Tattoos - Popular Decoration or Dangerous Fad?

By  Michael Smith

NEW YORK, Sept. 13-Tattoos, traditionally the preserve of seamen and bikers, have become the fashion accessory of the 21st century. One American in eight has a tattoo, including nearly 40% of every person ages 20 to 25.

But are tattoos safe? That depends on whom you ask -- and what you mean by safe. Views vary widely.

• The tattooing industry says the process is unlikely to transmit disease simply because tattoo operators are careful and clean, although there are few regulatory agencies making sure they adhere to hygienic standards.
• The Centers for Disease Control and Prevention (CDC) regards tattooing as risky in principle, but doesn't see any evidence of widespread transmission of disease.
• Studies by epidemiologists at the University of Texas Southwestern Medical Center in Dallas link commercial tattoo parlors to an unrecognized epidemic of hepatitis C (HCV).
• Top infectious disease specialists take another tack -- that commercial tattooing is safe, but that amateur and prison tattoos are dangerous.
• The FDA says the colors that go into tattoo ink are "technically illegal" since they haven't been approved for that use and, as a result, are worrisome. But aside from a recent spate of about 50 allergic and other reactions to certain inks, the FDA doesn't see much of a problem.
• Dermatologists say the biggest problem is the "remorse factor" -- the morning-after realization that a tattoo of the current boyfriend's name may not play well when the current passion -- but not the tattoo -- fades.

"Any time you pierce the skin, you're at risk of something," said Kathleen Ciampi, executive director of the Society of Permanent Cosmetics Professionals. "It's an invasive procedure …. A tattoo is essentially a colored wound."

But, Ciampi said, by and large, the industry is careful to minimize the risk of infection. Needles are never re-used, for instance, and clients are given careful instruction on how to care for their tattoo after it's done.

"The amount of problems is insignificant," Ciampi said, despite the growing number of people sporting tattoos.

That, in a nutshell, is also the CDC's position: It's possible that tattoos transmit disease -- and it does happen -- but hygienic procedures minimize the risk. There is so far little evidence -- except in "very selected populations" -- of the transmission of blood-borne diseases.

"Any procedure in which the skin is broken and in which the equipment could be contaminated with blood, has the potential to spread a variety of infections," said Miriam Alter, Ph.D., associate director for science in the Division of Viral Hepatitis at the CDC.

But for the major blood-borne diseases -- hepatitis B and C or HIV -- "we have no evidence that people who have been tattooed in the past and have no other risk factors are at increased risk," Dr. Alter said.

"That doesn't mean it doesn't happen," she said, "but I believe the preponderance of studies indicate (tattooing) is not a significant source of infection for hepatitis B or C."

Not so, said Robert Haley, M.D., professor of medicine and chief of the epidemiology division at UT Southwestern Medical Center.

Dr. Haley speaks in almost apocalyptic terms of a tidal wave of HCV that is poised to swamp the nation, an epidemic that is "going to dwarf" HIV/AIDS in terms of morbidity and mortality.

"This is a major public health crisis, but no one's aware of it," Dr. Haley said.

Much of that epidemic, he said, is fueled by commercial tattoo parlors -- an opinion based on a 2000 study he conducted to try to tease out the sources of chronic HCV infections, which he says affect 3% to 4% of the American population.

Dr. Haley and colleagues conducted interviews with 629 consecutive patients in a Dallas orthopedic spinal clinic between July 1, 1991, and November 15, 1992. The patients were asked about a range of HCV risk factors; any tattoos were directly observed and measured.

Later, blood tests showed that 43 patients were seropositive for HCV.

Analysis showed that there were four independent significant risk factors for HCV infection, Dr. Haley said:

• Injection-drug users were 23 times as likely to be infected as the group as a while. Odds ratio of 23.0 with a 95% confidence interval ranging from 7.5 to 70.6.
• Men who held ancillary hospital jobs were more than nine times as likely to be infected. Odds ratio was 9.6 with a 95% confidence interval ranging from 3.8 to 24.3.
• Patients who had tattoos from commercial tattoo parlors were more than six times as likely to be infected. Odds ratio was 6.5, with a confidence interval from 2.9 to 14.8.
• Finally, drinking three or more six-packs of beer per month made a patient four times as likely to be infected. The odds ratio was 4.0, with the confidence interval ranging from 1.8 to 8.7.

"In our study," he said, "tattooing accounted for about 40% of HCV infections. I think this is a major silent public health risk that is going unaddressed."

