The practices of body arts — tattooing and body piercings — have become so commonplace that most healthcare professionals will confront the health risks caused by both. Knowledge of these practices will better equip healthcare professionals across disciplines to address medical problems arising from these body arts, as well as recognize contraindications when patients present for imaging studies such as general radiography, CT and MRI.
Tattooing and body piercing are practiced worldwide and have a long history.1 With this extensive history, it is not surprising that the body arts continue to capture the imagination of many. Tattoos include drawing simple, solitary designs or multiple and complex patterns on the body.2 Tattoos can be black and white or color, and once applied are difficult to remove. Permanent facial makeup is also a tattoo procedure.3
Body piercing is the practice of puncturing or cutting into the body to insert a device or piece of jewelry. It can be a solitary earring or multiple rings inserted in areas such as the tongue, lips or ears. Some body piercings can be easily removed and reinserted, while others are considered permanent, due to location, style or method of insertion.
Overall, there is an increase in the number of people getting tattoos and body piercings, with multiple tattoos and piercings more common in younger people and tattoos among those of lower educational status.4
The average age of tattooing recipients has dropped to 14.5 years. Teenagers who gravitate to tattooing are no longer stereotyped as low academic achievers; recent studies show that 60% of teenagers who received a tattoo had grades of A or B. However, these adolescents are still often described as “risk takers” and although tattoos are often associated with uniqueness and artistic individuality, medical practitioners will sometimes use the presence of a tattoo as a means of identifying teens at risk.5,6 Although tattoos still often carry a stigma of their associated past, the acceptance of tattoos is on the rise and a large number of women now bear small, large or multiple tattoos, with evidence showing that tattooing among adult women has quadrupled in the past 25 years.
Unlike tattooing, body piercing varies little by educational status.
History of Body Tattoos
Historical evidence of tattooing in Egypt dates as far back as 2000 BC. Tattoos have been discovered on female Egyptian mummies and also on the bodies of figurines dated 4000 BC to 2000 BC.2 Tattoos using needles were so commonplace during the Third and Fourth Dynasties (2686 BC to 2493 BC) that even clay dolls of that period were adorned with tattoos. Nubian mummies from around 400 BC were found with tattoos of the Egyptian god of revelry (Bes), or the Egyptian sun god (Ra).2 In some cultures, tattoos have been associated with spiritual or healing rituals; for example, females were often given tattoos on their abdomens or thighs during the birth process. The Greeks and Romans used tattoos to show ownership of slaves, while other cultures had tattoos denoting nobility. In ancient Egypt, tattooing was a form of social identification, and as the Egyptians traveled, they passed on their culture of tattoos to those in Crete, Persia and Arabia.2
Some of the oldest known picture tattoos were discovered just after World War II on the mummified remains of a Pazyryk chieftain. The Pazyryks lived in Eastern Europe and Western Asia from 600 BC to 200 BC. The tattoos on a chief’s arms included a donkey, a mountain ram, two deer, a mountain goat and an unidentified carnivore. His legs had a huge fish stretching from his knees to his feet. Female Pazyryk mummies from this period show similar tattoos of animals, and historians believe the tattoos represented a way of honoring the animals or were a possible means of absorbing the characteristics of the animal in the tattooed person. Evidence of picture tattoos was found on a Scythian chief who lived about 2 BC. His remains were discovered in the Altai Mountains of Southern Siberia, and his tattoos represent totems and game animals.2
In 1991, the Iceman, the perfectly preserved, mummified remains of an ancient man, was found in the area of the Italian-Austrian border.2,7 The Iceman has been carbon dated to be around 5,200 years old, placing his lifetime around 3300 BC. His finger showed clear evidence of tattooing. More than 58 tattoos, most likely made with charcoal, were found on his body. His left knee had six straight parallel lines; there were also lines of tattoos above his kidneys and numerous lines of tattoos on his ankle.7
Tattoos are a part of both modern and ancient Western civilization. The Indians of North and South America routinely tattooed their faces and bodies. Most of theses tattoos were simple pricks with color introduced into the scratches. Buddhists have been tattooing before the first century, and their designs are still in practice today. Hindus enjoy tattoos in all forms, except tattoos of their gods.1,2
In early Japan, approximately 10,000 BC, tattooing of the face and body was used for spiritual, ritual or decorative purposes. However, even in a single culture the significance of tattoos could change with the times. In the period starting about 300 AD to 600 AD, Japanese tattoos assumed negative connotation; tattoos were used on prisoners and slaves.8
As far back as 1200 BC, the Polynesians and the Maori people of New Zealand used a wood-carving method of tattooing to create complex designs on the face and buttocks by cutting the skin with small bone-cutting tools. Water and soot was combined to form a pigment that was driven into the skin. Some peoples of the South Pacific created very artistic and elaborate geometric designs covering their entire bodies.1
More Recent Influences on Tattooing Practices
Tribes and cultures have tattooed themselves for many reasons; however, with the advent of Judeo-Christian religion, the tradition of tattoos became banned and, in many cultures, even the idea of tattoos became repulsive.1 Some Christian groups still regard tattoos as the “mark of the beast” that is referenced in the Bible.
