TATTOO: The Invaluable Compendium for Dermatologists Savitha AS, Shashikumar BM, R Raghunatha Reddy
INDEX
Note: Page numbers followed by f refer to figure and t refer to table.
A
Acrylic paint 142
Acrylic paint tattoo 143f
Additives 25
Adjuvant treatment 47t
adamantinoma 47t
ameloblastoma 47t
ectodermal dysplasia 47t
scleroderma 47t
Seathre-Chotzen syndrome 47t
Sturge-Weber syndrome 47t
Allergic contact dermatitis of
beard 84f
scalp 85f
Allergic reaction 67f
Allergic tattoo reaction 74f
Anesthesia 98
Application of tattooing techniques in dermatology 46
Aspergillus 64
Aspergillus fumigatus 64
Atrophy with calcinosis cutis 92f
self-manual dermabrasion 92f
B
Bacterial infections 59
pyogenic infections 59
Benign tumors 76
Black henna tattoo 142
Blastomycosis 59
C
Calligraphy 143
Candida 64
Classification of tattoos 39t
identification tattoos 39t
emblems 39t
life events 39t
personal data 39t
love tattoos 39t
idealized love 39t
mother 39t
sentimental 39t
Complications of tattoos 55
cutaneous complications 56
atypical mycobacteria 59t
erysipelas 59t
fasciitis 59t
folliculitis 59t
furunculosis 59t
gangrene 59t
inoculation leprosy 59t
inoculation syphilis 59t
inoculation tuberculosis 59t
necrotizing 59t
tetanus 59t
extracutaneous complications 56
Complications in tattoo procedures 127
Contact dermatitis 141f
Control program 61
Council of Europe (CoE) 152
D
Dark tattoos 148f
Decal tattoos 145f
Dermabrasion 91f
Dermal scatter reduction 115
Diascopy 115
E
Eczematous dermatitis 65
Epidermal cysts 76
Epidermal melanin 97
Ethambutol 61
European Union (EU) cosmetics directive 152
Evolution of colorants 25
Excision 129
elliptical excision 129
punch excision 129
serial excision 131
S-plasty 131
Eye protection 98
F
Fish scale holographic tattoo 147f
Fluence 99
Foil/flash tattoos 146f
Food and Drug Administration (FDA) 145
Fungal infections 64
G
Gentian violet 136
Glucose-6-phosphate dehydrogenase 141
Gunpowder 108
H
Hepatitis B and C 127
Hepatitis D 151
Histiocytofibroma 76
Human immunodeficiency virus (HIV) 64
Humby's knife 133
Hydrogen peroxide 136
Hypertrophic scar 78f
Hypopigmentation 119f
I
Imiquimod 115
Indigofera argentea 142
Isoniazid 61
K
Keloidal scar 121f
Keratoacanthoma (KA) 76
Kirby-Desai scale 108
Koebnerization 78, 127
chronic lupus erythematosus 127
lichen planus 127
psoriasis 127
sarcoidosis pyoderma gangrenosum 127
L
Laser technique 99
Laser therapy 99
Lawsonia inermis 139
Leishmaniasis 64
Lichenoid papules 65
Lichenoid reaction 67
Liquid eyeliner 143, 144f
waterproof 143
M
Malignant tumors 76
Mantoux test 61
Melanoma 77
Methicillin-resistant Staphylococcus aureus 127
Micropigmentation
for lip vitiligo 48f
of scalp 49f
Microsporum canis 64
Mnemonic tattoos 37
Molluscum contagiosum 127
Mycetoma 59
Mycobacterium
abscessus 61
chelonae 61
fortuitum 61
haemophilum 61
immunogenum 61
tuberculosis 61
Mycobacterial infections 59
atypical mycobacterial infections 59
cutaneous tuberculosis 61
leprosy 61
N
Naphthalene 141
Natural pigments 26
mineral pigments 27t
organic pigments 27t
Nd:Yag laser 103f
Newer techniques for laser tattoo removal 108
R0 method 109
R20 method 109
Nonpermissible tattoos 160
