T he words of the French Bohemian author, Arsene Houssaye, “when Art is understood by everybody, it will no longer be Art,” were not meant to describe the fascinating phenomenon of body art but they certainly remain true. Tattoos, body piercings and other skin adornments, while misunderstood by many, have become quite popular in modern society. These practices have a long and fascinating cultural history that’s intriguing to every dermatologist and to all who study the human condition. These practices began thousands of years ago. The famous “Iceman,” who was recovered in the frozen mountains of Northern Italy, displayed tattoos dating back almost 5,300 years (Bahn & Everett, 1993). These simple markings appear to have been placed over arthritic joints as a form of shamanistic treatment. The remarkable scarification rituals of African tribes hold great interest for dermatologists because, while some Africans find these scars and keloids to be signs of beauty, Americans often present to their dermatologists for the treatment and removal of their keloids. It’s been postulated that the “tribal” designs of the tattoos of New Guinea, New Zealand and the South Pacific actually had their beginnings in the characteristic skin markings of the dermatophyte Trichophyton concentricum, which causes tinea imbricata or “Tokelau.” The influence of these swirls within swirls is seen not only in their tattoos but also in the art of this area. The Meaning of Tattoos The tattoo has long held negative connotations and is even forbidden in the Old Testament. In Leviticus 19:28 it says “Ye shall not make any cuttings in your flesh for the dead nor print any marks upon you. I am the Lord.” In the 1800s, Sir William Osler viewed the presence of a tattoo on a patient as a sure sign of syphilis. He stated “I often think that if I look closely enough at tattooings, I can see the track of the spirochete!” (MacDermot, 1971). From that time, tattoos have been considered to be a marker of a patient as a “risk-taker” (Armstrong et al. 2000, Carroll et al.2002). Tattoos are often a sign for group identification and solidarity. Bikers, homosexuals and gang members often can be recognized by their tattoos. Former prison inmates, I.V. drug abusers and Neo-Nazis also have distinctive tattoos. Probably the most unforgettable tattoos are the serial numbers present on the arms of the Nazi concentration camp survivors (Goldstein et al., 1979). This testament to man’s inhumanity to man is immortalized at the Holocaust Memorial in Miami Beach. The Five Major Tattoo Types We have defined five major types of tattoos, as described below. Traumatic tattoos are caused by the unwanted imbedding of dirt or debris beneath the skin, which leaves an area of pigmentation after healing. This commonly occurs in “road rash” after a motorcycle accident or after a puncture injury from a pencil, known as a “graphite tattoo.” Amateur tattoos are placed by the persons themselves or by their friends and often show very little artistry or detail. The most common method involves placing India Ink beneath the skin with a pin. Others use pen ink, charcoal or ashes as the pigment. Professional tattoos take two forms: cultural and modern. • Cultural tattoos are placed using the time-honored method of a certain cultural ethnicity. The tattoos of the South Pacific Islands are placed by this method and display the artistry of their particular heritage. • Modern tattoos are performed using the “tattoo gun” and are placed by experienced artists who are paid for their work. Modern tattoos use a variety of pigments and their artistry varies from poor to fantastic. Medical tattooing is commonly used to delineate permanent landmarks for radiation therapy and are often placed by a physician. Cosmetic tattooing is a rapidly growing area of the tattoo industry. A tattoo artist can place permanent makeup, such as eyeliner, lip liner, lipstick, rouge and eyebrow pencil. Cosmetic tattooing is also used to camouflage vitiligo, to replace a nipple on a post surgical breast, or to camouflage an undesired tattoo. Possible Complications No matter what type of tattoo a patient has, there are always risks and possible adverse reactions that you, as the dermatologist, may need to treat. There are complications of tattooing of which you should be aware. Infections may occur directly after tattooing (Braithwaite et al., 1999). Often the initial breaking of the skin barrier may lead to impetigo or cellulitis. The risk of bloodborne diseases, such as HBV, HCV and HIV, is tantamount. Although because tattoo studios have embraced universal precautions there has been no documented spread of HIV through professional tattooing. Hypersensitivity