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Glenn D. Braunstein, M.D. Headshot

Tattoos: Inks Raise New Health Concerns About Age-Old Designs

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While they've adorned skin since time immemorial as exotic emblems of beauty, rebellion or even criminality, if I start talking about tattoos, I can tell that lots of you of a certain age will react simply by sighing deeply or clucking your tongues in disapproval.

Sorry, Mom and Dad: we're long past the time when just sailors, soldiers, performers in burlesque acts or gangsters got inked. An estimated 45 million Americans have tattoos, and that number is quickly rising. Although the practice seemingly is becoming, along with piercings, ubiquitous among certain younger or youthful-minded folk across the country, the ink that tattoo artists inject remains unregulated. And while many potential risks are well known, others -- including long-term aesthetic and health concerns -- are less certain.

The focus of fears by most public health officials about body inking once concerned properly sterilized needles, spreading infections and unsanitary conditions at tattoo parlors. Scientists now are saying attention needs to be diverted to the very ink inside a tattoo needle.

As the market for tattoos has expanded wildly, so, too, have the types of materials employed, including UV inks that glow in the dark and permanent makeup. How toxic are their components, especially over the long run?

Not All Inks Are Equal

One recent study examined black ink, common in nearly every tattoo, as the skin designs often are dark or entirely black. Black tattoo inks are based on soot and iron oxide, they are unregulated and many contain hazardous chemicals that potentially can stay in the skin for a lifetime, absorb UV radiation and may affect skin integrity, researchers say.

Tattooing can require injections of substantial amounts of black ink, meaning large amounts of chemicals shot into and under the skin; many of these chemicals -- such as benzo(a)pyrene, a carcinogen found to cause skin cancer in animal tests -- are toxic, so some advocates have called for further scrutiny and oversight of tattoo inks. The study also suggests that the substances in black tattoo inks -- materials known as polycyclic aromatic hydrocarbons (PAHs) -- migrate into subjects' lymph nodes, which aid an individual's body in filtering out disease-causing organisms.

The FDA's National Center for Toxicological Research is investigating tattoo inks and whether their movement in the body has health consequences. Tattoo pigments are subject to U.S. Food and Drug Administration regulation, but the agency's website says that, "because of other public health priorities and a previous lack of evidence of safety concerns, FDA has not traditionally regulated tattoo inks or the pigments used in them."

While some tattoo inks contain pigments that are FDA-approved, others use materials more typically associated with automotive and industrial paints. A study in the Archives of Dermatology examined samples of 30 tattoo inks and identified aluminum, oxygen, titanium and carbon as the most common elements in them, with researchers concluding components vary vastly.

The FDA has received reports of adverse tattoo reactions, prompting investigators to further study the safety of inks, especially their long-term effects and how they interact with light or metabolize in the body.

The agency's experts say there's an absence of "systematic" studies and little information is available about how the pigments break down, though they note that tattoos tend to fade over time or when exposed to sunlight. They cite the color yellow, particularly when "Pigment Yellow 74" is involved in the tattoo ink, as susceptible to fading and disappearing

In the meantime, those wanting to get inked up should beware: regulators say those multiple reports of bad reactions they have received have come both immediately and even for years after from those getting tattoos. Again, some of the itching and inflammation appears to occur after tattooed folks expose themselves to the summer sun.

The well-known risks associated with tattoos include: infection, as unsterilized needles can carry infections including HIV-AIDS and hepatitis; allergies from various ink pigments; unwanted scar tissue, which can appear after a new tattoo, or after the removal of a tattoo; small knots or bumps known as granulomas, which may form around materials the body finds abnormal (in this case tattoo pigments).

In rare cases, some people experience temporary swelling or burning on their tattooed skin while undergoing magnetic resonance imaging (MRI). An unidentified pro football player suffered such an injury, prompting experts to publish a warning in a sports medicine journal about the prevalence among athletes of both tattoos and the need for MRI tests for injuries; they said caregivers should be wary of tattoos laden with black ink and pigments containing iron oxide, which may be more likely to react electromagnetically with the imagining technology and cause burns.

What Are They Thinking?

I know that those of us of a certain age may need to count to 10 and control our judgmental selves as more people around us display "tats." However, such personal decorations may have been as common in history as they are now, with archeological findings suggesting that as long as 5,000 years ago, Oetzi, a well-preserved "Iceman," had 57 tattoos on his body. In ancient Egypt, tattoos were familiar and in the South Pacific, they are widespread and marks of societal significance, while in Japan, as, frankly, in parts of Southern California, inking is a critical part of life in criminal gangs. There certainly are scholarly publications indicating that those with tattoos can evidence higher levels of mental disturbance or, among teenagers, a greater likelihood of maturity and adjustment issues than those without tattoos.

In Los Angeles in the 21st century, of course, tattoos need not mean anything more than do a pair of stylish shoes or a bright-colored jacket. But just because they're seemingly everywhere in our entertainment-industry driven metropolis doesn't mean that they won't pose quandaries, say for parents of young people who announce their desire for ink. Yes, they adorn people of all levels of education, income, race and color and women get half of the inkings these days. But pragmatism and the cosmetic surgery practitioners who are busy trying to erase skin designs testify that, no matter how fashionable, tattoos may be -- yes, Mom and Dad -- an adornment that must be carefully considered.

Unwanted Ink

If your tattoo's been around for years and your work or personal circumstances shift so that your impulse inking doesn't seem so hot, lasers offer a reliable removable tool. They're an improvement over what was available, including bleaches or wearing long-sleeves or other disguising clothes. The lasers break up the pigment in the tattoo with a high-intensity light beam. But if you're considering this process, research the options with care; choose a qualified dermatologist or health care professional to perform your tattoo removal. Inks respond differently to lasers, so some tattoos may require multiple procedures with different types of lasers to produce the results that will satisfy you. Black often is the easiest color to remove since it absorbs all laser wavelengths.

Most patients do not require anesthesia while undergoing tattoo removal, though a topical anesthesia or pain injections may be used. While laser tattoo removal is relatively safe and effective, infection and scarring still are risks. You also may experience hypo- or hyper-pigmentation, where patches of your skin may appear lighter or darker than surrounding areas.

So, considering the risks, potential costs, time and inconvenience, is it worthwhile to be the coolest person at the club, restaurant or party, with a body covered with all manner of colorful designs, maybe even skin art aglow in black light? That's not a doctor's call. I can say that customs and fashions, especially in a place like L.A., change faster than the blink of a strobe light. So, ask yourself: how are you likely to feel in 10 or 20 years about the mural that you want to cover your back? Asking yourself what your parents and (future) kids might think about it also may help you make a rational decision about body art.