O
Oleylphosphocholine (OLPC) 64
Oral retinoids 98
P
Pachuco cross 40f
Palisading granuloma 68
Parasitic infections 64
Partial surgical excision 91f
Paucibacillary multidrug therapy (PB MDT) 61
Perfluorodecalin spray 110f
combining lasers 111
ablative 111
fractional laser 112
fractional resurfacing 112
monotherapy 111
nonablative laser 111
fractional resurfacing 112
Permanent makeup (PMU) 152
Permissible tattoos 160
Petechiae 118f
Philosophical tattoos 37
Photosensitivity 66
Picosecond lasers 114
carbon dioxide (CO2) laser 114
picosecond alexandrite laser 114
Pigments used in tattoo 26t
cadmium sulfide 26t
ferric oxide 26t
guignets green 26t
lead carbonate 26t
mercury sulfide (cinnabar) 26t
zinc oxide 26t
Plaques 65
Polymerase chain reaction (PCR) 61
Postinflammatory hyperpigmentation (PIH) 97
P-phenylenediamine 83
Primary treatment 47t
depigmentation and hyperpigmentation 47t
eyebrow reconstruction 47t
hemangioma 47t
keloid formation 47t
klippel-trenaunay-weber syndrome 47t
trichotillomania 47t
verrucae vulgares 47t
vitiligo 47t
xanthelasmata 47t
Prolonged waxing 74f
Pseudoepitheliomatous 76f
Pseudoepitheliomatous hyperplasia 127
Pseudolymphomatous reaction 127
Pseudomonas aeruginosa 59
Psychosocial complications 80
extracutaneous complications 82f
Purpura 118f
Pyrazinamide 61
Q
Q-switched lasers 90
R
Residual atrophic scar 74f
Revised national tuberculosis 61
Rifampicin 61
Rules and regulations of biomedical waste management 159
S
Salabrasion 135
Sarcoidal reaction 68, 70f
Scalp micropigmentation 149
Seborrheic keratosis 76
Services Selection Board (SSB) 159
Skin disorders 77
Skin tumors 75f
Sporotrichosis 59
Squamous cell carcinoma 77
Staphylococcus aureus 59
Streptococcus 59
Sun protection 97
Superficial dermabrasion 135
Systemic allergic reaction 121f
T
Tattoo and religion 3
branding tattoo 3
decorative tattoo on hands 5f
henna tattoos 7
modern tattoo 4
tattoo parlor 4
Tattoo-induced pseudolymphoma 67
Tattoo in field of medicine 9
rising trends of tattooing 10
Tattoo policy 159
Tattoo regulations 151
Tattoo-related disease transmission 11
Tattoo socks 149f
Tattoo with a tattoo gun 93f
Technique of tattooing 7
electric tattoo machines 8
traditional method 8f
Test patch 98
Textural changes 120f
Tinea 59
Topical eutectic mixture 117f
Triamcinolone acetonide 136
Trichophyton tonsurans 64
Type i hypersensitivity reactions 141
conjunctivitis 141
dry cough 141
dyspnea 141
sneezing 141
swelling of the face 141
urticarial rashes 141
Types of tattoos 14
airbrush tattoos 22
decorative tattoos 14
amateur tattoos 17
cosmetic tattoos 17
make shift tattoo 17t
effect tattoos 20
extensive tattoo 19, 19t
identification tattoos 19
impulse tattoos 19
newer tattoos 20
professional tattoos 15
coil tattoo machines 15, 16t
rotary tattoo machines 15, 16t
types of decorative tattoo 15t
medical reconstructive tattoos 20
metallic jewelry tattoos 23
traumatic tattoos 22
U
Ulcerated plaques 65
V
Verrucous lesions 65
Viral infections 63
molluscum contagiosum 63
Vitiligo over tattoo 79f
W
Waning 74f
Wetting 25
White lace tattoos 146f
Whitening of the lesion 100f
X
Xerotic eczema 79f
Z
Zygomycosis 59
×
Chapter Notes