is another reaction patients may have. They may develop hypersensitivity to tattoo pigments; most commonly the red color from a reactive pigment called cinnabar. Contact dermatitis to para-phenylenediamine in temporary henna tattoos is often reported (Chung et al., 2001, Brancaccio et al., 2002). There’s also been concern about tissue trauma and misdiagnoses from iron oxide and heavy metal pigments in tattooed patients who undergo MRI. Scarring and keloid formation is another bothersome complication of tattooing. Tattoo Removal And of course, after time, many patients decide they no longer want to have a tattoo. The removal of tattoos has a varied history and is still not optimum, despite much improvement and media reports otherwise. In 1979, Murray Zimmerman warned against the litigious nature of tattoo patients. He stated “I have a perfect solution to the threat of incurring suits for the alleged unsightly scars resulting from removal of tattoos. That perfect solution is this: ‘Don’t undertake removal of tattoos’”(Zimmerman, 1979). New hope may be forthcoming with the recent report of the removal of tattoos with topical imiquimod and tretinoin in guinea pigs (Solis et al., 2002). Current treatments include excision of the tattoo, salobrasion, dermabrasion, cosmetic over-tattoo and, of course, laser. Despite fantastic laser work on a minority of patients, the treatment of tattoos with lasers may have poor results, cannot be predicted with true accuracy, and may require multiple expensive sessions. This often leaves the patient with high expectations frustrated and unhappy. (For more on laser treatment, see “What Dermatologists Need to Know about Laser Removal of Tattoos”) History and Complications of Piercing Body piercing is another form of skin adornment where jewelry is worn through the skin. Female ear piercing has long been accepted in Western culture, but in the last 25 years, male ear piercing and the piercing of other areas has become widespread. Navel piercing has become fashionable and more extreme piercings of the eyebrows, nipples, lips, tongue and genitals have also become common. Oral and genital piercing is often associated with reported sexual enhancement (Scully & Chen, 1994). Also done in an effort to enhance sex, some have started using artificial penile nodules, which are made by placing inert foreign material (plastic beads, pearls, etc.) beneath the skin of the penis. This skin adornment seems to have originated in Asia and has been called a variety of names, including penis marbles (Fiji) (Norton, 1983), Bulleetus (Philippines) (Sugathan,1987), Chagan balls (Korea), Tancho’s nodules (Japan) (Kikuchi,1984), and Apradravyas (India). Recently subcutaneous nodules and implants have found wider cosmetic use among those interested in “body modification.” Any time the skin is broken for a piercing, there is a risk of infection. Abscess formation, chondritis of the ears (Turk-taub & Habal, 1990)(Cosette,1993), candidal infection, and even toxic shock syndrome and sepsis (McCarthy et al., 1988) have been reported. The risk of bloodborne diseases, such as HIV, HBV, HCV is present among amateur piercers who don’t properly clean their equipment. Embedding of jewelry where the skin grows over the jewelry may occur and is often the result of using studs that are too tight. Many people are hypersensitive to the nickel in some jewelry and may develop a chronic dermatitis. These patients should only wear gold or platinum jewelry. The unwanted forcible removal of the jewelry during trauma may lead to a permanent deformity that cannot be rectified without surgery. Trauma to the teeth requiring restorative dentistry may also be caused by oral jewelry (Scully & Chen, 1994). The most common complication of piercing is the development of keloids. This is seen frequently in Americans of African descent. Treatment of keloids can often be frustrating and depends largely on surgery and/or intralesional steroids. There have also been reports of the use of cryosurgery and intralesional interferon. In some cases, however, of skin adornment, keloid formation is desirable. Scarification is a skin adornment that takes two forms — branding and cutting. In these methods, the more permanent the scar, the better. Branding is the use of a hot metal design, which burns a design into the skin. This is a recognized ritual behavior in some college fraternities. Cuttings are also done in the skin using a sharp knife or scalpel to leave permanent scarifications. The history of skin adornments and body art is long and interesting but the future is bound to be even more fascinating to dermatologists and others who study and care for the skin.
