Patients With Psoriasis Must Know the Risks of Tattooing

How much patients with psoriasis know about tattooing and its potential complications is the focus of a study published in Clinical, Cosmetic and Investigational Dermatology that also offers advice to practitioners.

Tattoos today have become immensely popular and widely accepted among the public. Although psoriasis should not prevent interested patients from getting tattoos, there are caveats.

Patrycja Rogowska, MD, and colleagues conducted an online, anonymous, questionnaire-based analysis of 150 tattooed patients with psoriasis. Investigators wanted to examine patients’ knowledge of and attitudes toward tattooing. They distributed the questionnaire to online psoriasis communities from April to September 2020. Rogowska is a member of the Department of Dermatology, Venereology and Allergology, Faculty of Medicine, at the Medical University of Gdańsk in Poland.

WHO GETS TATTOOED?

Of 150 respondents, 134 were female and 16 were male. Rogowska and colleagues reported an age range of 16 to 62 years, with a mean age of 32. Most respondents (143/95.3%) were given diagnoses of type 1 psoriasis before age 40 years; 7 received diagnoses of type 2 (4.7%). Investigators reported that many lived in urban areas (119/79.3%). Tattooing was most popular among those with a high school education (73/48.7%) and those with higher education (61/40.7%). Sixteen respondents (10.7%) reported elementary levels of education.

TATTOOING TRENDS

Most respondents received their psoriasis diagnoses before getting tattooed (114/76%), whereas 36 (24%) were diagnosed after. Investigators said all but one of the tattoos were decorative, with 1 respondent reporting permanent makeup. There were 96 respondents with black ink tattoos, whereas 54 had ink in multiple colors. Further, 14 respondents had tattoos covering more than 10% of their bodies, 18 had tattoos covering 5% to 10% of their bodies, and 118 had tattoos covering less than 5%. Most respondents went to a professional tattoo artist (130/86.7%), whereas 20 (13.3%) obtained their ink from an amateur.

Investigators said 76% of respondents reported wanting a tattoo to improve their appearance. Also, 60% said the tattoo was to express their personality and 39.3% said it was to honor milestone life events. “While choosing a tattoo parlor, most of the respondents were seeking information about it on the internet and through their acquaintances,” the authors wrote.¹

Rogowska et al noted that 4 respondents (2.7%) wanted to camouflage psoriatic lesions and 7 (4.7%) thought a tattoo would distract onlookers from their condition. “In the subjective measurement of the respondents, having a tattoo improved their level of psoriasis acceptance in 27 (18%) of the investigated cases, while self-esteem increased in 76 respondents (50.7%),” investigators said.¹

MEDICAL KNOWLEDGE OF TATTOOING

Only 8% of patients (12) had a dermatological consult before getting their tattoos, and only 18% of respondents reported that the tattoo artist had recommended a dermatological consult. Investigators reported 67.3% of respondents (101) were in active treatment while being tattooed. Of 150 total respondents, 69 were receiving topical treatment, 23 were receiving systemic treatment, and 9 (6%) were receiving phototherapy. Out of all 150 responses to the survey, 8 (5.3%) were taking methotrexate, 5 (3.3%) were taking cyclosporine A, 1 (0.7%) was taking acitretin, and 9 (6%) were being treated with biologics.

COMPLICATIONS

Tattooing complications for patients with psoriasis seem to be mild and more prevalent during active disease or with systemic treatment, Rogowska et al reported. Only 8.7% of respondents (13) had tattoo-associated cutaneous complications, with Koebner phenomenon most frequent (8/5.3%) “Only in one of those cases, a koebnerization secondary to tattoo has been the first onset of psoriasis,” researchers said.¹

Two respondents (1.3%) reported a general flare-up of psoriasis symptoms. There were 2 cases (1.3%) of pruritic rash on the site of the tattoo. One case (0.7%) experienced healing disruption that showed a prolonged inflammatory state at the tattoo site. Of the 13 who experienced complications, 7 were actively being treated: 1 with psoralen–UV-A therapy, 1 with methotrexate, and 5 with topical psoriasis treatment. “In only 1 case out of 13, a dermatological consultation has taken place before tattooing,” study authors reported.¹

TATTOOING CONTRAINDICATIONS

Active systemic therapy for psoriasis can leave patients who are planning to be tattooed vulnerable to complications. The authors reported that oral retinoids can thin the skin and cause excessive dryness. It can also impair wound healing and increase the chance of infection. They also said phototherapy can cause ink to fade prematurely and can trigger photosensitive reactions. Immunosuppressants increase infection risk locally and systemically, especially in unhygienic tattooing conditions.

“There are only a few cases of serious tattoo-related infectious complications caused by immunosuppression described in the literature; however, this risk should not be ignored,” the authors wrote.¹ Although most infections are local, they can be dangerous or even life-threatening in cases of septicemia, the authors cautioned.

Investigators recommended dermatological counseling for patients with psoriasis who are considering tattooing, to determine the best time to have the procedure done and to assess the safest location for the tattoo. Providers may prescribe prophylactic antibiotics to prevent infection. They can also advise patients to avoid amateur providers and select safer, professional tattoo parlors.

The study authors also recommended patients get an individual risk assessment from a provider. In addition, they said tattoo artists should educate themselves about complications and follow necessary precautions. “We believe that a standardized questionnaire, inclusive query about the client’s medical history and medications, could be implemented by tattooists for the benefit of the whole tattoo-society,” researchers concluded.¹

Reference:

1. Rogowska P, Walczak P, Wrzosek-Dobrzyniecka K, Nowicki RJ, Szczerkowska-Dobosz A. Tattooing in psoriasis: a questionnaire-based analysis of 150 patients. Clin Cosmet Investig Dermatol. 2022;15:587-593. doi:10.2147/CCID.S348165