Tattoos and Autoimmune Disease

If you live with a chronic or autoimmune disease, you may be wondering if it is wise to get a tattoo. Whether or not it is safe to get a tattoo is a discussion that is best had with a healthcare professional.

Several questions should be considered beforehand, including if the disease or condition is well controlled and if there is an increased risk of developing a complication, such as an infection. In all cases, tattooing should only be performed by a licensed, experienced professional who uses sterile equipment in a reputable location.

General Considerations

Today, roughly one-third of Americans have a tattoo. While tattooing is both a common (and, in some cultures) ancient practice, tattoos are not without risk — even for people who don’t live with autoimmune disease or chronic illness.

But when one has a chronic or autoimmune disease such as inflammatory bowel disease (like Crohn’s disease or ulcerative colitis), lupus, multiple sclerosis, arthritis, or psoriasis, the body’s immune system fights healthy tissue by mistake. Inflammation throughout the body is a common side effect.

In addition, medicines that suppress the immune system, like corticosteroids, in turn, leave the body more susceptible to infection.

People who live with chronic conditions or autoimmune diseases often go through cycles with their health. There are times when the condition is well managed and others when it is less controlled. When there is a disease process that’s not under control, it is probably not the best time to consider body art.

Depending on a number of factors, including the type of condition(s), the medications needed, and one’s general health, there could be increased risks from getting a tattoo. Although there isn’t comprehensive data on the likelihood of adverse reactions, it is best to talk to a healthcare provider and wait until the condition is more stable before scheduling a tattoo session.

A Recent Case Report

One report, published in British Medical Journal Case Reports, focuses on a woman living in Scotland who experienced muscle inflammation after having a tattoo on her thigh. It was her second tattoo, the first being completed some years earlier without incident.

A lung transplant recipient living with cystic fibrosis, the woman was receiving immune-suppressing medications post-transplant and to manage her chronic illness. She was referred to a rheumatologist after 10 months of muscle pain and swelling, which began about a week after receiving the tattoo.

Providers did not initially connect the tattoo to the pain, but later made the association due to the timing of the onset of the problems and finding no other reasons for the pain (such as trauma). The authors of the case report could not definitively point to the exact cause of the pain, but hypothesized that it could be related to a bacteria being introduced into the muscle, or as a reaction to the ink. Treatment with physiotherapy helped resolve the pain and inflammation.

Sanitary Practices and the Risk of Infection or Disease

The process of tattooing involves injury to the skin, which may open it up to infection. Infection (due to either contaminated tattoo ink or improper hygiene) is one of the more common risks of tattoos, especially those done at home or in unlicensed facilities. People who live with autoimmune disease and already have a compromised immune system, or whose immune system is suppressed through medication, may be at increased risk of infections.

The body is less able to defend itself against bacteria when there is active inflammation or a lowered immune response. People who live with autoimmune conditions should follow the aftercare instructions from the tattoo artist carefully and consult a healthcare provider (such as a dermatologist) at the first sign of infection.

Skin Infections

Even when a tattoo is performed in a reputable facility, bacteria that live on the body may get under the skin during the process. During healing, the tattooed area may be itchy, and scratching it could lead to bacteria getting under the skin and causing infection.

Some itchiness is normal after receiving a tattoo. However, it could be a sign of infection if other symptoms are present, such as painful red bumps, pain, fever, chills, pus drainage, or an open sore. If you notice these signs after getting a tattoo, see a healthcare provider for diagnosis and treatment.

Equipment, ink, or needles that are not kept sterile or are reused can also become contaminated and lead to infection with bacteria such as Staphylococcus aureus. Cases of fungal infection have been reported also, but these appear to be rare.

Bloodborne Diseases

Another risk of receiving a tattoo in a non-sterile environment or with used equipment is in contracting a bloodborne disease, such as hepatitis.

In the United States, hepatitis C is the leading cause of liver cancer. There have been no reported outbreaks of hepatitis C among professional tattoo parlors where sterile equipment is used, but for tattoos given in a nonprofessional setting (at home or in prison, for example), the risk increases significantly.

According to the Centers for Disease Control and Prevention (CDC), there are no documented cases of HIV being transmitted through tattooing. However, there is a theoretical risk if sanitary practices are not used during the process.

Skin Conditions

A common concern about getting a tattoo is developing a skin condition or worsening an existing skin condition. These are often inflammatory conditions caused by the body’s overactive immune response. For instance, if you have a skin condition like eczema or psoriasis, getting a tattoo could cause it to flare up.

Allergic Contact Dermatitis

A retrospective analysis showed that allergic contact dermatitis after having a tattoo was rare (at a rate of less than 0.08%). More than half of those who had a reaction had some type of allergic response in the past.