Tattoos, Body Piercings and Other Skin Adornments
T he words of the French Bohemian author, Arsene Houssaye, “when Art is understood by everybody, it will no longer be Art,” were not meant to describe the fascinating phenomenon of body art but they certainly remain true. Tattoos, body piercings and other skin adornments, while misunderstood by many, have become quite popular in modern society. These practices have a long and fascinating cultural history that’s intriguing to every dermatologist and to all who study the human condition. These practices began thousands of years ago. The famous “Iceman,” who was recovered in the frozen mountains of Northern Italy, displayed tattoos dating back almost 5,300 years (Bahn & Everett, 1993). These simple markings appear to have been placed over arthritic joints as a form of shamanistic treatment. The remarkable scarification rituals of African tribes hold great interest for dermatologists because, while some Africans find these scars and keloids to be signs of beauty, Americans often present to their dermatologists for the treatment and removal of their keloids. It’s been postulated that the “tribal” designs of the tattoos of New Guinea, New Zealand and the South Pacific actually had their beginnings in the characteristic skin markings of the dermatophyte Trichophyton concentricum, which causes tinea imbricata or “Tokelau.” The influence of these swirls within swirls is seen not only in their tattoos but also in the art of this area. The Meaning of Tattoos The tattoo has long held negative connotations and is even forbidden in the Old Testament. In Leviticus 19:28 it says “Ye shall not make any cuttings in your flesh for the dead nor print any marks upon you. I am the Lord.” In the 1800s, Sir William Osler viewed the presence of a tattoo on a patient as a sure sign of syphilis. He stated “I often think that if I look closely enough at tattooings, I can see the track of the spirochete!” (MacDermot, 1971). From that time, tattoos have been considered to be a marker of a patient as a “risk-taker” (Armstrong et al. 2000, Carroll et al.2002). Tattoos are often a sign for group identification and solidarity. Bikers, homosexuals and gang members often can be recognized by their tattoos. Former prison inmates, I.V. drug abusers and Neo-Nazis also have distinctive tattoos. Probably the most unforgettable tattoos are the serial numbers present on the arms of the Nazi concentration camp survivors (Goldstein et al., 1979). This testament to man’s inhumanity to man is immortalized at the Holocaust Memorial in Miami Beach. The Five Major Tattoo Types We have defined five major types of tattoos, as described below. Traumatic tattoos are caused by the unwanted imbedding of dirt or debris beneath the skin, which leaves an area of pigmentation after healing. This commonly occurs in “road rash” after a motorcycle accident or after a puncture injury from a pencil, known as a “graphite tattoo.” Amateur tattoos are placed by the persons themselves or by their friends and often show very little artistry or detail. The most common method involves placing India Ink beneath the skin with a pin. Others use pen ink, charcoal or ashes as the pigment. Professional tattoos take two forms: cultural and modern. • Cultural tattoos are placed using the time-honored method of a certain cultural ethnicity. The tattoos of the South Pacific Islands are placed by this method and display the artistry of their particular heritage. • Modern tattoos are performed using the “tattoo gun” and are placed by experienced artists who are paid for their work. Modern tattoos use a variety of pigments and their artistry varies from poor to fantastic. Medical tattooing is commonly used to delineate permanent landmarks for radiation therapy and are often placed by a physician. Cosmetic tattooing is a rapidly growing area of the tattoo industry. A tattoo artist can place permanent makeup, such as eyeliner, lip liner, lipstick, rouge and eyebrow pencil. Cosmetic tattooing is also used to camouflage vitiligo, to replace a nipple on a post surgical breast, or to camouflage an undesired tattoo. Possible Complications No matter what type of tattoo a patient has, there are always risks and possible adverse reactions that you, as the dermatologist, may need to treat. There are complications of tattooing of which you should be aware. Infections may occur directly after tattooing (Braithwaite et al., 1999). Often the initial breaking of the skin barrier may lead to impetigo or cellulitis. The risk of bloodborne diseases, such as HBV, HCV and HIV, is tantamount. Although because tattoo studios have embraced universal precautions there has been no documented spread of HIV through