Appears to be necessary make a well-informed and responsible autonomous decision before tattoos

A recent study published in the journal Scientific Reports[1] (see HERE) has shown that the pigments used in tattoos can be detected in the regional lymph nodes, structures related with the immune system. Using complex detection techniques, the authors were able to identify organic pigments, heavy metals such as chromium, cobalt, manganese and nickel, and titanium dioxide in skin and lymphatic tissues from human cadavers. There is also evidence that these toxins cause ultrastructural changes in the tissues adjacent to the tattoo particles. This suggests that the pigments used in tattoos release chemical toxins that migrate to other tissues in the body, causing long-term deposition of toxic elements and pigments, and conformational alterations of biomolecules that probably contribute to cutaneous inflammation and other conditions.

Tattoo chemical products in tattoo inks

Almost at the same time this study was published, the European Commission’s science and knowledge service[2] (see HERE) published a report on the safety of tattoos, in which it expressed the need for a full risk assessment of the ingredients used in these techniques, including their phototoxicity, absorption level, distribution, metabolism and excretion, as well as the Derived No Effect Level (DNEL), data that are largely unknown at present. It is also imperative to evaluate whether the risks derived from the use of certain chemical products in tattoo inks are adequately controlled or should be addressed by an additional European Union measure.

That is to say, we have an increasingly widespread practice that enjoys great acceptance in wide sectors of the population — perhaps influenced by sports and public figures who display large tattoos — for which, on the other hand, there is insufficient evidence on the levels of safety offered, ignoring to a large extent the side effects that may arise from their use, both short- and long-term. To date, the risks of their use have centred more on the likelihood of transmission of infectious diseases through improper handling of the instruments used in tattooing.

The study now published extends the risk beyond the transmission of infections such as hepatitis, HIV and others, or dermatological complications at the site of application, as it reveals that the toxic pigments can be found in distant tissues of the body and remain in them for a long time, increasing their toxicity in the long term. 

Effects of laser

The laser techniques used to remove tattoos, far from resolving the problem, exacerbate it. According to the author of the study,[3] the laser acts by breaking the pigment particles into smaller fragments which can thereby be spread further throughout the body, reaching other organs or tissues where they exert their toxic effect. Application of the laser also causes chemical changes in the pigment substances used, which may result in new toxicity risks.

Bioethical analysis

With the new findings, ethical dilemmas arise regarding the use of tattoos that should be mentioned, albeit briefly. First of all, the use of techniques — in this case cosmetic and non-therapeutic — would not be ethically acceptable if it did not offer reasonable assurances of safety for users. The bodies responsible for the authorisation and regulation of these practices must rigorously evaluate new data on toxicity and associated risks as they become known, to regulate their use or restrict it if necessary.

Many pharmacological treatments, subject to exhaustive pharmacotherapeutic control, have limitations in their use as they present side effects that are, in many cases, more minor than those observed in the practice of tattooing, and those that may arise from the latest findings to which we refer in this article.

The principle of informed consent and the preservation of the of patient autonomy

In addition to this first biosafety-related aspect, a second bioethical-related conflict arises: informed consent and the preservation of the principle of patient autonomy. As regards informed consent, in order for it to be valid, the patient must be precisely and clearly informed of all the aspects that surround a proposed intervention or treatment, in which it is ultimately they who reserve the right to accept or reject it. This decision cannot be properly taken without knowing all the extremes of their side effects, risks and potential benefits. The new risks associated with these practices, together with the lack of knowledge regarding their safety to which the European Commission refers, make it very difficult to make a well-informed decision about whether or not to have a tattoo. Users are agreeing to these en masse from a position of ignorance in many aspects, making it impossible to make a well-informed and responsible autonomous decision.

It should also be noted that this problem is exacerbated in the case of minors: added to the aforementioned conflict is the legal incapacity to decide about interventions such as these, since, in fact, they get tattoos on a massive scale, often without the consent of their parents or legal guardians.

Conclusion

The widespread and growing practice of tattooing, far from being risk free, presents toxicity levels which are largely unknown by the population who have one. The absence of regulation, in part due to the paucity of data on the potential consequences of their use, constitutes a situation of risk and lack of protection for users, who cannot freely decide to have a tattoo or not if they do not possess relevant up-to-date information on its risks. The article now published proposes not to underestimate these, but rather to warn about the serious effects that may manifest in the long term, likely when it is too late to implement a solution.

[1]Schreiver I et al. Synchrotron-based ν-XRF mapping and μ-FTIR microscopy enable to look into the fate and effects of tattoo pigments in human skin. Scientific Reports 2017;7:11395

[2]EU SCIENCE HUB. The European Commission’s science and knowledge service. Safety of tattoos and permanent make-up: Final report.2017. https://ec.europa.eu/jrc/en/publication/eur-scientific-and-technical-research-reports/safety-tattoos-and-permanent-make-final-report

[3] http://www.elmundo.es/ciencia-y-salud/salud/2017/09/13/59b7cb2f22601db5068b4634.html

Julio Tudela

Pharm P.h.D.

Bioethics Observatory

Photo TatoosME

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