Islam prohibits any type of body mutilation, including tattoos.
Those with tattoos are banned from burial in Jewish cemeteries; however, after WWII, with countless Jews tattooed with numbers against their will by the Nazis, this law was no longer enforced. In spite of this, tattoos may still be frowned upon in strict Jewish communities.1
In the late 18th century, Captain James Cook reported tattooing in the South Pacific islands. Naturalist Joseph Banks described the Tahitian practice of “ta-tu,” and the word “tattoo” comes from the Tahitian word tattau, which means “to mark.”
Tattooing was considered so exotic during the 18th and 19th centuries that European and U.S. societies used tattooed Indians and Polynesians to draw crowds at circuses and fairs. It was circuses that kept tattooing alive and often served as a showcase for tattoo artists, who could attract other customers by exhibiting their work.1,3
In the Victorian era, tattoos again became fashionable and were popular among European royalty. Because it was a very slow and painful process, however, tattooing soon lost its credibility.1,2
The electric tattooing machine was invented in 1891 by Samuel O’Reilly. Tattooing reached its height in the early 1900s, declined during the mid-1900s, and became popular again in the 1990s.
Today, tattoos in Japan have become associated with organized crime, especially full body tattoos applied in Tebori, the traditional Japanese art. Tattooing was finally outlawed in the 19th century and was not repealed until 1948. The negative association continued in the U.S. and Russia, where many prisoners and criminal gangs use distinctive tattoos as a method of member identification, symbolic of murder or death of a friend. Tattooing remains common in U.S. military units.1,8
Tattoos are also used for permanent cosmetics to reshape, recolor, recreate or modify eyebrows, lips, beauty marks and cheek blush.
In the criminal world, a tattoo can be the only means of identifying a victim or perpetrator.
Medical Use for Tattoos
Post-mastectomy patients are using tattoos to enhance nipple-areola reconstruction.1,2 In the medical world, some even use tattoos to indicate medical problems such as diabetes or epilepsy.9
Method of Tattooing
There are three types of tattoos:
- Permanent: color is inserted into the skin permanently
- Permanent makeup: a permanent tattoo is applied to look like an eyebrow, lip liner, eyeliner or blush
- Henna (mehndi): a natural plant dye (henna) is used to darken the skin, does not require needle use and lasts up to three weeks
Permanent tattooing involves placing unique, permanently colored designs on the body. Contrary to popular belief, most colors used in tattooing are not inks, but pigments, which may be naturally occurring minerals, vegetable dyes or even acrylic plastic colorants. Tattooing color agents have to be dispersed in carriers such as alcohol, USP filtered water and USP glycerin. Alcohol carriers must have an alcohol content of 15% or higher to have a sterilizing nature. Tattoo pigments are not well regulated by the U.S. FDA and may contain wood powder and carbon, and metals such as iron, copper and aluminum. To minimize infection, single-use containers of pigment should be used. Red pigments are associated with the highest incidence of allergic reaction. Red, yellow and dark pigments are the most difficult to remove.1,3 Henna is not FDA-approved for use on the skin.3
Before applying the tattoo, the tattooer shaves the area, and then either draws or stencils a design on it. Common designs are names, crosses, animals and original decorative tracings. After the skin is sprayed with an antiseptic agent and covered with a light layer of petroleum jelly, an outline of the design is tattooed using a tattoo machine, which is a needle bar containing a number of needles that move up and down with a frequency of up to 2,000 times per minute. During their vibration cycle, the needles protrude out of the bar to puncture the skin and deposit the ink colorant. This outlining procedure is the most painful part of the tattoo process.1