professional tattooing. Hypersensitivity is another reaction patients may have. They may develop hypersensitivity to tattoo pigments; most commonly the red color from a reactive pigment called cinnabar. Contact dermatitis to para-phenylenediamine in temporary henna tattoos is often reported (Chung et al., 2001, Brancaccio et al., 2002). There’s also been concern about tissue trauma and misdiagnoses from iron oxide and heavy metal pigments in tattooed patients who undergo MRI. Scarring and keloid formation is another bothersome complication of tattooing. Tattoo Removal And of course, after time, many patients decide they no longer want to have a tattoo. The removal of tattoos has a varied history and is still not optimum, despite much improvement and media reports otherwise. In 1979, Murray Zimmerman warned against the litigious nature of tattoo patients. He stated “I have a perfect solution to the threat of incurring suits for the alleged unsightly scars resulting from removal of tattoos. That perfect solution is this: ‘Don’t undertake removal of tattoos’”(Zimmerman, 1979). New hope may be forthcoming with the recent report of the removal of tattoos with topical imiquimod and tretinoin in guinea pigs (Solis et al., 2002). Current treatments include excision of the tattoo, salobrasion, dermabrasion, cosmetic over-tattoo and, of course, laser. Despite fantastic laser work on a minority of patients, the treatment of tattoos with lasers may have poor results, cannot be predicted with true accuracy, and may require multiple expensive sessions. This often leaves the patient with high expectations frustrated and unhappy. (For more on laser treatment, see “What Dermatologists Need to Know about Laser Removal of Tattoos”) History and Complications of Piercing Body piercing is another form of skin adornment where jewelry is worn through the skin. Female ear piercing has long been accepted in Western culture, but in the last 25 years, male ear piercing and the piercing of other areas has become widespread. Navel piercing has become fashionable and more extreme piercings of the eyebrows, nipples, lips, tongue and genitals have also become common. Oral and genital piercing is often associated with reported sexual enhancement (Scully & Chen, 1994). Also done in an effort to enhance sex, some have started using artificial penile nodules, which are made by placing inert foreign material (plastic beads, pearls, etc.) beneath the skin of the penis. This skin adornment seems to have originated in Asia and has been called a variety of names, including penis marbles (Fiji) (Norton, 1983), Bulleetus (Philippines) (Sugathan,1987), Chagan balls (Korea), Tancho’s nodules (Japan) (Kikuchi,1984), and Apradravyas (India). Recently subcutaneous nodules and implants have found wider cosmetic use among those interested in “body modification.” Any time the skin is broken for a piercing, there is a risk of infection. Abscess formation, chondritis of the ears (Turk-taub & Habal, 1990)(Cosette,1993), candidal infection, and even toxic shock syndrome and sepsis (McCarthy et al., 1988) have been reported. The risk of bloodborne diseases, such as HIV, HBV, HCV is present among amateur piercers who don’t properly clean their equipment. Embedding of jewelry where the skin grows over the jewelry may occur and is often the result of using studs that are too tight. Many people are hypersensitive to the nickel in some jewelry and may develop a chronic dermatitis. These patients should only wear gold or platinum jewelry. The unwanted forcible removal of the jewelry during trauma may lead to a permanent deformity that cannot be rectified without surgery. Trauma to the teeth requiring restorative dentistry may also be caused by oral jewelry (Scully & Chen, 1994). The most common complication of piercing is the development of keloids. This is seen frequently in Americans of African descent. Treatment of keloids can often be frustrating and depends largely on surgery and/or intralesional steroids. There have also been reports of the use of cryosurgery and intralesional interferon. In some cases, however, of skin adornment, keloid formation is desirable. Scarification is a skin adornment that takes two forms — branding and cutting. In these methods, the more permanent the scar, the better. Branding is the use of a hot metal design, which burns a design into the skin. This is a recognized ritual behavior in some college fraternities. Cuttings are also done in the skin using a sharp knife or scalpel to leave permanent scarifications. The history of skin adornments and body art is long and interesting but the future is bound to be even more fascinating to dermatologists and others who study and care for the skin.
