Every few months, Shannon Elliott undergoes another treatment to remove two tattoos she had done when she was a teenager. During each 15-minute session, a dermatologist uses a laser to break up the tattoo ink, which is then cleared away by the white blood cells in her body. It's an ongoing, painful process and one that the 28-year-old woman chose because she felt that her tattoos might be promoting an unprofessional image. The tattoos -- one an image of Spiderman -- had lost some of the appeal they'd had when she first got them. "They just didn't mean as much to me as they used to," Elliott says.

Elliott works for the dermatologist who is removing her tattoos free of charge. She says she would otherwise be unable to afford the high-tech procedure, which can cost $100 to $150 per square inch, and take from six to 15 sessions.

Dermatologist Robyn Gmyrek, MD, an assistant clinical professor in department of dermatology at New York Presbyterian Hospital, Columbia University, says that in her experience, nearly half of all people who get tattoos end up regretting the decision. (Of course, most dermatologists are not likely to see people who are pleased with their tattoos, so her estimation may be high.) Nonetheless, all who arrive at her door wanting them removed have good reasons. Among that group are people who don't want to see reminders of their former gang affiliations -- or past relationships. People may also dislike how a tattoo changes over time. For example, pregnancy can irreversibly distort a stomach tattoo, and the effects of aging can cause skin to sag, stretching out a once-beautiful tattoo.

People choose to get tattooed for a variety of reasons -- to memorialize a loved one, to mark an important time in their lives, or just because they like body art. Whatever the reason, if you want to avoid being one of those people who regrets getting a tattoo, carefully consider a tattoo's color, size, and location. But most importantly, to avoid the risk of infection or illness, make sure you're being tattooed by someone who uses sterile equipment.

If you walked into a doctor's office and saw dirty floors and peeling paint, you'd probably be leery of being treated there. You should be just as hesitant to get a tattoo at any place that seems unclean.

Tattooists use tattoo "guns" that pierce the skin with needles to inject ink. So a clean environment is crucial to prevent germs from entering your freshly tattooed skin. Your tattoo artist should wear gloves to avoid coming into direct contact with your blood, and should use new, unopened ink packages for your tattoo. Needles and ink should never be reused.

Sterilization of equipment is what prevents most skin infections associated with tattooing. The Alliance of Professional Tattooists, a nonprofit group that advocates health and safety in tattooing, says the only acceptable means of disinfecting and sterilizing tattoo equipment is an autoclave -- a pressurized, steam-heated machine. Make sure that's what your tattooist uses to sterilize his or her tattoo gun. He or she shouldn't be offended if you ask to see it.

Professional tattooists charge about $100 to $150 per hour for their work. Some people might be tempted to seek out the less expensive services of an amateur tattooist, but the lower cost isn't worth the added health risk.

In 2004 and 2005, clusters of staph infections resistant to common antibiotics -- known as methicillin-resistant Staphylococcus aureus, or MRSA -- were seen in people in Ohio, Kentucky, and Vermont. The Centers for Disease Control and Prevention (CDC) identified 34 people with MRSA who got their tattoos from 13 unlicensed tattooists in the three states. (Another 10 people contracted the disease from contact with those who had contracted MRSA from tattoo parlors.) According to the CDC's report, all cases stemmed from unsanitary tattooing.

Most of the MRSA cases were mild to moderate and the patients recovered, although four of them required hospitalization. Law enforcement officials who visited seven of the unlicensed tattoo parlors reported that infection control was weak at best, with tattooists failing to change gloves between clients and not washing their hands or sterilizing their equipment. In Ohio, 13 of the infected people reported getting tattoos in places like public parks or people's homes from amateur tattooists who used guitar-string tattoo needles and ink-jet printer cartridge dye.

Before your appointment, make sure you've eaten and are well-rested and hydrated. Expect some discomfort and minor bleeding. Drinking alcohol or taking aspirin before your appointment could cause increased bleeding. Tattoo sessions generally last about three hours (larger tattoos require multiple sessions), so pace yourself. During the session, if you start to feel faint or need to move, tell your tattooist right away so you can take a break.

