Body modifications using tattoos, piercings and other techniques are part of a current fashion trend, particularly among teenagers and younger generations. Permanent decorative tattoos and piercings, and branding, scarification and implanting have increased in popularity over the past years in Western countries. However, the introduction of pigments, dyes and needles into the dermis is not devoid of potential adverse effects, mostly affecting the skin. The adverse skin reactions caused by permanent tattoos can be inflammatory reactions (acute inflammatory or delayed inflammatory reactions), infections, and potential genotoxic/cytotoxic effects. The adverse skin reactions caused by piercings can be infections, allergic contact dermatitis to metals, hypertrophic or keloid scars, and bleeding. Body modifying art is a relatively safe procedure when performed by professional artists who have received education on appropriate hygiene technique and apply strict sanitary precautions in their shops — even if reports of complications remind us the importance to improve the safety of these techniques — to preserve the health and the skin physiology of the customers. Those who decide to obtain a body modifying procedure should be advised to contact their physician or a dermatologist if any symptoms occur in order to receive the correct therapy.

Body modification using tattoos, piercings, and other techniques are a fashion trend, particularly among teenagers and the younger generations. These decorative techniques can be interpreted as a means of communication, an expression of identity, or a way to show their association with the cult of the body, known today as body art.

There are many reasons for this kind of practice, such as rebelliousness, fashion, memories of events, differentiation, and in some countries the enjoyment of ethnic and tribal influences1,2. Permanent decorative tattooing and piercings have increased in popularity over the years in Western countries and it has been estimated that the prevalence of tattoos and body piercing among adults aged 18–50 years in the USA is 24% and 14% respectively. The prevalence of body piercing for people aged 16 years and over is 10% in the UK, while the prevalence of tattoos and piercings in Italian adolescents is 6% and 20% respectively, and 10% and 8% (excluding ear piercing) in the Australian community aged 14 years and over3–5. Regulations have been implemented in Western countries to improve safety conditions for body modifying techniques, but the introduction of pigments, dyes, and needles into the dermis is not devoid of potential adverse effects, mostly affecting the skin6–8. Two Italian studies9,10 have investigated the awareness of the health risks connected to body art practices among the youth population, and found that adolescents are often unaware of the complications arising from body art techniques. For these reasons, dermatologists and primary care physicians must be familiar with the possible skin complications that can occur after receiving body modification in order to identify the most appropriate treatment, and health education programmes should be designed in order to provide health risk information to youths1,9–12.

In this article, the authors describe the possible adverse effects and complications that can occur after tattooing, piercing, and other forms of body modifying art, such as scarification, branding, and implanting.

Methods

The authors carried out a review of the available literature from PubMed on body art and its complications, using the following keywords: ‘body art’, ‘tattoo’, ‘henna tattoo’, ‘piercing’, ‘scarification’, ‘adverse effects’, and ‘complications’. All relevant papers were included with no chronological limit.

Permanent tattoos

Tattooing is the act of making indelible forms and pictures by inserting pigments into punctures in the skin. The origin of the tattoo is not completely clear, but it is known that they have been practiced throughout history by many civilisations for different purposes or reasons.

Permanent tattoos can be divided into three main groups:

• Traumatic tattoos are those in which the skin is penetrated by a specific material in an accidental manner (such as skin abrasions after an accident)
• Cosmetic or micropigmentation tattoos used as permanent make-up to outline eyes, lips, and eyebrows, as well as in breast reconstruction for the nipple-areola
• Decorative tattoos should be done by professional tattoo artists, and must be carried out under strict conditions of health and hygiene in authorised establishments, and always under the control of regional government and local authorities.

Pigments used by professional tattoo artists are composed of highly varied inorganic metal salts and organic plants, such as carbon, mercury, cadmium, cobalt, titanium, zinc, and manganese13.

Adverse skin reactions caused by permanent tattoos

Inflammatory reactions

Acute inflammatory reactions are those that appear immediately after the application of a tattoo, owing to the trauma caused to the skin by multiple intradermal injections of pigment into the skin, and usually last for 1–2 weeks14. Patients are generally advised by the tattoo artist of the risks prior to treatment, and tend not to require medical care, apart from, at most, the application of a topical corticosteroid and antibiotics.

Delayed inflammatory reactions can also appear weeks — and even years — after a tattoo has been applied, such as:

• Allergic contact dermatitis characterised by the appearance of eczematous lesions confined to the tattooed area, with occasional secondary spread (this is true especially for red tattoos and particularly those containing mercury)14
• Photo-induced reactions such as erythematous–oedematous lesions that occur following exposure to ultraviolet radiation. These reactions are most often caused by yellow and red cadmium-containing pigments1
• Lichenoid reactions to the tattoo are similar to lichen planus lesions (chronic papular dermatosis), and are most often seen in tattoos with pigments containing mercury14
• Granulomatous reaction is a particular type of chronic inflammatory reaction characterised by the accumulation of activated macrophages, especially in association with the use of chromium, mercury, cobalt, and magnesium15,16
• Pseudolymphomatous reactions including indurated erythematous and violaceous nodules confined to the tattoo area. Histologically, they are identical to cutaneous T-cell or B-cell lymphomas, but biologically, they are benign. This type of skin reaction has mainly been described for red pigment tattoos, but there have also been reports for green and blue pigments17,18
• Pseudoepitheliomatous hyperplasia benign tumour, in which the skin becomes thick, irregular, and hyperkeratotic; however, it is a rare tattoo reaction19.