T he words of the French Bohemian author, Arsene Houssaye, “when Art is understood by everybody, it will no longer be Art,” were not meant to describe the fascinating phenomenon of body art but they certainly remain true. Tattoos, body piercings and other skin adornments, while misunderstood by many, have become quite popular in modern society. These practices have a long and fascinating cultural history that’s intriguing to every dermatologist and to all who study the human condition. These practices began thousands of years ago. The famous “Iceman,” who was recovered in the frozen mountains of Northern Italy, displayed tattoos dating back almost 5,300 years (Bahn & Everett, 1993). These simple markings appear to have been placed over arthritic joints as a form of shamanistic treatment. The remarkable scarification rituals of African tribes hold great interest for dermatologists because, while some Africans find these scars and keloids to be signs of beauty, Americans often present to their dermatologists for the treatment and removal of their keloids. It’s been postulated that the “tribal” designs of the tattoos of New Guinea, New Zealand and the South Pacific actually had their beginnings in the characteristic skin markings of the dermatophyte Trichophyton concentricum, which causes tinea imbricata or “Tokelau.” The influence of these swirls within swirls is seen not only in their tattoos but also in the art of this area. The Meaning of Tattoos The tattoo has long held negative connotations and is even forbidden in the Old Testament. In Leviticus 19:28 it says “Ye shall not make any cuttings in your flesh for the dead nor print any marks upon you. I am the Lord.” In the 1800s, Sir William Osler viewed the presence of a tattoo on a patient as a sure sign of syphilis. He stated “I often think that if I look closely enough at tattooings, I can see the track of the spirochete!” (MacDermot, 1971). From that time, tattoos have been considered to be a marker of a patient as a “risk-taker” (Armstrong et al. 2000, Carroll et al.2002). Tattoos are often a sign for group identification and solidarity. Bikers, homosexuals and gang members often can be recognized by their tattoos. Former prison inmates, I.V. drug abusers and Neo-Nazis also have distinctive tattoos. Probably the most unforgettable tattoos are the serial numbers present on the arms of the Nazi concentration camp survivors (Goldstein et al., 1979). This testament to man’s inhumanity to man is immortalized at the Holocaust Memorial in Miami Beach. The Five Major Tattoo Types We have defined five major types of tattoos, as described below. Traumatic tattoos are caused by the unwanted imbedding of dirt or debris beneath the skin, which leaves an area of pigmentation after healing. This commonly occurs in “road rash” after a motorcycle accident or after a puncture injury from a pencil, known as a “graphite tattoo.” Amateur tattoos are placed by the persons themselves or by their friends and often show very little artistry or detail. The most common method involves placing India Ink beneath the skin with a pin. Others use pen ink, charcoal or ashes as the pigment. Professional tattoos take two forms: cultural and modern. • Cultural tattoos are placed using the time-honored method of a certain cultural ethnicity. The tattoos of the South Pacific Islands are placed by this method and display the artistry of their particular heritage. • Modern tattoos are performed using the “tattoo gun” and are placed by experienced artists who are paid for their work. Modern tattoos use a variety of pigments and their artistry varies from poor to fantastic. Medical tattooing is commonly used to delineate permanent landmarks for radiation therapy and are often placed by a physician. Cosmetic tattooing is a rapidly growing area of the tattoo industry. A tattoo artist can place permanent makeup, such as eyeliner, lip liner, lipstick, rouge and eyebrow pencil. Cosmetic tattooing is also used to camouflage vitiligo, to replace a nipple on a post surgical breast, or to camouflage an undesired tattoo. Possible Complications No matter what type of tattoo a patient has, there are always risks and possible adverse reactions that you, as the dermatologist, may need to treat. There are complications of tattooing of which you should be aware. Infections may occur directly after tattooing (Braithwaite et al., 1999). Often the initial breaking of the skin barrier may lead to impetigo or cellulitis. The risk of bloodborne diseases, such as HBV, HCV and HIV, is tantamount. Although because tattoo studios have embraced universal precautions there has been no documented spread of HIV through professional