Health beyond the headlines

2×2 Gallery: When Tattooing is Infectious

Rare epidemiological infections and home tattooing

By Joshua Brooks

Published February 19, 2013

Last January, the Monroe County Department of Public Health in upstate New York received an unusual report.  A patient, newly tattooed, had paid a visit to a local dermatologist complaining of a persistent, raised red rash on his arm that appeared after he received a tattoo on the same area three months before. A biopsy of the tattoo revealed Mycobacterium chelonae, a rapidly growing, non-tuberculous mycobacteria. The case raised red flags for Kennedy, a physician and investigator at the health department. “From the perspective of a local health department, investigating tattoo infections is not necessarily something that is typical for us,” Kennedy said. “This was new turf for us.”

Kennedy and his colleagues, John Ricci, M.S. and Brenden Bedard, M.P.H., interviewed the itchy index patient—the first patient diagnosed with the rash—only to discover that other patrons tattooed in the same parlor by the same Rochester tattoo artist may have had similar reactions. It was up to Kennedy and his team to determine, for sure, what could have caused these infections.

The epidemiologists interviewed the tattoo artist, sampled water, ink and surfaces in the parlor, and biopsied the tattooed lesions of the rash in 18 of the 19 patients they believed were caused by the body art. In the end, Mycobacterium chelonae was isolated in 14 samples taken from the patients. The findings of the investigation were published in September in the New England Journal of Medicine.

With tattoos’ rise in popularity, the findings were disconcerting. Twenty-one percent of adults in the United States have one or more tattoos – an increase from 14 percent in 2008, according to a 2012 Harris Poll of 2,016 adults. Little monitoring and evaluation of tattoo parlors and their practices, as well as lax reporting and record keeping of artists’ inks and patrons’ tattoo-related infections, may mean that cutaneous mycobacterial infections are undercounted, said Kennedy and his colleagues. What’s more, the surprising culprit in the Rochester-area infections highlights a gap in how tattooing and artists’ materials, such as ink, are regulated.

Anyone who has a tattoo or knows someone who does can attest to their literal and figurative infectiousness. Tattooees usually show them off with pride, humor and satisfaction. Rarely will a first tattoo be the last. And tattooing is no longer performed solely in commercial parlors. Some underground artists tattoo their friends and other comers at home or other locations – out of sight of the public health authorities charged with keeping the practice safe. That compounds the subversive nature of an already rebellious activity.

“There are worse things that young people with disposable time and incomes can participate in,” said Caleb, a Brooklyn painter who tattoos his friends for free as a recreational a pastime. For bone fide commercial tattoo artists and recreational tattooers like Caleb, many of whom pride themselves on the precautions they take to keep their patrons safe, the specter of infection raises uncomfortable questions about how involved government can be in safeguarding patrons, particularly in casual, non-professional settings. On separate occasions, we spoke with Caleb, whose name has been changed here to prevent his being identified if pending tattoo regulations are enacted, and three of the NEJM article authors about this tension.

Scroll through the slides for the rest of the story.

Caleb first began tattooing when he was 19 after pooling his money with his roommates to buy a tattoo machine. “I had always drawn,” Caleb said. Tattooing “seemed like an appropriate social application of an otherwise reclusive endeavor.” It took time, however, for Caleb to gain any skill. “When I first started out, I had no idea what I was doing. The machine would stop working, ink wouldn’t stick and lines often resembled polygraph test papers. They were very amateurish, though like any good scar they came with a story and it was always between good friends.

“It seems like whenever I tattoo strangers, who are very set on one idea or style that is not my own, they turn out bad,” he said. But, that’s part of the appeal. For Caleb and his friends, the tattoos, even those that turn out differently than expected, are “a means to manifest a moment that, left unedited, will age and grow with you.”

For Kennedy and colleagues, the dermatologist’s report was unexpected. “We certainly weren’t thinking about it [tattoo infection] at the time,” Kennedy said. The usual suspects in a tattooee’s rash are behavioral reasons, such as unclean tables and floors, dirty tattoo needles or tattoo ink open to the air or diluted with unsterilized water, or poor aftercare.

“In my experience, the poor aftercare of tattoos is responsible for the majority of infections or complications,” Caleb said. “This goes for shop and home tattoos alike. You are basically prescribed a certain topical medication, and when followed incorrectly, like any prescription, there can be problems.”

If it’s performed in dirty environments or without sterile techniques, tattooing can increase the risk of transmission of infectious diseases like HIV, hepatitis, and skin infections caused by Staphylococcus aureua, Mycobacterium chelonae or other bacteria. “I go to every length possible to insure the safety of the people I tattoo and myself,” Caleb said. “I change gloves after setting up the machine and surface, making sure that the skin doesn’t come into contact with anything that may be on the equipment.” Similar to practices outlined on New York State Department of Health website, Caleb explained his procedure: “The skin is thoroughly cleaned with a medical level soap before any contact from the needle. Once washed, the area must be shaved before tattooing, to insure that hair does not get caught in the needle or tube. I always use disposable razors.” Caleb said his equipment is sterile, too. “A vacuum-packed, single-use, disposable needle and tube combination is the best option for tattooing from home.” The single-use needles are disposable and used only once per person, reducing the risk of transmitting any infections. “Tattoo shops typically use a heavier, aluminum tube that is sterilized after each use. [These needles are cleaned after use and autoclaved to kill any microbes.] I typically use a single, black ink while tattooing. Ink is dispensed from its container into thumbnail sized plastic cups while setting up. These cups are properly disposed of after use and never shared.”