Save Clear


History and Epidemiology of TattooChapter 1

Savitha AS,
Lakshmi DV
 
INTRODUCTION
Skin was the first canvas for art. Tattooing is an ancient technique and human tattoos have been identified from ancient times, dating back even to the Stone Age 5,300 years.1 Historical and archeological evidence show that tattooing was practiced throughout the world as indigenous cultures from every continent. The body marks by tattooing process acted to negotiate relationships between individuals and their society, nature, and the spiritual realm. Through their traditions, they have functioned to signal entry into adulthood, reflect social status, document martial achievement, demonstrate lineage and group affiliation, and to channel and direct preternatural forces.2 In ancient cultures, the house served not only as a physical shelter but also as a border between the family and the outside world. People used items and rituals with magical or spiritual meanings to protect the front door which was seen as the most “fragile” opening of the house. Similar to this belief, the skin was often regarded as the border between the human body and the exterior world and the human body was also protected in fragile places with the help of permanent skin markings.3 Hence, art of tattoo was not mere esthetic on body but beyond; an amalgamation of their life, culture, nature and afterlife.
 
ORIGIN OF THE TERMINOLOGY “TATTOO”
It is likely that the word “tattoo” is an onomatopoeia; that is, a word that sounds like the special sounds this technique makes. The word tattoo is English in origin and attributed to Captain Thomas Cook who wrote about his travels in Polynesia in 1766–1779. In a narrative referred to in the ship's log for HMS Endeavour on 29th July 1769, published in 1773 with the title 2“Captain Cook's First Voyage”, he explained the origin of the word as being an adaptation of the Polynesian word “tatow”: ‘Both sexes paint their bodies “tatow” as it is called in their language. This is done by inlaying the color of black under their skins in such a manner as to be indelible’.4 The term “tattooing” is derived from “tattau”, a Tahitian word which translates essentially as “to mark” and is a process of implantation of permanent pigment granules in the skin.5 Thus, the origin and historical meaning of the word “tattoo” is believed to have two derivations as follow: (i) “ta”—striking something (Samoan/Polynesian) (ii) “tatau”—to mark something (Tahitian).
The Latin word “Picti” was first used in a panegyric written by Eumenius in AD 297 which means “painted or tattooed” people. Roman military commanders used to describe the inhabitants of present day Scotland as the Picts, group of late Iron age and early medieval Celtic people, who terrified the Roman legions with their naked painted bodies from black or dark blue dye of woad leaves (cabbage plant of European origin) and drew complex war designs. Similarly, word Britons means “people of the designs”.6
 
TATTOOING AS A CULTURE
Tattoos are known from ancient Egypt, from South America, as mentioned from Eskimos in Greenland and Canada, from Africa and the Pacific Ocean region, where they were very common. One of the major intentions of tattooing was to mark an individual as a part of a tribe known as Tribal tattoos (ethnic tattoos/clan markings or magic tattoos). In many cultures, tribal tattoos have been for men, women and children. Tattoos have often been carried out when a person reached a certain age, as a mark that the person has had a kind of confirmation of being included in the tribe's communal life and responsibility, or as a sign that the tattooed person was now to be considered as adult and sexually mature.1
Among the Maoris and Inuits, aborigines of New Zealand linear face tattoos were carried out by pricking pigment into the skin or inserting it with blackened threads and were known as Moko style tattoos (moko meaning to strike or tap). It was used as a form of identification with regards to rank, genealogy, tribal history, eligibility to marry, beauty and virility. Maori women were traditionally only allowed to be tattooed on their lips, around the chin, and sometimes the nostrils. While in Africa, they have most often been designed as linear body tattoos cut into the skin with the possible intention of scarification; in Asia there have been many different forms carried out using a variety of techniques and have been placed on very different parts of the body.7 Hawaiians also celebrate specific tattoo Gods where in priests conducted tattooing.
3Totem animal tattoos were also another common motif in primitive tattoos and animal is thought to have a special spiritual relationship with the bearer of tattoo and acts as a spirit guide.
Totem animals such as snakes, frogs, butterflies wolves or bears signified that the individual has taken on the physical prowess of that animal. In China, tattooing one's animal astrological symbol, such as the pig or the horse is thought to bring good fortune and images of Koi, carp or goldfish were thought to bring prosperity and wealth to the bearer.
 