Once the outlining is completed, the design is colored with an apparatus called a “shader,” which is equipped with five to 13 flat needles and five to seven round needles, which are attached to a bar. The shader goes approximately one-tenth of an inch into the dermis and introduces color into the skin. The vibrating needles of the shader can cause considerable bleeding, and the process must be interrupted frequently to wipe away blood.1,3
Tattooing practitioners should wear gloves, and all equipment should be disposable or, at the very least, sterilized in an autoclave. Also, people set to receive tattoos should be told not to take nonsteroidal anti-inflammatory drugs, alcohol or aspirin before the procedure. Avoiding these chemicals can minimize bleeding. Excessive bleeding causes colorants to flow out of the tattoo. People with bleeding disorders and those who have trouble healing, such as diabetics, should not receive tattoos.3,6
Of particular medical concern are tattoo procedures carried out by nonprofessionals. Teenagers are especially tempted to have tattooing done by amateurs, including their friends, and may even do it themselves. Amateurs frequently use straight pins or pens to introduce colorants such as mascara, charcoal or even dirt. These types of tattoos have a high risk of becoming infected and/or causing serious allergic problems.3
After receiving a tattoo, the design should be bandaged for 12 to 24 hours, after which the tattoo should be washed with warm water. Tattoos should be bathed with an antibiotic ointment applied three times a day for one week.1 Some tattoo artists recommend against spreading antibiotic cream on the tattoo, as this can cause allergic reactions.6 Tattooists also advise against the use of rubbing alcohol, peroxide or petroleum jelly. Tattoos should be protected from the sun for two weeks; exposure to hot tubs, swimming and prolonged bathing should be avoided for several weeks.1,3,10
Tattoos and Medical Imaging
Tattoos have been known to cause burns during MRI. The burns, although infrequent and generally minor, may require treatment with a cold pack.10 A more common occurrence is a tingling or burning sensation at the site that often will not prevent the MRI from being performed. Decorative tattoos cause more problems, including swelling and erythema; there are reports of patients receiving second-degree burns on decorative tattoos that used a ferromagnetic pigment.11,12 The ink used in black or dark brown tattooing may contain metallic compounds that have ferromagnetic properties, such as iron oxide. These pigments have a greater potential for burn during MRIs.13 Other studies suggest that some patients with permanent makeup can experience minor burns because the pigmentation does not lie as deeply under the skin as a tattoo.10
Tattoos have also been associated with an increase in intracellular water temperature, which can lead to edema and burning for up to 48 hours after the scan. MRI technology is also very sensitive to metallic materials, and the presence of a tattoo has the potential to undermine the effectiveness of the imaging by producing artifacts.10,12 In some cases the presence of eyelining tattoos can cause distortion of the normal signal, resulting in mimicking an actual ocular disease, such as a ciliary body melanoma or cyst.10
Presence of a tattoo can cause concern during a lumbar puncture or epidural injection in interventional radiology or anesthesiology. The concern is that the needle could transfer particles from the pigment into the epidural space. Some healthcare practitioners advise that whenever possible, injections should not be made into a tattooed area.11,12
The healthcare provider will need to assess the patient thoroughly prior to any imaging study to determine the presence of tattoos or permanent makeup. The patient should also be counseled regarding the possible complications associated with permanent body art and should be encouraged to report any signs of discomfort or pain.
A cold compress can be applied to the tattoo site during the MRI procedure as a precaution.9 Many MRI departments have detailed questionnaires that patients must complete before the examination. Any patient questionnaire should include questions on cosmetic applications, such as eyeliner, lipliner and lip coloring, as well as decorative tattoos. Some units use a portable metal detector to ensure that a patient will never enter the MRI suite if there is any evidence of metallic implants.13