What do I do With This Abnormal Tattoo?

A Focused Guide on Tattoo-Related Complications for the Emergency Physician

An estimated 10–20% of Americans have tattoos, with the prevalence dramatically increasing among younger generations.¹ Tattoos are typically done in professional settings, but education on best practices regarding hygienic tattooing and after-care varies heavily. Some tattoos are done by amateurs with minimal or no training in these best practices, further increasing the risk of complications.¹

Some patient populations are at increased risk of tattoo-related complications, particularly those who are immunocompromised, have numerous allergies, or have certain dermatologic conditions.²

This article will focus on the appropriate empiric treatments for tattoo-related complications in the emergency department based on an initial skin examination.

Normal Healing
The normal healing process of a tattoo includes symptoms such as pruritus, pain, and paresthesias. Examination findings include bleeding, edema, erythema, tenderness, serous drainage, crusting, and localized lymphadenopathy. These signs and symptoms are limited to the area immediately surrounding the tattoo and persist for 2–3 weeks on average, with gradual improvement following a 2–3 day period of improvement.^3,4

Discharge recommendations for a patient with a normally healing tattoo are not standardized but should include constant sun protection, avoidance of contact with non-potable water, and covering the skin with a dry cloth dressing.⁵ Spreading redness, worsening pain, and increasing edema should prompt re-evaluation.

Infectious Complications
Infection in the area of a tattoo can be difficult to differentiate from normal healing as described above. Infection typically results in progressively worsening edema, warmth, and erythema over a short period of time (2–3 days). The locus of infection may be a single color of the tattoo in the setting of non-sterile ink or the entire tattoo if contamination of the tattoo needles or skin is the primary source of infection.^3,4 The incubation time of infections is inconsistent, but signs and symptoms generally present within 4–22 days of tattoo placement.⁴

Folliculitis presents with pustules and papules at the base of hair follicles. Impetigo presents with papules that progress to vesicles with an erythematous base and rupture to form an adherent honey-colored crust. Ecthymapresents with deeper lesions that are “punched-out” with raised violaceous margins. These lesions will typically be clustered within the tattooed area of skin but may affect normal skin close to the tattoo. These lesions are known as superficial pyogenic infections and are typically due to infection with methicillin-sensitive staphylococcus aureus (MSSA).⁶ Isolated folliculitis often spontaneously resolves but may be treated with topical mupirocin 2% TID for 5 days. Impetigo and ecthyma can be treated with cephalexin QID for 7 days. Patients with a history of MRSA may be treated with doxycycline 100 mg BID, clindamycin 450 mg QID, or trimethoprim-sulfamethoxazole 160/800 mg BID for up to 14 days with primary care follow-up to ensure resolution.⁶

Erysipelas and cellulitis are defined by an area of warmth, edema, and erythema that spreads more intensely than expected during the normal tattoo healing process. In tattooed skin, these infections will often present as a sudden increase in the erythema and edema after an initial period of improvement following tattoo placement. Antibiotics that cover MSSA and beta-hemolytic streptococci such as cephalexin 500 mg QID for 6 days are appropriate initial treatments.^6,7 Intravenous antibiotics and MRSA coverage with vancomycin 15 mg/kg should be considered in patients with systemic signs of infection, purulent drainage, immunosuppressive conditions, or known MRSA colonization.⁶While official recommendations are limited, a patient who appears systemically well but has the aforementioned risk factors for MRSA could be treated with oral doxycycline 100 mg BID, clindamycin 450 mg QID, or trimethoprim-sulfamethoxazole 160/800 mg BID for 14 days with strict return precautions.

Mycobacteria naturally present in tap water can be introduced into the skin if non-sterile water or improperly stored sterile water is used to dilute ink. Mycobacteria grow slowly and can cause infectious symptoms months after wound healing.^2,4 Mycobacterial infections present with a combination of scattered erythematous papules, nodules, pustules, ulcers, and plaques in multiple stages of healing that are not limited to the area of the tattoo.⁸ If a mycobacterial infection is suspected, referral to dermatology for biopsy-guided treatment is required.

Finally, necrotizing infections are possible in the setting of tattooing. These present similarly to necrotizing infections from any other source and should be treated with intravenous piperacillin-tazobactam 3.375 g, vancomycin 15 mg/kg, clindamycin 900 mg, and prompt surgical referral.³

Allergic Complications
Tattoo inks are composed of numerous compounds that all act as antigens and provoke an immune response. These antigens can cause serious localized reactions in some patients. The most common allergic responses to tattoo ink are contact dermatitis, photodermatitis, and lichenoid reactions.^2,8

Contact dermatitis is a type IV hypersensitivity reaction to a component of the tattoo ink. Unlike contact dermatitis which results from superficial skin contact, dermatitis resulting from the injection of tattoo ink is typically more severe. Contact dermatitis typically presents within 2 weeks of tattoo placement with erythema, edema, and bullae in the area of the tattoo. This may lead to desquamation of skin, crusting, and increased serous drainage. The most severe symptoms will be present in the area of the tattoo, but mild symptoms may be present in patches surrounding it.^3,4Topical treatment with triamcinolone 0.1% or clobetasol 0.05% is preferred due to the long courses of systemic steroids that would be required to provide extended relief.⁹ Continuing treatment until the patient can seek dermatology follow-up is recommended. Lack of relief with topical therapies or greater than 30% total body surface area involvement should be treated with prednisone 0.5–1 mg/kg tapered by 50% per week for 3 weeks.⁹