TATTOO AND RELIGION
At about 1900 tattoos were disliked, disapproved of and not very prevalent in cultural circles in Europe as well as in the general population. In the old testament of the Bible, the book of Leviticus, verse 19:28 says: “Ye shall not make any cuttings in your flesh for the dead, nor print any marks upon you: I am the LORD. I am the LORD”. The church and its missionaries around the world had argued against tattoos for centuries. At the Catholic council of Calcuth in Northumberland in 787, the church banned markings/tattoos on the skin. Also the Koran was and is against tattoos—the dead must not be marked. Tattoos were and are regarded as barbarian by the great religions. The Vikings, however, continued to believe in the Nordic gods and sometimes had tattoos.7 The Roman Empire was also against tattoos and they were forbidden by Emperor Constantine (307–337). Therefore, hardly anyone in civilized Europe had tattoos until modern times, with the exception of certain purposes, such as marking criminals and foundlings.8
 
Tattoo as Symbol of Punishment
Branding tattoo describes a forced marking of individuals by a ruling authority. In the late middle ages, the practice focused on a differentiation between burning, pinching with a cold iron, and perforating the skin with needle stitches which were rubbed over with coal dust.8 The purpose of these branding tattoos was usually to recognize what criminal act a person had committed, and besides being a physical punishment, this branding “marked” a criminal and led to his isolation within society.
Japanese tattoo artists developed the uniquely-Japanese traditional art tattoo art form, called horimono. Punitive tattoos were called irezumi; ire, or ireru means “to insert” (meaning the insertion of the pigment) and zumi means the ink itself. During the Edo period, tattooing as punishment, along with amputation of noses and ears, occurred between the eras of Kanbun (1661–1673) and Tenna (1681–1684). By 1720 punitive tattoos had replaced the amputation as part of the Kyōhō Reforms (1716–1736). These reforms, 4among other things, disassociated the tattooing from death penalty, instead imposing it as punishment for minor offenses.9
 
Modern Tattoo10
In the 1960s tattooing for art's sake alone became popular. Some people collect tattoos the way others collect antiques or works of art. In the 1970s, artists trained in traditional fine art disciplines began to embrace tattooing and brought innovative imagery and drawing techniques to the industry. Advances in electric needle guns and pigments provided them with new ranges of color, delicacy of detail and artistic possibilities. The cultural status of tattooing has steadily evolved from that of an anti-social activity in the 1940s to that of a trendy fashion statement in the year 2000. First adopted and flaunted by influential rock stars like the Rolling Stones in the early 1970s, tattooing had, by the late 1980s, become accepted by mainstream society. Cosmetic tattooing originated during ’20s and ’30s. Many artists started offering specialties such as moles and beauty marks rosy cheeks, permanent eyeliner and red lips to both male and female customers.
During the last 15 years, two distinct classes of tattoo business have emerged. The first is the “tattoo parlor” that glories in a sense of urban outlaw culture, advertises itself with garish exterior signage and offers less than sanitary surroundings. The second is the “tattoo art studio” that most frequently features custom and fine art designs, all of the features of a high-end beauty and “by-appointment” services only. Today's fine art tattoo studio draws the same kind of clients as a jewelry store, fashion boutique, or high-end antique shop.
 
