Tattoo complications: Diagnosis and treatment

Sebastiaan Alain Servé van der Bent

Research output: PhD ThesisPhd-Thesis - Research and graduation internal


Tattoos are a popular form of body art. In Europa and the USA, the prevalence varies between 10-20%. Despite its popularity, complications of tattooing can occur. Little is known about its clinical aspects, pathomechanism and treatment modalities. This thesis includes an overview of all cutaneous tattoo complications, including permanent makeup. These complications can be categorized in infectious, inflammatory, neoplastic and miscellaneous reactions. Infections are mainly superficial and of bacterial origin. Inflammatory complications include allergic reactions and autoimmune skin diseases. Of all allergic reactions to tattoo pigments, red pigments are most frequently involved. Autoimmune skin disease that may be related to tattoos include psoriasis, lichen planus, sarcoidosis, vitiligo and lupus erythematosus. They may be locally triggered by the procedure of tattooing which is referred to as the Köbner phenomenon. Although tattoo ink is thought to contain potential carcinogenic substances, the association between tattoos and skin cancer is interpreted to be coincidental because of the low reported number of cases. Miscellaneous complications include misapplication, pigment changes, blow-outs, neurosensory reactions, scars and keloids. Of all chronic tattoo reactions, allergic red tattoo reactions are the most frequent. In this thesis, the aetiology, clinical aspects and treatment of these chronic skin reactions are studied. For these studies, analyses was performed of skin biopsies, in vitro sensitisation tests, 3D-scanner and the clinical presentation. In the majority of these reactions, the clinical presentation is a plaque-like elevation of the red tattooed skin. One of the studies report that the average time of onset of symptoms is 1 year after the tattoo is placed. Histopathologically, the most frequent inflammation pattern is a predominant histiocytic reaction with interface dermatitis. These and other studies indicate that these reactions are likely to be caused by a delayed type IV allergic reaction. In addition, a study has been performed regarding the treatment of these allergies by using the CO2 laser. Not rarely, disorders in the tattooed skin can be the first manifestation of an autoimmune disease. In a study with patients with swelling of the tattooed eyebrows (permanent makeup), it was shown that these granulomatous reactions can be the first manifestation of systemic sarcoidosis. Another study was performed among sarcoidosis patients, focusing on the prevalence of tattoos and tattooed skin adverse events. Moreover, in this thesis, the successful treatment of a particular condition is described: tattoo associated uveitis. The discussion of the thesis is aimed at the origin and pathomechanism of allergic red tattoo reactions and the still largely unexplained (granulomatous) inflammatory black tattoo reactions.
Original languageEnglish
QualificationDoctor of Philosophy
Awarding Institution
  • Vrije Universiteit Amsterdam
  • Rustemeyer, Thomas, Supervisor
  • Wolkerstorfer, A., Co-supervisor
Award date8 Apr 2021
Place of Publications.l.
Print ISBNs9789493197497
Electronic ISBNs9789493197497
Publication statusPublished - 9 Apr 2021

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