Tattooing has gained tremendous popularity in Western countries. In Australia, Finland France and Germany, approximately 10% of the populations have at least one tattoo . The ‘tattoo craze’ is particularly strong among the young generation, in which every third or fourth person has a tattoo.
Tattoos have definitely become mainstream, but possible dangers from tattoo inks include bacterial contamination, allergies, toxic effects and eventually the risk of cancer. Two in three people report side-effects after getting a tattoo. Even the new proposals developed by the European Chemical Agency(ECHA) are insufficient to guarantee safe inks without risk of toxicity and cancerogenicity. At the EADV Congress which opened today in Paris, the EADV reiterates its demand that tattoo inks should be properly tested and should at least meet the same safety standards as cosmetic products.
This form of body art has definitely become mainstream. It is remarkable, therefore, that European requirements and restrictions regarding the composition of tattoo inks are still not enough to guarantee safety. Potential dangers from tattoo ink include bacterial contamination, allergies and the risk of toxic effects. Even more so, given that two in three people report some side-effects after getting a tattoo; for example, sun-sensitivity is a common finding. Although there is still a lack of reliable epidemiological studies, even the risk of cancer has to be considered.
Although health and safety regulations have been established by the Council of Europe, resolution ResAp2008(1) , focusing on hygiene rules to prevent infections (e.g. so that diseases such as Hepatitis B and HIV are not transmitted by sharing needles, etc.), tattooing is not without its risks. The quality and sterility of tattoo inks, which are generally not controlled, still give reason for concern. A Danish study  of bacterial contamination of 58 new inks showed that 10% of the inks are contaminated with bacteria, i.e. Staphylococci, Streptococci, Pseudomonas species and Enterococcus/Coli. These contaminated inks may lead to infection, especially in people at risk (e.g. people with heart diseases, diabetes and patients with a weak immune system).
Allergies and toxicity are further points of concern. The requirements and the restrictions of resolution ResAp2008(1) regarding the composition of tattoo and PMU inks are insufficient to guarantee safety. Tattoo inks consist of pigments and dyes, additives and even nano-particulate traces of heavy metals, as well as hazardous impurities from the production process. Tattoo colorants may release carcinogenic aromatic amines and polycyclic aromatic hydrocarbons. In many cases, the ingredients and chemicals are not clearly labelled. The market is poorly controlled. Some pigments used in tattoo inks are not listed by the Scientific Committee for Consumer Products (SCCP), an advisory body to the European Commission, and therefore are not allowed in cosmetics. Moreover, illegal products and counterfeits of poor quality can easily be purchased on the internet.
On request of the European commission, ECHA (European Chemical Agency) has prepared two pathways for improving the composition of tattoo inks; these have now been submitted for public consultation and for comments from the Member States, and their final publication is expected at the end of 2018. “Unfortunately, the ECHA proposals are still insufficient to guarantee safe inks without any risk of toxicity and cancerogenicity”, explains Dr. Christa De Cuyper, MD, Board member of the European Academy of Dermatology and Venereology (EADV). “To eliminate carcinogenic substances and to limit long-term toxic effects, strict measures and well-defined safety limits for the used substances are needed with appropriate analytical methods for controlling such use; the ECHA proposals do not provide adequate solutions to meet these requirements.” According to the expert, a positive list of safe products should be developed. The inks should be tested for their potential toxicity, phototoxicity, substance migration, carcinogenicity and possible metabolic conversion. “Tattoo inks should at least meet the same safety standards as cosmetic products”, postulates Dr. De Cuyper. “It would even be preferable if they were as safe as medicines because they are injected under the skin. There is scientific evidence that tattoo ink ingredients are transported into the body. The can be found e.g. in draining lymph glands. In laboratory settings they are also detected in the liver of mice.” As a consequence, both the EADV and the European Society on Tattoo and Pigment Research (ESTP) are strongly demanding better regulation.
Tattooists and their clients need safe and reliable products. It is the responsibility of the authorities to assure (and protect) public health.
Progress has been made in matters of hygiene, at least. The European Committee for Standardization (Centre Europeèn de normalization/CEN) finalized hygiene standards this year, which will be published at the end of 2018. They give an overview of good practice (procedure), instruments, organization and infrastructure of the tattoo parlour and requirements for training of tattooists. These new standards will be discussed on Friday morning in a meeting with tattooists and tattooist trainers at the Musée des Moulages of l’Hôpital Saint Louis during the EADV Congress, which opened today in Paris.
 Kluger N. Epidemiology of tattoos in industrialized countries. Curr Probl Dermato. 2015; 48: 6-20
 Resolution ResAP(2008)1 on requirements and criteria for the safety of tattoos and permanent make-up (superseding Resolution ResAP(2003)2 on tattoos and permanent make-up): https://search.coe.int/cm/Pages/result_details.aspx?ObjectId=0900001680…
 Høgsberg T, Saunte DM, Frimodt-Møller N et al. Microbial status and product labelling of 58 original tattoo inks. J Eur Acad Dermatol Venereol 2013; 27(1): 73-80
Founded in 1987, EADV is a non-profit association whose vision is to be the premier European Dermato-Venereology Society, with the key aims of improving the quality of patient care, providing continuing medical education (CME) for all Dermato-Venereologists in Europe, and advocacy on behalf of the specialty and patients.