HISTORY OF INDIAN TATTOOING11
In India, the practice of tattooing is a part of folk and tribal art. In the northern and northwestern regions, the tradition of tattooing has been prevalent among the Bhils and Santhals in central India, the Kanbis and Warlis in the Gujarat region, and among the Banjaras of Rajasthan. The young and old generations of Kanbi and Warli women practice tattooing on the forehead and cheeks. The characteristic symbol that is tattooed is of a tree and its leaves on the forehead. Tattoos are used both as a mark of beautification as well as a totem. Many women bear tattoo marks of the peepal tree or acasia tree, which is of religious significance in Hinduism. Men of these communities get tattooed the figure of the Hindu gods Hanuman, Krishna, the motif of “Om”, etc. and their own names. The Rabaris, a wandering tribe of the Kutch, use tattooing as a practice of beautification of women. The women of this community wear small motifs on the throat, chin, and entire arms and on their hands (Fig. 1.1).
5
zoom view
Fig. 1.1: Decorative tattoo on hands on Rabaris woman.
Source: Photo courtesy Meena Khadri. [online] Available at http://www.thebetterindia.com/58170/india-tattoo-tradition-history/
Amongst the Santhals of Bengal and Jharkhand, among women tattooing marks an important rite of passage for girls between the ages of 10 years and 11 years before their marriage. It is believed the painful experience prepares a girl for motherhood and gives her the strength to face the challenges of life. The men inscribe tattoos called “sikkas” on their forearms and wrists, named thus because they are usually the size of coins called “sikka”. On the contrary, among Arunachal Pradesh's Apatani tribe tattooing its womenfolk was done to make them unattractive to rival tribes in neighboring districts, who might otherwise abduct their prettiest women. The Apatani tattooing procedure involved using thorns to cut the skin and soot mixed in animal fat to fill in the deep blue color. The wounds were then allowed to get infected so that the tattoos became larger, darker and clearer (Figs. 1.2 and 1.3).
The four prominent tribes namely the Gonds, Pardhans, Kolam, Korku and the nomadic Banjara tribe are the communities in Maharashtra that have been practicing tattooing. Moving southwards, the Malagasy-Nias-Dravidians of the Malabar Coast have been documented to be using “medicinal tattoos” as cures for physical ailments. The affected area of the body is believed to be cured by inscribing of a tattoo over it. Medicinal tattoos have been documented to be used in other communities in the world for treatment of joint-related conditions such as rheumatism.
In Nagas tribes, tattooing is linked to the identity and honor of the community.
6
zoom view
Fig. 1.2: Tattoo in Apatani woman.
Source: Photo courtesy Priyanka Verma. [online] Available at http://www.thebetterindia.com/58170/india-tattoo-tradition-history/.
zoom view
Fig. 1.3: Women of the Kutia Kondh tribe of Orissa, called the “the people of the spirit world”, ink themselves with beautiful geometric facial tattoos; it is said these identifying marks ensure they recognize each other once they enter the spirit world.
Source: Photo courtesy Wikimedia Commons.
7Most of the Naga tribes have been reported to have their faces tattooed with distinctive marks with which one can identify what region of the hills they belong. Among Konyaks of Nagaland facial tattoo were used to commemorate their head-hunting expeditions. Facial tattooing was prevalent among the Noctes and Wanchos of Arunachal as well.
The tattooing of body parts for sexual expression also has a long history to realize significance of body adornment for sexual provocation. In central India, the Baiga female tattooed symbol of a peacock at the breast when a girl reaches puberty. It is strictly not tattooed until she is adolescent. Apart from this symbol, they also tattooed a symbol of basket (dauri) at their breast when a girl reaches puberty.12 In Southern India, permanent tattoos are called “pachakutharathu”. They were very common, especially in Tamil Nadu, before 1980. The nomadic Korathi tattoo artists traveled the countryside in search of clients. The kollam, a sinuous labyrinthine design believed to ensnare evil beings, is inked on bodies to permanently keep them safe and secure until reunited with deceased ancestors in the afterlife.
 
Henna Tattoos
Henna tattoos are also used for centuries by Muslims and Hindus for cosmetic purposes. Henna has been used as a dye for the skin, hair and nails for over 4,000 years, and as an expression of body art, especially in Islamic and Hindu cultures in the Arab, African and Indian world. At events such as wedding parties, public celebrations, and religious ceremonies, henna is applied to the skin of the hands and feet. A range of products such as lemon, vinegar or tea leaves are used to prevent the deterioration of tattoos. It is a temporary tattoo that stains the skin in reddish-brown and disappears after 2 or 3 weeks by the natural process of renewal of the epidermis. These mehndi tattoos are used as a reminder of happiness and as a form of blessing for the wearer. In recent years, a new mode of henna application, the so-called temporary black henna tattoo, has become fashionable, especially among children, adolescents and young adults in western countries.13,14 Black henna is the combination of henna proper and p-phenylenediamine (PPD).
 
