weeks); and response to appropriate antibiotics (eg, macrolides and quinolones) [47-49,62]. The outbreaks were associated with commercially-obtained prediluted gray ink, and the cases resulted from the use of nonsterile water by the manufacturer or tattoo artist for dilution of black ink to the desired shade of gray [47-49]. The clinical manifestations, diagnosis, and treatment of nontuberculous mycobacterial skin and soft tissue infections are discussed separately. (See "Nontuberculous mycobacterial skin and soft tissue infections in children".)

The US Food and Drug Administration (FDA) encourages health care providers to report tattoo-related adverse events, including infection, to MedWatch: The FDA Safety Information and Adverse Event Reporting Program [46].

Systemic infection — Systemic infections occur less frequently than local infections as a complication of tattoos. Systemic infection is more likely to occur in people who have had amateur tattoos or have not followed the aftercare instructions.

●Hepatitis B and C – Hepatitis B and C can be transmitted during tattooing, particularly when tattoos are obtained in unregulated establishments, which may reuse or inadequately sterilize instruments [68-71]. The magnitude of risk is unknown. (See "Epidemiology, transmission, and prevention of hepatitis B virus infection", section on 'Percutaneous inoculation' and "Epidemiology and transmission of hepatitis C virus infection", section on 'Other percutaneous exposures'.)

●Human immunodeficiency virus (HIV) infection – Although HIV infection may be transmitted through tattooing, there are no known cases of such transmission [72]. (See "Epidemiology of pediatric HIV infection", section on 'Risk factors for HIV acquisition'.)

●Mpox – A few studies have described mpox (previously referred to as monkeypox) infections associated with new tattoos [73,74]. Many of these infections were systemic, but some of the individuals had only a rash at the site of inoculation.

●Infective endocarditis – Infective endocarditis is an extremely rare complication of tattooing [75-78]. Nonetheless, health care providers should consider the possibility of infective endocarditis in patients who present with unusual clinical events (eg, unexplained fever, rigors, weakness, myalgia, arthralgia, lethargy, or malaise) between one week and two months after tattooing.

The diagnosis and treatment of infective endocarditis are discussed in detail separately. (See "Infective endocarditis in children".)

●Sepsis – Recent tattoo placement may provide a portal of entry for systemic bacteremia and sepsis [79-81]. Immunocompromised patients may be at particular risk for infection due to unusual pathogens (eg Vibrio vulnificus following seawater exposure) [79]. We advise patients to avoid recreational water exposure in the weeks after tattoo placement. (See 'Aftercare instructions' above.)

Skin reactions — Skin reactions to permanent or temporary tattoos include acquired hypersensitivity reactions to the tattoo pigment [36,41,82], sarcoidal reactions (picture 4) [83], scleroderma-like reaction [84], granulomatous reactions (picture 5), recurrent inflammation (which may be associated with uveitis) [85], and keloid formation/hypertrophic scarring [86,87]. (See "Cutaneous manifestations of sarcoidosis", section on 'Tattoo sarcoidosis'.)

●Permanent tattoos – Delayed hypersensitivity reactions localized to the site of ink injection are well described in association with metallic salts used in tattoo pigments (eg, mercury, chromium, cadmium, cobalt, nickel) [36,41,82].

Dermatitis from a fresh tattoo (non-henna) can initially be treated with a topical glucocorticoid unless it is draining (suggesting superinfection, which requires antimicrobial therapy). Referral to an allergist or dermatologist may be warranted for patients who develop severe local reaction to tattoo pigments or henna or those determined to proceed with tattooing despite a previous local reaction, since these patients may be at increased risk for serious systemic hypersensitivity reaction. (See "Management of allergic contact dermatitis in adults".)

●Temporary henna tattoos – Localized hypersensitivity reactions are relatively uncommon after placement of red henna tattoos [88]. Contact allergy to "black henna" tattoos (picture 6) is more common (estimated frequency of 2.5 percent) because of the addition of paraphenylenediamine (PPD), which is highly sensitizing [88]. Localized allergic reactions to PPD are treated in the same way as localized reactions to non-henna tattoos; however, lifelong avoidance of PPD and potentially cross-reacting compounds is recommended. (See "Common allergens in allergic contact dermatitis", section on 'Hair care products' and "Management of allergic contact dermatitis in adults".)

Case reports have also identified localized scarring, persistent hypopigmentation or hyperpigmentation, and anaphylaxis after placement of black henna tattoos or other exposure to black henna (eg, in hair dye) [88].

Cancer — Whether tattoo pigments have local or systemic carcinogenic effects is unclear [38,39]. Some components of tattoo ink have been classified by the International Agency for Research on Cancer as carcinogenic (eg, cadmium and cadmium compounds) or possibly carcinogenic (eg, cobalt sulfate and other soluble cobalt salts, carbon black) to humans [89]. However, extensive reviews of the literature (1938 to 2018) found only 64 cases of skin cancer arising in tattoos (23 cases of squamous cell carcinoma and keratoacanthoma, 30 cases of melanoma, and 11 cases of basal-cell carcinoma) [39,90]. The small number of reported cases suggests a coincidental rather than causal association, but higher quality studies are needed.