The colors in your tattoo will be boldest right after your appointment. Expect the design to lose a little intensity as your skin heals.

After getting a tattoo, it's common for the area to be inflamed and tender -- sort of like a sunburn. Your tattoo artist will lightly bandage the area to absorb bleeding and protect you from infection, but after 12 to 24 hours, the bandages should come off so the skin can "breathe." In the first few days, it's common for tattoos to seep ink. Dress accordingly, and if you have white sheets on your bed, consider wearing loose-fitting clothing over your tattoo when sleeping to prevent ink from staining the fabric.

Gmyrek, the dermatologist from New York Presbyterian Hospital, says taking care of a tattoo as it heals is important to preventing infection. "After-care is very important," she says. "Be mindful that you have microscopic openings in the skin, like any other wound, after you get a tattoo -- so keep it clean."

Both health professionals and tattoo artists recommend cleaning a fresh tattoo with soap and water after removing the bandages. Gmyrek also recommends applying an over-the-counter antibiotic ointment during the healing process, which can take seven to 10 days. You should also ask your tattooist for recommendations. Tattoo artists might suggest you try products that are specifically designed for use on freshly tattooed skin; check with your dermatologist or primary care physician before using them.

Let a tattoo scab over while it's healing. Picking at the scabs can increase the chance of infection, cause scarring, and damage the tattoo's design, according to Mayo Clinic. Check the tattoo daily and call your doctor if you see changes in appearance, such as spreading redness.

Other signs of a staph infection include red, swollen, painful areas with discharge, and might look like a pimple or boil. Doctors can treat most staph infections easily, but others can rapidly become life-threatening if left untreated. "If redness or yellow crusting appears on the fresh tattoo or surrounding area, seek medical attention," Gmyrek says. (Because these infections often worsen quickly, go to an emergency room if you develop signs of a staph infection over a weekend.)

Never get a tattoo over a mole. Dermatologists recommend that you routinely check the size, shape, and color of your moles as a way to detect skin cancer in its early stages. But if you cover a mole with a tattoo, you probably won't be able to tell if your mole changes.

You might think that you're in the clear once your tattoo heals, but in some instances, problems may occur long after the process itself.

Occasionally, some people experience allergic reactions to tattoos they've had for years, just as people can develop allergies to food and other things that never bothered them before.

The pigment that is most commonly the cause of an allergic reaction is mercuric sulfide -- or cinnabar -- used in some red inks. But different hues of blue, green, and yellow have been known to cause reactions, too.

Some people may develop granulomas, or clusters of cells that can be caused by an allergic reaction and appear as bumps in or around a tattoo. (Granulomas can also be a sign of a serious disease called sarcoidosis, which causes the body's immune system to overreact, forming cell clusters that damage its own tissue.) If your doctor confirms the presence of tattoo granulomas, ask whether steps should be taken to determine if the granuloma was caused by a local, allergic reaction to the pigment, or if it is a symptom of the more serious disease.

On rare occasions, tattoos may cause complications during an MRI (the medical procedure that uses radio waves and a magnetic field to create images of the body and head). If someone with permanent eyeliner has an MRI on the eye, tattoo pigments could interfere with the quality of the image. Other possible effects include swelling or burning of the tattooed area. The Food and Drug Administration (FDA) says the metallic components of some makeup pigments might be the cause of such complications.

Cosmetic tattooing -- or permanent makeup -- is a relatively new trend, gaining popularity in the last 20 years. It can be a way to shave several minutes off the time it takes to get ready for work each morning. But because cosmetic tattooing is a fairly new field, there are some inherent problems.

In 2004, the FDA issued a warning concerning certain shades of ink used in permanent lip liner, eyeliner, or eyebrow color. At the time, the FDA was investigating more than 50 adverse reactions, including swelling, peeling, blistering, and scarring. Some women had trouble eating and talking as a result of lip liner tattoos. The North West Institute of Esthetics, a prominent esthetician training institute in Oregon, advises against the application of permanent lip liner, which, at the very least, can make a woman look like she has a ring around her mouth if she's not wearing lipstick.

