Tattoos

Michele Van Vranken, MD

It seems like everyone has a tattoo these days. What used to be the property of sailors, outlaws, and biker gangs is now a popular body decoration for many people. And it's not just anchors, skulls, and battleships anymore - from school emblems to Celtic designs to personalized symbols, people have found many ways to express themselves with their tattoos. Maybe you've
thought about getting one. But before you head down to the nearest tattoo shop and roll up your sleeve, there are a few things you need to know.

So What Exactly Is a Tattoo?
A tattoo is a puncture wound, made deep in your skin, that's filled with ink. It's made by penetrating your skin with a needle and injecting ink into the area, usually creating some sort of design. What makes tattoos so long-lasting is they're so deep - the ink isn't injected into the epidermis (the top layer of skin that you continue to produce and shed throughout your
lifetime). Instead, the ink is injected into the dermis, which is the second, deeper layer of skin. Dermis cells are very stable, so the tattoo is practically permanent.
Tattoos used to be done manually - that is, the tattoo artist would puncture the skin with a needle and inject the ink by hand. Though this process is still used in some parts of the world, most tattoo shops use a tattoo machine these days. A tattoo machine is a handheld electric instrument that uses a tube and needle system. On one end is a sterilized needle, which is
attached to tubes that contain ink. A foot switch is used to turn on the machine, which moves the needle in and out while driving the ink about 1/8 inch (about 3 millimeters) into your skin.
Most tattoo artists know how deep to drive the needle into your skin, but not going deep enough will produce a ragged tattoo, and going too deep can cause bleeding and intense pain. Getting a tattoo can take several hours, depending on the size and design chosen.

Does It Hurt to Get a Tattoo?
Getting a tattoo can hurt, but the level of pain can vary. Because getting a tattoo involves being stuck multiple times with a needle, it can feel like getting a bunch of shots or being stung by a hornet multiple times. Some people describe the tattoo sensation as "tingling." It all depends on your pain threshold, how good the person wielding the tattoo machine is, and where exactly on your body you're getting the tattoo. Also, keep in mind that you'll probably bleed a little.

If You're Thinking About It
If you're thinking about getting a tattoo, there is one very important thing you have to keep in mind - getting it done safely. Although it might look a whole lot cooler than a big scab, a new tattoo is also a wound. Like any other slice, scrape, puncture, cut, or penetration to your skin, a tattoo is at risk for infections and disease.
First, make sure you're up to date with your immunizations (especially hepatitis and tetanus shots) and plan where you'll get medical care if your tattoo becomes infected (signs of infection include excessive redness or tenderness around the tattoo, prolonged bleeding, pus, or changes in your skin color around the tattoo).
If you have a medical problem such as heart disease, allergies, diabetes, skin disorders, a condition that affects your immune system, or infections - or if you are pregnant - ask your doctor if there are any special concerns you should have or precautions you should take beforehand. Also, if you're prone to getting keloids (an overgrowth of scar tissue in the area of the wound), it's probably best to avoid getting a tattoo altogether.
It's very important to make sure the tattoo studio is clean and safe, and that all equipment used is disposable (in the case of needles, gloves, masks, etc.) and sterilized (everything else). Some states, cities, and communities set up standards for tattoo studios, but others don't. You can
call your state, county, or local health department to find out about the laws in your community, ask for recommendations on licensed tattoo shops, or check for any complaints about a particular studio. Professional studios usually take pride in their cleanliness. Here are some
things to check for:

• Make sure the tattoo studio has an autoclave (a device that uses steam, pressure, and heat for sterilization) . You should be allowed to watch as equipment is sterilized in the autoclave.
• Check that the tattoo artist is a licensed practitioner. If so, the tattoo artist should be able to provide you with references.
• Be sure that the tattoo studio follows the Occupational Safety and Health Administration' s Universal Precautions. These are regulations that outline procedures to be followed when dealing with bodily fluids (in this case, blood). If the studio looks unclean, if anything looks out of the ordinary, or if you feel in any way uncomfortable, find a better place to get your tattoo.
  

What's the Procedure Like?
Here's what you can expect from a normal tattooing procedure:

• The tattoo artist will first wash his or her hands with a germicidal soap.
• The to-be-tattooed area on your body will be cleaned and disinfected.
• The tattoo artist will put on clean, fresh gloves (and possibly a surgical mask).
• The tattoo artist will explain the sterilization procedure to you and open up the single-use, sterilized equipment (such as needles, etc.).
• Using the tattoo machine (with a sterile, single-use needle attached), the tattoo artist will begin drawing an outline of the tattoo under your skin.
• The outline will be cleaned with antiseptic soap and water.
• Sterile, thicker needles will be installed on the tattoo machine, and the tattoo artist will start shading the design. After cleaning the area again, color will be injected.
• Any blood will be removed by a sterile, disposable cloth or towel.
• When finished, the area, now sporting a finished tattoo, will be cleaned once again and a bandage will be applied.
  