Hemolytic crisis in glucose-6-phosphate dehydrogenase deficiency — Red henna may precipitate acute hemolysis in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Several cases of fulminant hemolysis have been reported in children with G6PD deficiency after placement of red henna tattoos [88,91,92]. (See "Diagnosis and management of glucose-6-phosphate dehydrogenase (G6PD) deficiency".)

OTHER CONSIDERATIONS — Tattoos may be associated with a variety of other complications or health considerations, including:

●Magnetic resonance imaging – Burning sensation and intense pain over tattooed sites that contain heavy deposits of metallic oxides or iron or titanium have been reported [93-97], but the risk appears to be low [98]. In a prospective study that included 585 magnetic resonance imaging sessions (using five different scanners) in 330 volunteers with a total of 932 tattoos, the probability of tattoo-related adverse reaction was estimated to be ≤0.30 percent (95% CI 0.01-1.69 percent) [99]. (See "Anesthesia for magnetic resonance imaging and computed tomography procedures".)

●Epidural anesthesia – Whether lumbar tattoos merit special consideration in patients who require lumbar epidural analgesia remains controversial [93,100-104].

●Surgery – Tattoos that are located in operative fields (eg, abdominal tattoos) may require special procedures for preservation [105].

●Monitoring nevi – Placement of a tattoo near or within a melanocytic nevus can make it difficult to monitor for changes suggestive of melanoma [106,107]. (See "Atypical (dysplastic) nevi", section on 'Full-body skin examination'.)

●Pregnancy – Issues related to tattooing in pregnancy are discussed separately. (See "Maternal adaptations to pregnancy: Skin and related structures", section on 'Tattoos and piercing'.)

PREVENTION OF INFECTION — The risk of localized infection can be reduced when the person obtaining the tattoo:

●Understands the procedure

●Obtains it in an establishment that uses sterile procedures

●Follows appropriate aftercare instructions for cleaning and maintenance (see 'The tattooing process' above)

Patients should complete hepatitis B immunization before tattooing. (See "Hepatitis B virus immunization in infants, children, and adolescents".)

To avoid tattoo-related infection, the United States Centers for Disease Control and Prevention and US Food and Drug Administration recommend that tattoo artists [48,108]:

●Avoid using products that are not intended for use in tattooing (eg, drawing ink)

●Avoid dilution of ink before tattooing; if dilution is necessary, only sterile water should be used

●Avoid using nonsterile water (eg, tap water, bottled water, filtered water, distilled water) to wash the skin before or rinse equipment during tattoo placement

●Follow aseptic techniques during tattooing (ie, hand hygiene and the use of disposable gloves; using new needles with each tattoo and disposable single-use ink cups)

We do not provide prophylactic antibiotics for patients with congenital heart disease (CHD) before tattooing. The American Heart Association does not recommend prophylactic antibiotics for patients with CHD before obtaining body art (tattoos or body piercings) [109], although some expert clinicians disagree with this recommendation [110-114].

TATTOO REMOVAL — Tattoo removal usually is more involved, takes more time, and is more expensive than tattoo application. Tattoos generally are removed with laser therapy, which usually requires multiple sessions; complete removal is not guaranteed [115]. Techniques that have been used in the past include cryosurgery, thermal cautery, or surgical resection. All of these methods may leave scars or residual pigment. An alternative to removal is covering the unwanted tattoo with another design.

Tattoo removal, including techniques and adverse effects, is discussed separately. (See "Tattoo removal".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)

●Basics topic (see "Patient education: Tattoos and body piercings (The Basics)")

SUMMARY

●Tattooing is increasingly common among adolescents and young adults. (See 'Epidemiology' above.)

●When counseling patients about tattooing, primary care clinicians can provide education and resources (table 1) to help them make informed decisions. This includes discussion of the motivational factors (ie, perceived benefits) and health risks; choice of the tattoo design, site, and artist; and anticipatory guidance about prevention of infection and when to seek medical care for complications. It also includes a discussion of relative contraindications to tattoo placement. (See 'Counseling patients about tattoos' above.)

●Tattooing may be performed by commercial or amateur artists. The tattooing technique and aftercare instructions may affect the risk of complications. (See 'The tattooing process' above.)

●Health risks include localized infection, systemic infection, and skin reactions. Whether tattoo pigments have local or systemic carcinogenic effects is unclear. (See 'Health risks' above.)

●The risk of infection can be reduced if the patient obtains the procedure in an establishment that uses sterile procedures, follows appropriate aftercare instructions, and completes hepatitis B immunization before tattooing. (See 'Prevention of infection' above.)

●Tattoo removal generally is more involved, takes more time, and is more expensive than tattoo application. Complications of tattoo removal include hypopigmentation, hyperpigmentation, hypersensitivity reaction, scarring, and residual pigment. (See "Tattoo removal".)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges R Michelle Schmidt, MD, MPH and Myrna L Armstrong, EDd, RN, FAAN, who contributed to an earlier version of this topic review.