The legality of home tattooing is murky, however. Even for commercial settings, many states don’t have laws or regulations about who can tattoo, the conditions in which tattooing is allowed, or what kind of equipment can or should be used. “When we questioned everyone in the case, they said that the tattoo artists at the shop were using best practices—single-use containers, not going back into the ink itself,” Kennedy said. “That suggested that there was nothing really going on at the facility and that it may be the ink.” The investigative team from the Monroe County health department collected samples of water and ink at the tattoo parlor to rule out any other sources of contamination. “When we collected samples from the water from the faucet in the tattoo facility and in the basement, those came out negative for Mycobacteria chelonae,” Kennedy said. “But we did find it in an unopened bottle, and that was the smoking gun if you will.”

Testing the ink was not without difficulties. “We had to have the state reference laboratory agree to do the analysis on the ink,” Kennedy said. “They are used to running clinical specimens and not specimens in ink, so they had to figure out how to do that. There was another learning curve there.” Once they found Mycobacterium chelonae in the ink bottle and in most of the biopsies of suspected patients, a link was made.

Tattoo ink is considered a cosmetic and can be subjected to premarket approval, but due to competing public health priorities and lack of evidence of safety problems associated with these pigments, the FDA does not generally exercise regulatory authority for color additives in the inks.

As an ink purchaser, Caleb believes the products should be better regulated. “Tattooing is incredibly popular. These [ink makers] are no longer garage-based, DIY companies,” he said. “The companies should be held responsible and higher regulations and standards should be put into effect.”

But even a crackdown on ink makers may not be enough to stave off infections resulting from tattooing. Other nontuberculosis Mycobacterial skin infections in Iowa and Washington had unclear origins, but in Colorado the artist had diluted the ink with distilled or reverse-osmosis water, which is not always sterile. These and other bacterial infections, as well as other potential tattoo-related infections such as hepatitis or HIV, call into question whether these risks are a result of an industry that goes largely unregulated in both commercial and recreational settings.

Once the Monroe County officials zeroed in on the ink, the FDA investigated how and where it was made. “To our knowledge, nothing was ever found in regards to contamination,” Bedard said, adding that the ink was made six or seven months before the FDA inspected the manufacturing site. The FDA did not respond to a call about whether anything was found at the ink-manufacturing site. According to the NEJM study, the manufacturer voluntarily recalled the ink. Still, the FDA hasn’t issued any new ink regulations to minimize the risk of infection from the products.

Caleb said commercial parlors exist not necessarily to administer cleaner tattoos than recreational practitioners can provide—just more sophisticated images. “I do enjoy giving them [tattoos], and I imagine I have gotten a little better, but for me it’s all in good, nearly harmless fun, as long as I’m doing it [cleanly] with friends,” he said. For everyone else, he added, “tattoo shops are there for a reason: You have an idea, you find the right artist and you get it zapped up. They do it right!” Going to a commercial parlor, the NEJM study suggests, does not necessarily eliminate the risks associated with tattooing. Infections may originate not only from unsanitary practices, but may also come from ink.


When told of the home-tattooing Caleb performs on his friends, the NEJM investigators warned that contaminated inks may not be the only risk. “Really, if you look at references in the literature,” Bedard said, “we were really one of the only ones that found something in a sealed bottle. The majority of the time these infections associated with ink were caused at the artist level, based on their practices. So, ours was a very unique investigation.” Added Ricci: “I would argue that if you’re doing an invasive procedure that involves blood in a home setting, it would seem kind of imprudent to me. Could it be done safely? Maybe so, but it doesn’t seem like a good idea.”

Though aware of bloodborne pathogens and potential diseases, Caleb admits, “I feel safer tattooing with gloves on than riding the L [subway train] in the morning.” He jokes, “I tattoo close friends, because I know they’ll forgive me if I misspell something.”

Kennedy said his team hopes its findings will lead state and local health departments to institute stronger regulations, guidelines and record-keeping practices in the tattooing community. Until then, tattoo artists—commercial and recreational—may be their own best police. In interviews conducted with tattoo artists at a Rochester-area convention, Kennedy said, epidemiologists found that many were willing to self-regulate to prevent other infections by only using ink from established and well-known manufacturers that were recommended by other reputable artists and trying new ink on themselves before using it on clients.


“We’re depending on passive surveillance,” Kennedy said, referring to reporting of infections by patients and doctors, rather than the active surveying of disease by public health authorities through interviews. “If there is another outbreak in the area, we have a mechanism in place that will more likely alert us to it.” For a practice like tattooing, particularly the home tattooing that Caleb partakes in, this heightened awareness of risk and safe practices, as well as prompt reporting of infections, may be the best way to reduce risk of infection until more meaningful regulations are implemented.

Photos by Clay Kesseck

Edited by Jordan Lite. Additional research by Arti Virkud.

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