TECHNIQUE OF TATTOOING
The classic tattoo pigment was simply whatever was at hand, which was typically soot; that is, carbon from burnt wood that was used as black pigment. Black was the dominant tattoo color, but sometimes pulverized colored minerals from nature were used for tattoos.15 It is essential for classic tattoos to be permanent. By using a suitable technique or operation, the natural pigment was placed between the collagen fibers in the skin's corium (synonymous to dermis), which is a relatively stationary and mechanically bearing tissue, which can function as a matrix for the pigment for a lifetime.
8
zoom view
Fig. 1.4: Traditional method of tattooing.
The pigment can be pricked into the skin or rubbed into small cuts in the skin, carried out using a cutting object, with or without wanting to create scar formation in addition to the tattoo. It is believed that prehistoric man cut holes in his skin, charred sticks in the fire, let them cool and then applied the black substance to the wound to create tribal markings.1 In the Pacific Ocean area, a technique was practiced where the needle was placed at an angle of about 90° on a stick. The stick was hit or hammered with frequent blows, so that the pigment placed on the skin was put in the corium in almost the same way as modern tattoo machine. A straight stick with a shape nearly like a drumstick was used as a hammer (Fig. 1.4).
Electric tattoo machines were introduced as a patented tattoo machine in 1891 by the American Samuel F O’Reilly. This machine was powered by a small rotating electric motor. In 1899, the Englishman Alfred Charles developed the tattoo machine that was based on two coils and electromagnetism, which conquered the world, and which is the dominant type today. However, recently improved rotary machines are making a comeback. Tattoo machines were the technical prerequisite for the very large prevalence of tattooing in Europe and other industrialized societies, introduced by seafarers everywhere, starting in the seaports. Since the 1700s seafarers have been tattooed when they were out in the world on dangerous voyages with 9sailing ships to faraway lands. It was the seafarers and the opening of the seven seas that brought tattoos to Europe.
 
TATTOO IN FIELD OF MEDICINE
Tattooing as a form of therapy was perhaps as early as the 4th–5th millennium BC. In 1991 in the Ötztaler Alps in Austria near Innsbruck, a frozen mummy was found, the Iceman—popularly called “Ötzi”. The well-preserved mummy had black tattoos in the form of parallel lines that were tattooed into the skin across the large joints, such as the wrist joints, knee joints and foot joints, as well as on the back. It is assumed that the tattoos were medically performed in order to heal joint discomfort.15-17 The placement of these tattoos on the lines of the spinal cord, behind the knees and ankles suggest the use of the practice as a form of acupuncture therapy. A crude practice of medical tattooing was performed by Galen in 150 CE. He tried to cover leukomatous opacities of the cornea by cauterizing the surface with a heated stilet and applying powdered nutgalls and iron or pulverized pomegranate bark mixed with copper salt.18
The Tibetans equated designs called mantra wheels were tattooed on chakra (energy points) on the body to help the bearer of the tattoo achieve physical, emotional and spiritual harmony. Sometimes tattoos were created from medicinal dyes and marked on acupuncture points of the body in an attempt to cure chronic health problems and diseases. Older Maori women tattooed their lips and face to prevent failing vision. Ainu women of Japan tattooed a Goddess on their skin so that the evil spirits that bestowed disease would mistake them for the Goddess and flee in terror. In India, the Lord Hanuman was also tattooed on dislocated shoulders. In mid-1800s, A German physician Pauli used tattooing with mercury sulfide and white lead for the restoration of the natural color to the skin in cases on congenital vascular nevi. Other instances include the cosmetic tattooing with mercury sulfide after plastic lip procedures recommended by Shule in 1850 or the modern method of corneal tattooing put into practice by Louis Von Wecker in the 1870s.19 Now, medical therapeutic tattooing has been used as a camouflage technique in vitiligo, for breast areola reconstruction after cancer surgery, as camouflage for permanent hair loss after craniofacial surgery, and scars following plastic and reconstructive surgery.20
 
EPIDEMIOLOGY OF TATTOOING
In recent times, tattoos have steadily become more popular, particularly among young people as a means of self-expression or being different, and new social and cultural movements continue to support the popularity of such practices.21 10–30% of the adult population of industrialized countries 10are now tattooed.22 It has been suggested that there might be an association between risk behaviors and piercing and tattooing practices.23
 
