Frightful Or Functional? A New Era for Tattoos (Part Two): Risk & Regulation in Tattooing

Last week a new article came out from NEJM about risks associated with tattoo inks, which is receiving significant buzz in social and traditional media.

PM LeBlanc, KA Hollinger, KC Klontz. Tattoo Ink–Related Infections — Awareness, Diagnosis, Reporting, and Prevention. NEJM August 22, 2012. http://www.nejm.org/doi/full/10.1056/NEJMp1206063?query=TOC. DOI: 10.1056/NEJMp1206063

The response in the popular press is ranging from the mild (So Your Tattoo is Infected) to the overblown (There’s A Mysterious Tattoo Infection Outbreak Running Rampant). While this isn’t likely to change much for the roughly 1 in 5 persons in the United States who have tattoos already (4 in 10 for persons aged 18-29!), many healthcare professionals are wondering if they should advise patients to avoid tattoos altogether.

This is an especially tricky question because of the surprising aspects of regulation in the tattoo industry. There are over 21,000 licensed tattoo parlors in the United States, according to the most recent statistics. In Washtenaw Country, Michigan, home of the University of Michigan, there are 17 licensed body art facilities (the phrase used by the government to describe tattoo shops) as of August 27, 2012. Please note there are several tattoo shops listed in the Yellow Pages that are not on the state list of licensed facilities, and there are several on the state list that are not listed in the Yellow Pages! A web search will pull up MANY more shop names that are on neither list, but some of which are well reviewed online or state on their web site that they are the “prime destination for any of your typical body modification needs” (or phrases with similar impact). What does it mean for a tattoo parlor (or body art facility) to be licensed?

“Public Act 375, which was enacted in December of 2010, indicates that individuals shall not tattoo, brand, or perform body piercing on another individual unless that tattooing, branding, or body piercing occurs at a body art facility licensed by the Michigan Department of Community Health (MDCH).
Owners or operators of body art facilities will be required to apply for a body art facility license through MDCH.
Body art is becoming increasingly popular and the implementation of PA 375 sets statewide requirements for body art facilities aimed at decreasing the risk of transmission of bloodborne diseases such as hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV).” State of Michigan. Body Art Facility Licensing in Michigan. http://www.mi.gov/mdch/0,1607,7-132-44560_58283—,00.html

Licensing requires the staff associated with the facility attend a formal training and demonstrate awareness, knowledge, competency, and adherence to appropriate standards for infection control, medical waste handling, record keeping, confidentiality, and supplying aftercare recommendations to clients.

State of Michigan, Department of Community Health, Requirements for Body Art Facilities http://www.mi.gov/mdch/0,4612,7-132-44560_58283_58285_58287-219221–,00.html

The guilty organism this time was Nontuberculous Mycobacteria, also known as NTM. I say this time because, despite the reports that make it sound as if this is a new and urgent matter, it really isn’t. It certainly isn’t new, and the urgency comes mostly from trying to raise public awareness around a long-standing issue, and what are the best practices to keep in mind. Personally, I am hoping that folks don’t become overly concerned as a result of the hype, and place the risks in the appropriate context. Keep reading for why I think so.

First point to make is that most people who get tattoos do not get a skin infection. Second is that most people who do get a skin infection in their tattoo don’t get a serious infection, and will heal without significant medical intervention. Third is that most folk who do get a skin infection from a tattoo received at a professional tattoo show will have given it to themselves, by not following the instructions given by their tattoo artist, such as through improper hygiene at home or such activities as swimming. Tattoos are wounds, and the same healing guidelines apply as would to any minor medical procedure. Here is an excellent overview of ways in which people give themselves skin infections following tattooing (also known as “what not to do”).

Help Prevent a Tattoo Infection: http://autmblanche.hubpages.com/hub/Help-Prevent-a-Tattoo-Infection

You’ll have noticed the emphasis above on “professional tattoo shop.” Several articles have mentioned the reduction in risk from going to a professional tattoo artist as compared with having a friend do the tattoo. Statements such as these are not uncommon.