Allergic contact dermatitis occurs more often with certain colors used for tattoos, such as red, and typically presents as raised areas within the tattoo. An allergic reaction can cause itchiness, bumps, or a rash. In some cases, a reaction might not occur for multiple days, weeks, or months after receiving a tattoo.

Keloids

Keloids are a type of scar that grows when the skin is broken (like when getting a tattoo). The skin repairs itself aggressively, and the result is the formation of a large scar.

People who have had keloids in the past may be at risk for developing one after receiving a tattoo. Removing tattoos is also associated with the formation of keloids.

Granulomas and Sarcoidosis

One way the body tries to protect itself from a perceived irritant is by forming a granuloma around it. A granuloma on the skin may look like a lump of tissue. It’s thought that the granulomas form around the ink used in tattoos. They may show up years after a tattoo is placed.

Sarcoidosis is a rare condition where many granulomas grow. Some people have been diagnosed with sarcoidosis after having granulomas form around their tattoos, and it’s generally recommended that people already diagnosed with sarcoidosis not receive tattoos.

Erythema Nodosum and Pyoderma Gangrenosum

These two skin conditions are exceedingly rare with tattoos. When they do occur, they cause lesions and are often associated with inflammatory bowel disease or other chronic conditions.

Pyoderma gangrenosum, in particular, can cause deep ulcers that are difficult to treat. Erythema nodosum is characterized by inflamed red bumps on the shins and often tends to come and go. When caused by an underlying autoimmune condition, it will get worse during a flare-up.

Because both of these conditions sometimes result after there has been trauma, like a needle prick, to the skin or infection, it may be recommended by healthcare professionals that people who are prone to them not get tattoos. It has been reported that pyoderma gangrenosum can also occur as a late complication of tattoos that have existed for years.

Psoriasis

Psoriasis is a chronic skin condition that causes a rash that appears red with white scales. Some healthcare providers may recommend that people who live with psoriasis not receive tattoos. This is because it’s thought that the trauma to the skin caused by a tattoo could cause psoriatic lesions to develop in that area, even if no skin lesions are present, in a reaction known as the Koebner phenomenon.

In some cases, tattoo artists may be hesitant to work on clients who have active psoriasis, especially in an affected area of the body. People with psoriasis will want to consult with their healthcare team and consider their individual risks before getting a tattoo.

Tattoos and MRIs

There are some accounts of people experiencing burning or swelling at the site of a tattoo while undergoing magnetic resonance imaging (MRI). Some tattoos may also affect the quality of an MRI image.

For those who undergo MRIs as a regular part of managing their condition, it is worth keeping this potential adverse effect in mind. It’s not common for these problems to occur, but it may make sense to avoid getting a tattoo on a body part that might need regular monitoring with an MRI.

An MRI should not be avoided or put off because of the potential for a reaction: It is not common, and it’s usually more important that the MRI be done. In addition, patients should always tell radiology staff about any tattoos before an MRI.

Why Ink Color May Matter

The exact extent of adverse reactions to tattoos is not well understood in the United States. The color of the ink may be related to the risk of inflammation, allergic reactions, and hypersensitivity due to certain ingredients—including chromium in green ink, cadmium in yellow ink, mercury salt in red ink, and cobalt in blue ink.

In one study of people with tattoos who were selected at random in New York City, 10% reported an adverse reaction to a tattoo. For 42% of those who described the reaction as related to the colors used in the tattoo, red was the culprit.

While 90% of those surveyed had black ink in their tattoos, only 25% reported a reaction. The authors of the study conclude that such reactions to tattoos are common.

Testing the ink with a patch test on the skin may or may not be helpful. People who had a reaction to a tattoo and were later given a patch test with red ink did not have the same reaction.

It’s thought that the process of receiving the ink during the tattoo session is different from receiving the ink during a patch test. However, reputable tattoo artists will help with completing patch tests when clients have a concern about an allergic reaction. 

The Importance of Aftercare

It’s worth noting that tattoo artists should offer some guidelines about skin care after receiving a tattoo. According to one study of licensed tattooists in New York City, 56% received training on tattoo-related skin conditions, but 92% were consulted about skin issues by their clients.

Thus, adverse reactions may need to be evaluated by a dermatologist.

Keep these tips in mind before and after getting a tattoo:

• Seek out a reputable, licensed tattoo artist (in an establishment with proper health inspection), and ask questions about tattoos and autoimmune conditions.
• The skin in the area to be tattooed should be disinfected before starting.
• Tattoo artists should wear gloves while working.
• Equipment used should be from sealed packages to ensure they are sterile and only used once.
• Non-disposable equipment should be cleaned using a machine that sterilizes them with heat (an autoclave).
• After the tattoo is complete, keep the area clean with soap and water, avoid exposing it to the sun, use a moisturizer, and don’t go swimming.
• Don’t scratch or pick at any scabs that form on the tattoo.
• It can take a few weeks for a tattoo to heal, so it’s important to continue any aftercare instructions during that time.