Infectious disease specialists, though, are skeptical, if only because in Dr. Haley's analysis, injection drug use only accounted for 17% of infections.

Eugene Schiff, M.D., chief of hepatology at the University of Miami School of Medicine, said the first thing he looks for in a patient who's tested positive for hepatitis C is not a tattoo, but injection drug use at some time in the past.

"I see these patients every day, and we're not seeing it when they're clean as a whistle, except for a tattoo," Dr. Schiff said. Instead, he says, his patients usually admit to using injection drugs, even if only for a short time.

Indeed, Dr. Alter said, most other studies show a greater link to drug use (and to blood transfusions in the days before donors were screened). "One has to take a second look" at studies, such as Dr. Haley's, that show something different, she said.

The CDC conducts what it calls sentinel studies, in which patients who become ill with HCV in selected areas are interviewed to try to discover what risk factors were involved. Those studies, she said, consistently show about 1% of people with acute HCV have been tattooed.

Indeed, even among people under the age of 40 -- where the prevalence of tattoos is high -- the sentinel studies show the same thing.

"If what (Dr. Haley) is saying was true, we'd see so much hepatitis it would be unbelievable," Dr. Schiff said. "And we're not seeing that."

Dr. Haley counters that tattoos are likely to cause subclinical disease -- without significant symptoms -- and therefore won't be picked up by the sentinel studies. When a person gets HCV from a tattoo, it is "almost certain to be the asymptomatic variety," he said.

The source of the tattoo is also an issue, said Ruth Berggren, M.D., an infectious disease specialist at Tulane. While Dr. Haley worries about the commercial industry, Dr. Berggren said she's more likely to be concerned about a tattoo acquired in prison.

"There are a lot of people in our prisons who are infected with hepatitis C and HIV and there is a practice of doing homemade tattoos," Dr. Breggren said. "But it's impossible to sort out how important a risk factor it is (for diseases such as HCV or HIV) because there are other risk factors (such as) injection drug use or male-male sex."

What about the tattoo itself? The FDA has not traditionally regulated either tattoo inks or the pigments that go into them. Instead, the agency focuses on adverse events -- such as allergic reactions -- and alerting the public to such problems, said an official in the FDA's colors and cosmetics office.

For instance, last July the agency reported that inks made by a Texas company had been associated with a range of ill effects, including swelling, cracking, peeling, blistering, and scarring, as well as granulomas near the eyes and lips.

The ink maker agreed to remove the offending products from the market, the official said.

The pigments in the inks are another story. Officially, they are supposed to be approved by the FDA before they are used. Indeed, many are approved for other cosmetic uses. But of the 50-odd pigments used in tattoos, none has been formally approved for use in tattoos.

"Strictly speaking, colors used in tattoos are not legal," the official said.

But until recently, the official said, the agency had received few reports of adverse effects from tattooing.

Having your tattoo swell or crack is probably a sign that it wasn't a good idea, but even if all goes well many people sooner or later regret their decision -- and that's when they end up in the dermatologist's office.

"The remorse rate is very high with tattoos," said David Green, M.D., a private practitioner in Bethesda, Md., who's also on the clinical faculty at Howard University.

"You do get allergic reactions and other immediate problems," he said, "but remorse is the biggest side effect with tattoos."

Many tattoos can be removed, using visible light lasers, but others are more difficult usually because of the colors involved. For example, black, Dr. Green said, is easy, but green is hard.

Essentially, the Q-switched lasers used in tattoo removal smash the cell containing pigment, and the debris -- including the color -- is then removed by the body. But it's not as simple as that.

The laser treatment itself creates a wound that can become infected, said Melanie Grossman, M.D., a New York dermatologist who's also on the clinical faculty at Columbia and Cornell.

Other possible side effects include changes in skin color and scarring, Dr. Grossman said. The laser can change the color of the pigment, but not remove it. Or the laser treatment will remove some colors but not others.

"I tell patients one possibility is they'll be left with a kaleidoscope effect," she said.

But like Dr. Green's experience, the burgeoning of the tattoo industry has meant more work for her.

"The trend has been more and more mainstream people -- whatever that means -- are getting these things," Dr. Grossman said, and that means more and more people are coming to her office asking to get tattoos off.

"Usually, it's 'I got this last week and my parents hate it,' or 'I'm having a kid,' or 'I'm getting married and it will show above my dress,'" Dr. Grossman said.

"The biggest side effect is people get them and then they want them off."

http://www.medpagetoday.com/Dermatology/GeneralDermatology/1725