“The risk was higher if tattooing was done by a non-professional friend than by a professional tattooist.” (Ko et al, 1993)

“With the appearance of professional tattoo studios, the risk of infectious complications was reduced.” (Kazandjieva & Tsankov, 2007)

A 2003 Public Health Report found that professional tattoo artists are generally aware of best practices for asepsis and supportive of regulations in this area.

MJ Raymond, LL Halcón, PL Pirie. Regulation of tattooing in Minneapolis and St. Paul, Minnesota: tattooists’ attitudes and relationship between regulation and practice. Public Health Rep. 2003 Mar-Apr;118(2):154-61. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497524/

Here is an article from within the tattoo profession (by Mike Riina from Lansing, Michigan) about how to be an informed consumer, complete with tips for identifying good asepsis sterile environments in tattoo shops.

Mike Riina: How to Recognize Aseptic Technique in a Tattoo Shop: http://tattooartistmagazineblog.com/2011/09/07/mike-riina-how-to-recognize-aseptic-technique-tattoo-artist-magazine-blog/

Here are just a few photos from Ypsilanti-based Brite Idea Tattoo (one of the 17 licensed body art facilities in Washtenaw County, out of the approximately 21,000 such facilities nationwide) to illustrate some of the core concepts. (Full disclosure: Zera Anderson of Brite Idea Tattoo is my daughter, which is why I can get all these great photos.)

Is the facility licensed? Is the artist licensed? Are the licenses posted prominently? Are procedures for reporting complaints posted prominently?

Is the facility clean? Does the artist use an autoclave to sterilize instruments/needles? Are proper safety procedures posted?

In the main working area, are there additional cleansing resources, and are the single-use needles discarded in a sharps container?

Does the artist wear gloves while tattooing (and NOT wear gloves when answering the phone), and does the artist “bag” the tattoo gun, to help minimize risk?

So, if the tattoo profession is smart about asepsis and supportive of regulation, then what is all the fuss about right now? Here’s a quick superficial overview of recent reports for infectious diseases contracted via tattoos.

2003. RW Haley, RP Fischer. The tattooing paradox: are studies of acute hepatitis adequate to identify routes of transmission of subclinical hepatitis C infection? Arch Intern Med. 2003 May 12;163(9):1095-8. http://www.ncbi.nlm.nih.gov/pubmed/12742809

2006. Methicillin-Resistant Staphylococcus aureus Skin Infections Among Tattoo Recipients — Ohio, Kentucky, and Vermont, 2004–2005. MMWR June 23, 2006 / 55(24);677-679. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5524a3.htm

2008. N Kluger, C Muller, N Gral. Atypical Mycobacteria Infection Following Tattooing: Review of an Outbreak in 8 Patients in a French Tattoo Parlor. Arch Dermatol. 2008;144(7):941-942. http://archderm.jamanetwork.com/article.aspx?articleid=419799

2010. BD Lollis, RS Kent. Cluster of Nontuberculous Mycobacteria Skin Infections From Tattoos. AFRL-SA-BR-TP-2010-0001. (PDF) http://www.dtic.mil/dtic/tr/fulltext/u2/a523390.pdf

2012. DC McGouran, SK Ng, MR Jones, D Hingston. A case of cutaneous diphtheria in New Zealand. N Z Med J. 2012 Feb 24;125(1350):93-5. http://www.ncbi.nlm.nih.gov/pubmed/22382261

The earliest report I could easily find of an infectious condition transmitted via tattoo was from 1913.