tattooing. Hypersensitivity is another reaction patients may have. They may develop hypersensitivity to tattoo pigments; most commonly the red color from a reactive pigment called cinnabar. Contact dermatitis to para-phenylenediamine in temporary henna tattoos is often reported (Chung et al., 2001, Brancaccio et al., 2002). There’s also been concern about tissue trauma and misdiagnoses from iron oxide and heavy metal pigments in tattooed patients who undergo MRI. Scarring and keloid formation is another bothersome complication of tattooing. Tattoo Removal And of course, after time, many patients decide they no longer want to have a tattoo. The removal of tattoos has a varied history and is still not optimum, despite much improvement and media reports otherwise. In 1979, Murray Zimmerman warned against the litigious nature of tattoo patients. He stated “I have a perfect solution to the threat of incurring suits for the alleged unsightly scars resulting from removal of tattoos. That perfect solution is this: ‘Don’t undertake removal of tattoos’”(Zimmerman, 1979). New hope may be forthcoming with the recent report of the removal of tattoos with topical imiquimod and tretinoin in guinea pigs (Solis et al., 2002). Current treatments include excision of the tattoo, salobrasion, dermabrasion, cosmetic over-tattoo and, of course, laser. Despite fantastic laser work on a minority of patients, the treatment of tattoos with lasers may have poor results, cannot be predicted with true accuracy, and may require multiple expensive sessions. This often leaves the patient with high expectations frustrated and unhappy. (For more on laser treatment, see “What Dermatologists Need to Know about Laser Removal of Tattoos”) History and Complications of Piercing Body piercing is another form of skin adornment where jewelry is worn through the skin. Female ear piercing has long been accepted in Western culture, but in the last 25 years, male ear piercing and the piercing of other areas has become widespread. Navel piercing has become fashionable and more extreme piercings of the eyebrows, nipples, lips, tongue and genitals have also become common. Oral and genital piercing is often associated with reported sexual enhancement (Scully & Chen, 1994). Also done in an effort to enhance sex, some have started using artificial penile nodules, which are made by placing inert foreign material (plastic beads, pearls, etc.) beneath the skin of the penis. This skin adornment seems to have originated in Asia and has been called a variety of names, including penis marbles (Fiji) (Norton, 1983), Bulleetus (Philippines) (Sugathan,1987), Chagan balls (Korea), Tancho’s nodules (Japan) (Kikuchi,1984), and Apradravyas (India). Recently subcutaneous nodules and implants have found wider cosmetic use among those interested in “body modification.” Any time the skin is broken for a piercing, there is a risk of infection. Abscess formation, chondritis of the ears (Turk-taub & Habal, 1990)(Cosette,1993), candidal infection, and even toxic shock syndrome and sepsis (McCarthy et al., 1988) have been reported. The risk of bloodborne diseases, such as HIV, HBV, HCV is present among amateur piercers who don’t properly clean their equipment. Embedding of jewelry where the skin grows over the jewelry may occur and is often the result of using studs that are too tight. Many people are hypersensitive to the nickel in some jewelry and may develop a chronic dermatitis. These patients should only wear gold or platinum jewelry. The unwanted forcible removal of the jewelry during trauma may lead to a permanent deformity that cannot be rectified without surgery. Trauma to the teeth requiring restorative dentistry may also be caused by oral jewelry (Scully & Chen, 1994). The most common complication of piercing is the development of keloids. This is seen frequently in Americans of African descent. Treatment of keloids can often be frustrating and depends largely on surgery and/or intralesional steroids. There have also been reports of the use of cryosurgery and intralesional interferon. In some cases, however, of skin adornment, keloid formation is desirable. Scarification is a skin adornment that takes two forms — branding and cutting. In these methods, the more permanent the scar, the better. Branding is the use of a hot metal design, which burns a design into the skin. This is a recognized ritual behavior in some college fraternities. Cuttings are also done in the skin using a sharp knife or scalpel to leave permanent scarifications. The history of skin adornments and body art is long and interesting but the future is bound to be even more fascinating to dermatologists and others who study and care for the skin.
