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  1. Bergevin, Rita C. MA, RN-BC, CWCN

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My young adult patient wants to get a green cancer awareness ribbon tattoo in honor of her mother, who was recently diagnosed with lymphoma. My patient has asked me for information about tattooing. Can you tell me the most important considerations I should include in my teaching?-B.K., ILL.


Rita C. Bergevin, MA, RN-BC, CWCN, replies: Tattooing is defined as the introduction of exogenous pigments into the dermis to obtain a permanent design.1,2 Most commercial tattoo artists use a handheld electronically powered machine that punctures the skin with a single needle or multiple needles and coloring agents made of inorganic metallic salts and organic dyes and other kinds of organic molecules.2


Body art is increasingly common among young adults. Small surveys of college students (ages 18 to 25) indicate that 20% to 25% have tattoos. The prevalence is higher in larger surveys of adults ages 18 to 29, ranging from 22% to 40% depending on the age groupings.2 The desire to experiment with body art reflects the need for body identity or control or as a means to redefine themselves.2


Several points need to be considered in developing a teaching approach about tattooing. Tell those considering a tattoo about the regulatory standards for tattooing, stressing that the safety of tattoo pigment components for injection into the skin isn't well established because no tattoo ink or additive is FDA-approved. Oversight of the practice of tattooing and licensing of tattoo artists and facilities in the United States is left to individual states and counties rather than the federal government. Most standards relate to sanitation requirements and prohibit tattooing minors. A 2011 review of U.S. state tattooing regulations found that sanitation was effectively regulated in 36 states, infection control in 26, and training in 15.3 However, only 14 states effectively regulated all of these.


Anyone seeking a tattoo should be aware of the infection risks, including hepatitis B and C virus infection and local skin infection. Hepatitis B raises concerns because it can be readily transmitted, even with small blood exposures, and tattoo artists aren't required to be immunized for hepatitis B.2 An allergic reaction to the injected dyes is another risk, even when good technique is used. Also inform patients that no topical anesthetic is used to ease the pain of tattooing, and most tattoo artists are unlicensed.


People seeking a tattoo should carefully choose a reputable artist. Your patient would be well-advised to visit a commercial studio and confirm that the artists wash their hands and use a fresh pair of protective gloves. Needles and pigment tubes must come from sealed packages. Nondisposable equipment must be sterilized by autoclave. The body site for tattooing should be thoroughly cleaned with antimicrobial solution and aftercare instructions should be provided.


Encourage your patient and other young adults to talk to others who've been tattooed about local discomfort, adverse reactions, and any regrets they have. They can be encouraged to consider placing the tattoo in a concealed body area where they'll have control over who sees it.


The most commonly reported adverse reaction to tattooing is tenderness and pruritus associated with an allergic reaction, most commonly related to red and yellow pigments. This reaction usually recedes without consequence in 2 to 3 weeks.1,4 Some of these reactions are photo-aggravated, so warn your patient that edema and erythema may develop upon exposure to sunlight.5


Finally, make sure patients understand that removing a tattoo can be difficult and sometimes impossible. Laser tattoo removal often requires multiple (and expensive) treatments, and complete resolution of color may not be achieved in all cases. Laser-induced photochemical changes can occur in some tattoo inks, resulting in irreversible darkening of the tattoo. Many cosmetic tattoos contain iron oxide inks that laser irradiation changes from the ferric form to ferrous oxide, which is dark and insoluble. Certain pigments including red, brown, and white ones used for cosmetic tattoos are associated with the highest risk for this type of reaction.5




1. Kluger N, Koljonen V. Tattoos, inks, and cancer. Lancet Oncol. 2012;13(4):e161-e168. [Context Link]


2. Schmidt RM, Armstrong ML. Tattooing in adolescents and adults. 2016. http://www.UpToDate.com. [Context Link]


3. Carlson VP, Lehman EJ, Armstrong M. Tattooing regulations in U.S. States, 2011. J Environ Health. 2012;75(3):30-37. [Context Link]


4. Montgomery DF, Parks D. Tattoos: counseling the adolescent. J Pediatr Health Care. 2001;15(1):14-19. [Context Link]


5. Keaney T. Tattoo reactions. Medscape. 2015. http://emedicine.medscape.com/article/1124433-overview. [Context Link]