Adverse Reactions to Tattoos in the General Population of Denmark.

To the Editor: The prevalence of permanent tattooing is increasing,1Laumann A.E. Derick A.J. Tattoos and body piercings in the United States: a national data set.J Am Acad Dermatol. 2006; 55: 413-421Abstract Full Text Full Text PDF PubMed Scopus (440) Google Scholar, 2Sagoe D. Pallesen S. Andreassen C.S. Prevalence and correlates of tattooing in Norway: a large-scale cross-sectional study.Scand J Psychol. 2017; 58: 562-570Crossref PubMed Scopus (9) Google Scholar along with its harms. Case studies provide mounting evidence of various tattoo-associated skin problems often ascribed to red and black ink.3Brady B.G. Gold H. Leger E.A. Leger M.C. Self-reported adverse tattoo reactions: a New York City Central Park study.Contact Dermatitis. 2015; 73: 91-99Crossref PubMed Scopus (38) Google Scholar However, as the prevalence of tattoo-related skin reactions in the general population is unknown, the scale of the adverse reactions remains uncertain. Tattooing has been associated with marginalized societal groups,4Pers M. von Herbst T. The demand for removal of tattoos. A plea for regulations against tattooing of minors.Acta Chir Scand. 1966; 131: 201-204PubMed Google Scholar but little is known about the current social characteristics of the tattooed population. Our baseline cohort study from 2006 compromised 3471 randomly selected adult Danes representative of the general population. Five years later, a follow-up was conducted including 2212 individuals (participation rate 63.7%) who answered questions regarding permanent tattoos, adverse skin reactions, and social characteristics. Permanent tattooing was defined as a tattoo pricked into the skin by a needle. We used SPSS version 22 for descriptive statistics and regression models to estimate odds ratios (ORs) with 95% confidence intervals (95% CIs). In total, 14.2% had ≥1 tattoo (Table I). Tattoos were more frequent among the young age groups, with 28.6% for those 24-30 years of age and 27.1% for those 31-39 years of age compared with 10.4% in the 40-76 year age group. More men were tattooed than women, and men were younger (median age 20 years) than women (median age 28 years) when they had their first tattoo (P < .001). Notably, tattooed individuals were more often unmarried, less educated, and cohabiting than individuals without tattoos. Moreover, they had an unhealthy diet, frequently used tanning beds, and rated their social position as in the middle (Table I).Table ICharacteristics of study population from Health2006 cohort and logistic regression analysis with ≥1 tattoo as dependent variable and covariates influencing likelihood of having tattoo as independent variablesExplanatory variablesNo tattoos, % (n)≥1 tattoo, % (n)P value, χ2 testOR (95% CI)General All participants, n = 221285.8 (1899)14.2 (313) SexFemale, n = 119089.0 (1059)11.0 (131)<.001ReferenceMale, n = 102282.2 (840)17.8 (182)1.89 (1.48-2.43)∗Adjusted for age. Age group, y40-7689.6 (1546)10.4 (180)<.001Referenceφ31-3972.9 (283)27.1 (105)3.34 (2.53-4.40)†Adjusted for sex.24-3071.4 (70)28.6 (28)3.65 (2.28-5.84)†Adjusted for sex.Skin health Itchy skin ever48.3 (897/1856)46.5 (140/301).5581.05 (0.81-1.34) Itchy skin within past 12 months56.9 (645/1133)54.9 (100/182).6161.08 (0.78-1.49)Social characteristics and lifestyle Marriage, n = 2204Ever married85.6 (1619/1892)70.5 (220/312)<.001ReferenceUnmarried14.4 (273/1892)29.5 (92/312)1.80 (1.30-2.48) Cohabitation, n = 2162Never cohabited42.2 (783/1856)27.1 (83/306)<.001ReferenceEver cohabited57.8 (1073/1856)72.9 (223/306)1.74 (1.32-2.29) Educational level, n = 2132High59.0 (1082/1833)37.5 (112/299)<.001ReferenceLow, <7-10 y41.0 (751/1833)62.5 (187/299)2.92 (2.23-3.84) Social position, self-assessed, n = 2198High32.9 (620/1886)24.7 (77/312)<.05ReferenceMiddle64.8 (1222/1886)72.8 (227/312)1.74 (1.30-2.32)Low2.3 (44/1886)2.6 (8/312)1.51 (0.67-3.40) Diet, self-assessed, n = 2196Healthy27.0 (508/1884)20.5 (64/312)<.05ReferenceAverage64.9 (1222/1884)66 (206/312)1.20 (0.88-1.63)Unhealthy8.2 (154/1884)13.5 (42/312)1.83 (1.17-2.86)Tanning habits Use of sunscreen during summer63.4 (1194/1882)65.4 (202/309).5130.90 (0.68-1.18) Use of tanning bed8.7 (164/1889)26.9 (84/312)<.0013.89 (2.84-5.34)Bold indicates statistically significant by logistic regression analysis (P < .05).CI, Confidence interval; OR, odds ratio.