Rising Trends of Tattooing in Adolescence
According to the studies, the prevalence of tattoos in adolescents ranges from 4.5% to 23% and thus “age of adolescence” form first age for tattooing. Boys are three times more likely to get tattoo done than girls. However, recent Harris interactive study 2012 showed that adults aged 30–39 years are most likely to have a tattoo (38%) compared to both those younger (30% of those 25–29 years) and 22% of those 18–24 years.24 The reasons invoked by youth for tattooing or piercing refer mostly to the expression of individuality (i.e. to feel unique and special), to the confirmation of their personal identity, and to esthetics.25 A study by S Balci et al. among college going students showed significant association between getting tattoos and the students’ risk-taking habits of smoking, taking alcohol, addictive substance use, use of stimulant substances/pills, engaging in extreme sports, carrying sticks/switch blades/gas sprays, engaging in unprotected sex and frequently changing sexual partners. Tattoos are mostly seen on the back, shoulders, arms and legs.23 A study stated that friends were an important factor in the decision to have tattoos done. Armstrong et al. found that 63% of the students had the intention of getting another piercing and that 64% were thinking of getting another tattoo.26 Galle et al. reported that 53.6% of the students had their piercings and tattoos done at professional establishments and also that sterile and disposable instruments were used in the procedures in the case of 70.6%. These findings are a positive indication that young people generally contact reliable establishments to get their piercings and tattoos.27 Under the circumstances, it is imperative that young people receive education about the risks of piercing and tattooing and that the importance of having these performed by professionally trained people under sterile conditions is impressed upon them. Despite the increasing number of tattooed individuals, there are currently few requirements, little legislation and few criteria for the safety of tattoos.
 
TATTOOING AND BEHAVIORAL RISK
Given growth in popularity of tattoos, the prevalence and characteristics of those who have been tattooed have changed in the past decade. Professional tattooers with salons are on rise and amateur tattooing and self-tattooing are on decrease in urban areas. Uniqueness and gender seem to be motivating factors in tattoo procurement. In one study involving career-oriented women with tattoos, many of whom were counselors, nurses, physicians, lawyers, and business managers, deliberate decision making and 11self-controlled body site placement were described as assistive for their tattoo satisfaction. The tattoos symbolized individuality and identity, projecting both femininity and personal strength.28
Historically, tattooing has been associated with gang-related activities, drug use, prisoners and also underlying psychopathology. Tattoos are now regularly seen on celebrities, athletes, and middle-class young people. Tattooing is also viewed as a form of deviant behavior. Some studies have shown an increased prevalence of tattoos in young individuals attempting suicide.29 Among adolescents, tattooing has been associated with drug, and alcohol use, increased levels of sexual activity, suicide ideation, and illegal/violent behavior. A study using random digit dialing in the United States in 2004 survey 24% respondents had tattoos, with those who were younger, lower paid, had spent time in prison, used alcohol or drugs, and had achieved lower levels of education reporting the highest levels of tattooing.30
 
EPIDEMIOLOGY OF TATTOO-RELATED DISEASE TRANSMISSION
One of the earliest sources linking disease transmission to the practice of tattooing can be found in MF Hutin's “Recherches sur les Tatouages”, published in 1853. He relates the case of a tattooed soldier who suffered from syphilis due to misdeed of tattooist who remoistened dried ink with his saliva infected with Spirochaetaceae.31 After Hutin, and until the end of the century, only five cases of primary syphilis, from 1900 onwards there is decrease in trend of cases reported probably due to shift in the professional practices and standards of tattooists.32 Similarly, the trend from syphilis and tuberculosis in the late 19th and early 20th centuries shifted to hepatitis from around the 1950s right up until 1980, and HIV in the 1980s And ’90s. Tattooing and body piercing can be possible vectors for the transmission of blood-borne diseases such as hepatitis B, hepatitis C or HIV. A 1999 United Kingdom survey of family practitioners showed that 95% of them have seen patients with complications resulting from a piercing.33
A study of 31 female patients with leprosy lesions starting over tattoo marks was reported from a leprosy endemic area from India. In most cases, improper use of hygiene regimens, particularly contaminated needles are causal, but sometimes, contaminated pigments are implicated. Severe systemic mycoses can be transmitted rarely by tattooing.20
 
CONCLUSION
Tattoos have been around for centuries. As a form of identity, they have existed across cultures and geographies. They reflect time and society, and 12change as they change. The concept of tattooing has extended its arms even in medicinal healing science. Its knowledge has paved way through centuries and has survived through modern era with varied application. As the trend for getting tattoo is increasing, so is the awareness about professional tattooing and tattoo-related complications. Nowadays, the incidence of tattoo removal has also been more common.
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