Photodermatitis presents with the sudden onset of swelling, pruritus, pain, and erythema in one or more colors of a tattoo with sun exposure. Symptoms may occur in tattoos of any age. Photodermatitis is typically self-limited and improves gradually with the removal of the tattoo from the sun. While typically associated with red tattoos, reactions to black and blue ink are also common.¹⁰ Conservative treatment consists of cool compresses, cetirizine 10 mg qD to BID, and use of mineral sunscreens in the event of future sun exposure.

A lichenoid reaction is the most common tattoo-related complication. It can occur within weeks of tattoo placement or years later. A lichenoid reaction typically presents with multiple flat-topped papules or plaques within the area of the tattoo. Most notable is the lack of other exam findings that would suggest an infectious or allergic process. Acute treatment is not required. Follow-up with dermatology for biopsy is necessary to differentiate these lesions from other chronic skin conditions and verrucae from HPV infection.⁴

Autoimmune Complications
Patients with a history of lichen planus, psoriasis, and eczema may have localized flares of disease in the area of a recently placed tattoo¹¹. The skin trauma from tattoos may also induce the Koebner phenomenon, the diffuse spread of skin lesions from a chronic dermatosis in the setting of skin trauma.¹² In the emergency setting, lesions from these conditions are difficult to differentiate from allergic complications. Fortunately, management of these conditions is similar to allergic tattoo reactions: referral to dermatology for consideration of systemic treatment with immunomodulatory medications. If concern for infection is low, topical treatment with triamcinolone 0.1% or clobetasol 0.05% may provide some relief of symptoms.¹³

 Take-Home Points

• Progressive erythema, edema, and pain after an initial period of improvement are signs of tattoo-related infection.
• Patients with suspected tattoo-related infections who do not have systemic symptoms, histories of MRSA infections, and an absence of purulent production, and who are not immunocompromised, do not require MRSA coverage. They can be safely treated with a 6-day course of cephalexin 500 mg QID.
• A tattoo-related infection associated with systemic symptoms should prompt consideration of admission for intravenous vancomycin (typically 15 mg/kg).
• Allergic reactions to tattoo ink generally present with symptoms localized to the area of the tattoo and are best treated with topical triamcinolone 0.1% or clobetasol 0.05% followed by dermatology referral.

References

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2. Laux P, Tralau T, Tentschert J, et al. A medical-toxicological view of tattooing. The Lancet. 2016;387(10016):395-402. doi:10.1016/s0140-6736(15)60215-x
3. Acute complications of tattooing presenting in the ED. Am J Emerg Med. 2012;30(9):2055-2063.
4. Islam PS, Chang C, Selmi C, et al. Medical Complications of Tattoos: A Comprehensive Review. Clin Rev Allergy Immunol. 2016;50(2):273-286.
5. Liszewski W, Jagdeo J, Laumann AE. The Need for Greater Regulation, Guidelines, and a Consensus Statement for Tattoo Aftercare. JAMA Dermatology. 2016;152(2):141. doi:10.1001/jamadermatol.2015.4000
6. Stevens DL, Bisno AL, Chambers HF, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2014;59(2):e10-e52. doi:10.1093/cid/ciu296
7. Summary for Patients: Appropriate Use of Short-Course Antibiotics in Common Infections: Best Practice Advice From the American College of Physicians. Ann Intern Med. 2021;174(6):I22.
8. Falsey RR, Kinzer MH, Hurst S, et al. Cutaneous Inoculation of Nontuberculous Mycobacteria During Professional Tattooing: A Case Series and Epidemiologic Study. Clinical Infectious Diseases. 2013;57(6):e143-e147. doi:10.1093/cid/cit347
9. Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician. 2010;82(3):249-255.
10. Carlsen KH, Hutton Carlsen K, Serup J. Photosensitivity and photodynamic events in black, red and blue tattoos are common: A “Beach Study.” Journal of the European Academy of Dermatology and Venereology. 2014;28(2):231-237. doi:10.1111/jdv.12093
11. Rogowska P, Walczak P, Wrzosek-Dobrzyniecka K, Nowicki RJ, Szczerkowska-Dobosz A. Tattooing in Psoriasis: A Questionnaire-Based Analysis of 150 Patients. Clin Cosmet Investig Dermatol. 2022;15:587-593.
12. Orzan OA, Popa LG, Vexler ES, Olaru I, Voiculescu VM, Bumbăcea RS. Tattoo-induced psoriasis. J Med Life. 2014;7 Spec No. 2(Spec Iss 2):65-68.
13. Samarasekera EJ, Sawyer L, Wonderling D, Tucker R, Smith CH. Topical therapies for the treatment of plaque psoriasis: systematic review and network meta-analyses. Br J Dermatol. 2013;168(5):954-967.