∗ Adjusted for age.† Adjusted for sex. Open table in a new tab Bold indicates statistically significant by logistic regression analysis (P < .05). CI, Confidence interval; OR, odds ratio. Adverse reactions to tattoos were reported by 5.9% (18 of 306). The reasons for adverse reactions were eczema/rash (2.9%), infection (1.3%), erosions (1.0%), or all symptoms (0.7%). In most cases, the adverse reactions disappeared without any action; 5.6% of reactions disappeared after medical treatment and 11.1% of individuals had the tattoo removed (Table II). Red ink was involved in most adverse reactions.Table IISelf-reported adverse skin reactions in tattooed population (N = 306)Adverse skin reaction in tattoo and characteristicsValue, n (%)Adverse skin reaction in tattoo, self-reported18 (5.9) Eczema/rash9 (2.9) Infection4 (1.3) Erosion3 (1.0) All 32 (0.7)Sex, male9 (50)Age group, y 24-30, n = 281 (3.6) 31-39, n = 1056 (5.7) 40-76, n = 18011 (6.1)Low educational level (<7-10 years), n = 18710 (5.3)Skin health Itchy skin ever, n = 14012 (8.6) Itchy skin within the past 12 months, n = 1008 (8.0)Tanning habits Use of sunscreen, n = 20212 (5.9) Use of tanning bed, n = 844 (4.8)Color affected by adverse reaction (P value = .22, Fisher's exact test) Blue1 Black4 Red4 Green0 Yellow2 Mix∗Blue and red; red, green, yellow, and other; yellow and other; blue, red, green, and yellow; and black, red, green, and yellow.5 Other1 No answer1Handling of adverse reaction (P = .239, Fisher's exact test) Disappeared without any action12 Disappeared after medical treatment1 Tattoo had to be removed2 Other2 No answer1∗ Blue and red; red, green, yellow, and other; yellow and other; blue, red, green, and yellow; and black, red, green, and yellow. Open table in a new tab Our study suggests that tattooing is becoming more mainstream, which is in-line with previous literature.2Sagoe D. Pallesen S. Andreassen C.S. Prevalence and correlates of tattooing in Norway: a large-scale cross-sectional study.Scand J Psychol. 2017; 58: 562-570Crossref PubMed Scopus (9) Google Scholar We show that 5.9% of tattooed individuals report adverse reactions, which is high considering our focus on well-defined clinical symptoms. Potentially this restricted range of reactions from our questionnaire was a study limitation, resulting in an underestimation of the prevalence of tattoo-associated problems. Further, we do not know when the reactions occurred, and whether they were late events or associated with the pricking itself. A low rate of medical consultation and a habit of consulting the tattooist or asking tattooed friends for advice regarding tattoo-related skin problems have been shown elsewhere.5Hutton Carlsen K. Serup J. Photosensitivity and photodynamic events in black, red, and blue tattoos are common: a ‘beach study’.J Eur Acad Dermatol Venereol. 2014; 28: 231-237Crossref PubMed Scopus (61) Google Scholar However, the tattooist is not required to report adverse reactions or to provide general risk information. Face-to-face interviews in tattooed subgroups have shown that 42% of 144 tattooed sunbathers in Denmark experienced complaints5Hutton Carlsen K. Serup J. Photosensitivity and photodynamic events in black, red, and blue tattoos are common: a ‘beach study’.J Eur Acad Dermatol Venereol. 2014; 28: 231-237Crossref PubMed Scopus (61) Google Scholar and 10.3% of 300 tattooed individuals in Central Park, New York, had experienced an adverse reaction.3Brady B.G. Gold H. Leger E.A. Leger M.C. Self-reported adverse tattoo reactions: a New York City Central Park study.Contact Dermatitis. 2015; 73: 91-99Crossref PubMed Scopus (38) Google Scholar The high number of adverse reactions supports the need for systematic surveillance regarding tattoo-related skin problems. Our findings underline the importance of counseling emphasizing risks associated with red ink.