WHEN we innovate or do new things, we most times see the short-term consequences of our actions, but cannot foresee all the possible long-term effects until they occur. One such long-term result was published in the medical journal Obstetrics & Gynecology last week. It referred to the migratory effects of ink used in the tattooing of the skin.

Tattooing, as a form of body art, has become extremely popular in countries of the North and has been increasingly penetrating the cultures of many countries in the South. In a tattoo, the appearance of the body is modified by the insertion of indelible ink into the dermis layer of the skin in order to change the pigment found there.

Whilst tattoos have long existed among many cultures,,, such as the Ainu in Japan, the Khonds in India, the Maori of New Zealand, and the Samoans in Polynesia, the art form became popular in the West through the voyages of sailors who made tattooing fashionable. Modern materials and techniques now allow for a range of previously impossible designs and colours within tattoo art, and tattooing has become an acceptable form of western fashion, much as the multiple piercing of the ears and other body parts of both women and men has become commonplace.

THE TATTOOING PROCESS

The most common method of tattooing now is utilising the electric tattoo machine, which inserts ink into the skin through a single needle or a group of needles that are soldered onto a bar attached to an oscillating unit. The unit rapidly and repeatedly drives the needles in and out of the skin, usually 80 to 150 times a second. Because it breaks the skin barrier and inserts a foreign substance, tattooing carries a risk to health, including infection and possibly allergic reactions. Infections that may be caused by unsterilised tattoo equipment and contaminated ink include: surface infections of the skin, fungal infections, some forms of hepatitis, herpes simplex virus, tetanus, and HIV.

This procedure should therefore be performed in a sanitary manner, and the needles should be used only once in the process. Gloves must be worn by the tattoo artist at all times, the skin properly cleaned, and the wound must be wiped frequently with a wet disposable towel of some kind. The equipment must also be sterilised in a certified autoclave before and after every use.

TATTOOS ARE PERMANENT

Tattoos are considered permanent modifications of the skin, although some of the ink (the black and a couple, but not all of the colours) may possibly be removed through expensive laser treatment. The expense and pain of removing tattoos are typically far greater than the expense and pain of applying them. Many dermatologists regularly contend with regret by people who wish to have their tattoos removed. However, attempts at removal of tattoos have become more successful recently with the use of ablative fractioning resurfacing Q-switched laser.

TATTOO INK AND CANCER FALSE-POSITIVE

Doctors are now being warned that tattoo ink may look like the spread of cancer to the lymph nodes on diagnostic imaging, resulting in unnecessary surgery or treatment. A case report of a 32-year-old woman, who had locally advanced cervical cancer in California, revealed that she had applied 14 tattoos over an 11-year period that extensively covered her legs, with the most recent one having been applied two years before she appeared with cancer. As is customary in people with locally advanced cervical cancer, imaging was done before surgery to ascertain if the cancer had spread.

A whole-body PET-CT scan was done and revealed what appeared to be cancer spread into the left and right iliac lymph nodes, located deep in the lower pelvis. As a result, the patient underwent surgery for the cervical cancer, which included removing her womb, her fallopian tubes, and regional dissection of her lymph nodes.

The iliac lymph nodes were enlarged and pigmented, ranging in size from 1.5 to 2.0 cm. By the end of surgery, 40 lymph nodes had been removed. However, when pathologists examined the lymph nodes, there was no cancer.

TATTOO INK IN OTHER LOCATIONS

In other words, the iliac lymph nodes that were lit up with the tracer used in the PET-CT scanning had no cancer. The report stated that this was a case of “false-positive PET-CT scan resulting from the deposition of tattoo ink in the common iliac lymph nodes in a patient with cervical cancer”. The tattoo ink had simply migrated to the lymph nodes in the pelvis.

Tattoo ink has also reportedly appeared in other medical cases, including the regional nodes of patients with breast cancer, melanoma, testicular cancer, and squamous cell carcinoma.

The migration of the ink makes it difficult to differentiate grossly between the ink pigment and the metastatic disease, thereby resulting in unnecessary surgery.

With this new knowledge, therefore, should we reconsider indulging in tattoo body art?

Derrick Aarons MD, PhD is a consultant bioethicist/family physician, a specialist in ethical issues in medicine, the life sciences and research, and is the ethicist at the Caribbean Public Health Agency – CARPHA. (The views expressed here are not written on behalf of CARPHA)