Taking Care of a Tattoo
The last step in getting a tattoo is very important - taking care of the tattoo until it fully heals. Follow all of the instructions the studio gives you for caring for your tattoo to make sure it heals properly. Also, keep in mind that it's very important to call your doctor right away if you see or
feel any signs of infection such as pain, spreading redness, swelling, or drainage of pus. To make sure your tattoo heals properly:

• Keep a bandage on the area for up to 24 hours.
• Avoid touching the tattooed area and don't pick at any scabs that may form.
• Wash the tattoo with an antibacterial soap (don't use alcohol or peroxide - they'll dry out the tattoo). Use a soft towel to dry the tattoo - just pat it dry and be sure not to rub it.
• Rub antibiotic ointment into the tattoo. Don't use petroleum jelly!
• Put an ice pack on the tattooed area if you see any redness or swelling.
• Try not to get the tattoo wet until it fully heals. Stay away from pools, hot tubs, or long, hot baths.
• Keep your tattoo away from the sun until it's fully healed.
  

Even after it's fully healed, a tattoo is more susceptible to the sun's rays, so it's a good idea to always keep it protected from direct sunlight. If you're outside often or hang out at the beach, it's recommended that you always wear a sunscreen with a minimum sun protection factor (SPF) of 30 on the tattoo. This not only protects your skin, but keeps the tattoo from
fading.

What Are the Risks?
If you decide to get a tattoo, chances are everything will go as planned. But if disinfection and sterilization steps aren't followed, there are some things you need to be aware of that can go wrong. If you don't go to a tattoo studio or the tattoo studio doesn't follow precautions like using
sterilized equipment or if it shares ink between customers, you're putting yourself at risk for getting viral infections such as hepatitis, bacterial skin infections, or dermatitis (severe skin irritation).
Also, some people have allergic reactions to the tattoo ink. And if you already have a skin condition such as eczema, you may have flare-ups as a result of the tattoo. Serious complications can result if you attempt to do a tattoo yourself, have a friend do it for you, or have it done in any unclean environment. Because tattooing involves injections under the skin, viruses such as HIV and hepatitis B and C can be transferred into your body if proper precautions aren't followed. For this reason, the American Red Cross and some other blood banks require people to wait 12 months after getting a tattoo before they can donate blood.

Tattoo Removal
A lot of people love their tattoos and keep them forever. But others decide a couple of years down the road that they really don't like that rose on their ankle or snake on their bicep anymore. Or maybe you broke up with your boyfriend or girlfriend and no longer want his or her initials on yourstomach.

What then?
In the past, tattoo removal required surgery, but now it can be done through a medical procedure that uses a laser. Some tattoo shops also offer tattoo removal, but it's a better idea to make sure the person doing the removal is a medical doctor. Before you go just anywhere to get your tattoo removed, check with your doctor or contact the American Dermatological Association to find a reputable laser removal specialist in your area.
Although it's called tattoo removal, completely removing a tattoo can be difficult depending on factors like how old the tattoo is, how big the tattoo is, and the types and colors of inks that were used. Removal of the entire tattoo is not always guaranteed. It's best to consult with a dermatologist who specializes in tattoo removal to get your questions answered - such as whether anesthesia is used. The dermatologist can also give you a good idea of how much (if not all) of the tattoo can be removed. Laser tattoo removal usually requires a number of visits, with each procedure lasting only a few minutes. Anesthesia may or may not be used. What happens is the laser sends short zaps of light through the top layers of your skin, with the laser's energy aimed at specific pigments in the tattoo. Those zapped pigments are then removed by your body's immune system.
Removing a tattoo by laser can be uncomfortable and can feel a lot like getting a tattoo. The entire process can take several weeks. Just like when you get a tattoo, you must look after the wound area after a tattoo is removed. The area should be kept clean, but it shouldn't be scrubbed. Also, it might turn red for a few days and a scab might form. Don't rub or scrub the area or pick at the scab. Let it heal on its own. Laser tattoo removal is usually effective for the most part, but there can be some side effects. The area can become infected or scarred, and it can also be susceptible to hyperpigmentation, which causes the area where your tattoo used to be to become darker than your normal skin, or hypopigmentation, which causes the area where your tattoo used to be to become lighter than your normal skin color. Now for the big part - tattoo removal can be pretty expensive. Depending on factors like the size and design of the tattoo, removal can cost significantly more than the actual tattoo.

So Is It Worth It?
Is getting a tattoo worth the money and hassle? It's up to you. Some people really enjoy their tattoos and keep them for life, whereas others might regret that they acted on impulse and didn't think enough about it before they got one. Getting a tattoo is a big deal, especially because they're designed to be permanent. If you've thought about it and decided you want a tattoo, make sure you do a little detective work and find a clean, safe, and professional tattoo shop.
Also, remember that getting and maintaining a tattoo involves some responsibility - after you leave the tattoo shop, it's up to you to protect and treat it to prevent infections or other complications.
(AAFP)