1913. SE Dore. Case of (?) Tuberculous Infection of Tattoo Marks. Proc R Soc Med. 1913;6(Dermatol Sect):182-3. http://www.ncbi.nlm.nih.gov/pubmed/19976657

See? It is possible to get a variety of illnesses from tattoos, both bacterial and viral. The solutions recommended in the past have been for the tattoo artist to have good aseptic procedures, as discussed above. Many of the reported cases of infections from tattoos refer to tattoos done in prisons or by acquaintances or street artists. But even with a professional, responsible, well-trained tattoo artist, and even if you follow instructions religiously for proper aftercare, it is still possible to get an infection.

This is not a new problem, just the current incident. For this current incident, the outbreak of infection was traced back to contaminated ink from a single manufacturer. The tattoo artist had followed all the recommended safety procedures, with good sterilization and well kept autoclaves, gloves, and so forth. Some folk have previously expressed concerns about diluting tattoo inks with water that isn’t sterile.

“Previously published reports of tattoo-related nontuberculous mycobacterial infections suggested that tap water or distilled water used to dilute inks at tattoo parlors was a likely source of contamination.” Drage LA, Ecker PM, Orenstein R, Phillips PK, Edson RS. An outbreak of Mycobacterium chelonae infections in tattoos. J Am Acad Dermatol 2010;62:501-506

That was not the problem this time. The artist did not dilute the ink, and it was fresh from the manufacturer. It should have been fine. Here was the basic message from the NEJM/MMWR articles last week.

“Even if a person receives a tattoo at a tattoo parlor that maintains the highest standards of hygienic practice, there remains a risk of infection from the use of contaminated ink.” (LeBlanc et al, 2012)

While many news reports are focusing on the risk of the tattoos, the REAL risk is in the manufacturing process and the lack of regulation. If you read the reports carefully, you’ll noticed the FDA representatives saying that they are not allowed to regulate tattoo inks because they are considered a cosmetic. That is the real problem. They are only allowed to intervene after a problem has already cropped up. A responsible tattoo artist (or ink artist) has zero desire for their clients to be unhappy with their work, especially if injury or illness results. That doesn’t do anything good for them. Good tattoo artists are very interested in knowing about problems, helping clients take care of their new tattoos, and working with clients to figure out the problem when something does go wrong. The best recommendation, for now, is if you get a new tattoo:

1. Choose a responsible LICENSED tattoo shop.
2. Take good care of your tattoo afterwards, as instructed.
3. If something doesn’t seem right, or you get a rash or unusual bumps around the tattoo area, talk to the tattoo artist.
4. If the tattoo isn’t healing or shows signs of infection, talk to your doctor.
5. Remember, if there is a serious infection, you or your doctor should both let the tattoo artist know (so they can figure out which ink is causing problems and avoid problems for other clients), and also report the problem to the FDA.

FDA: Reporting Serious Problems to FDA: http://www.fda.gov/Safety/MedWatch/HowToReport/default.htm

That’s for right now. But for the future, as tattooing becomes ever more integrated into emerging technologies, the idea of non-regulation of tattoo inks and other cosmetics is only going to become more important and urgent. More on this in the next post.

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LINKS NOT CITED IN THE TEXT

J Hamblin. So Your Tattoo is Infected. The Atlantic AUG 23 2012, 12:59 PM ET. http://www.theatlantic.com/health/archive/2012/08/so-your-tattoo-is-infected/261476/.

J Welsh. There’s A Mysterious Tattoo Infection Outbreak Running Rampant. Business Insider Aug. 23, 2012, 6:13 PM. http://www.businessinsider.com/mysterious-tattoo-infections-outbreak-running-rampant-2012-8.

AE Laumann, AJ Derick. Tattoos and body piercings in the United States: A national data set. J Am Acad Derm Sept 2006 55(3):413-421. http://www.jaad.org/article/S0190-9622(06)00831-0/abstract.

The Millennials: Confident. Connected. Open to Change. Pew Research Center Publications. February 24, 2010. http://pewresearch.org/pubs/1501/millennials-new-survey-generational-personality-upbeat-open-new-ideas-technology-bound