In some states, licensing requirements for technicians who apply permanent makeup are disturbingly lax. Tattooing may be the responsibility of the state government or a county agency, but its regulation is virtually nonexistent in some areas. So don't assume that your tattooist is required to be licensed. Always ask about a person's credentials and experience, and insist on looking at a portfolio that showcases his or her work.

It is possible for HIV to be transmitted through tattooing under unsanitary conditions. In a study that spanned the years 1992 to 2005, the CDC reported that HIV transmission was associated with receiving a tattoo in prison. There have also been instances of people contracting hepatitis B after receiving a tattoo.

Hepatitis B is a disease caused by a virus (HBV) that attacks the liver. The virus can cause liver failure and death. HBV can be spread through sexual contact and by sharing needles, razors, or other items that might have blood on them. It can also be passed from mother to baby during birth.

The American Red Cross, citing concerns about hepatitis, says a blood donor must wait 12 months to donate after being tattooed if he was tattooed in a state that does not regulate the industry.

Aside from being vaccinated against HBV, following sanitary procedures are the best way to safeguard against contracting the virus through tattooing.

As for contracting hepatitis C (HCV), experts believe that tattooing is a risk factor for HCV transmission, but the evidence isn't conclusive. In a December 2006 position paper, the CDC noted that although there is always the risk of exposure to a disease like hepatitis C when skin is punctured, there is no data to support that tattooing alone puts a person at risk for HCV. However, a study of 626 spinal disorder patients in Dallas, Texas showed that receiving a tattoo from a commercial tattoo parlor was strongly associated with having hepatitis C antibodies. (This means that at some point in the past, the hepatitis C virus was present in the body.) The researchers did not find a correlation between tattooing and active hepatitis C infection, but the study results did suggest that receiving a tattoo can be an important risk factor for HCV transmission.

There may be many reasons why someone chooses to have a tattoo removed. Some tattoos might change in appearance with the contours of your body over time. Gmyrek, the dermatologist with Columbia University, says she's used lasers to remove the names of several of her patients' ex-girlfriends. Some people who grow tired of a tattoo might choose to have it lightened to the point that another tattoo -- or cover up -- can be put in its place.

The three most common methods of tattoo removal are dermabrasion, excision, and laser surgery.

Despite its high cost, laser treatments are the most popular method of tattoo removal. A person gets eight to 12 laser treatments and the skin gets lighter with each treatment. However, there is no guarantee it will completely erase all of the ink.

Gmyrek notes, for example, that some inks common in cosmetic tattooing can darken to black if lasers are used to try to remove them. And there are other possible drawbacks, including skin discoloration. Discoloration is the most common problem associated with laser removal of tattoos, and it's especially common in darker-skinned people. The skin's melanin might absorb the laser energy that's meant to break up the ink, resulting in a lightening of the skin called hypopigmentation. This can be temporary or permanent. A temporary darkening of the skin called hyperpigmentation almost always returns to normal after a while.

Many products on the market claim to be tattoo removal balms or creams, but don't be fooled. Gmyrek says she has seen some topical creams that contain skin lightening agents and exfoliants, neither of which could remove a tattoo.

As for Shannon Elliott, she's getting no pleasure from her laser tattoo removal sessions. She can smell her own burning skin, as the heat from the laser causes the skin to blister. It's a much more difficult process than getting a tattoo.

"As far as I remember, I think it hurts more -- and the healing process is worse," she says.

So if half of all people who get tattoos end up wanting them removed, what's her advice to all would-be tattoo aficionados? "Make sure you're in the right half."

-- Jenny Montgomery is a freelance journalist living and working in Indianapolis, Indiana.

References

First published December 6, 2007
Copyright © 2007 Consumer Health Interactive