Complications and measures

Needle prick in eyeball

 The figure below shows a case in which a needle was stuck in the eyeball during eyeliner treatment. Vasodilation is thus seen in addition to conjunctival edema when the depth reaches the sclera beyond the conjunctiva.

 Antibiotics and steroid eye drops subsided after about 6 weeks, but the pigmentation in the white of the eye remained.

Figure 14 

The reproduction of a figure in "Full-thickness eyelid penetration during cosmetic blepharopigmentation causing eye injury. J Cosmet Dermatol. 2008 Mar;7(1):35-8".

 The figure below is also a case of pigmentation caused by mistakenly pricking the white of the eye, which was scraped off with a diamond bur at an ophthalmologist from the cosmetic point of view . There were no symptoms such as pain immediately after the treatment, and only the pigmentation was a concern, so it is likely that the pigmentation remained in a relatively shallow layer.

 If the needle penetrates the sclera, it can damage the retina on the back and cause a retinal detachment, which can lead to inflammation throughout the vitreous, causing panophthalmitis. In that case, the risk of blindness is high, so in the unlikely event that a needle stick accident occurs, it is necessary to immediately consult an ophthalmologist, and it is desirable to maintain regular contact with an ophthalmologist.

Figure 15

The reproduction of a figure in "Inadvertent pigmentation of the limbus during cosmetic blepharopigmentation. Cornea. 2009 Jul;28(6):712-3".

Meibomian gland blockage

There are meibomian glands inside the eyelashes, and if permanent makeup is applied to this area to finish the eyeliner neatly, the openings of the glands may be damaged and blocked, resulting in dry eyes.  The figure below shows the remaining black pigment and the dilated meibomian gland (small yellow mass) with blocked orifice.

Figure 16

The reproduction of a figure in "A Case of Meibomian Gland Dysfunction after Cosmetic Eyelid Tattooing Procedure. J Korean Ophthalmol Soc. 2013 Jan; 54(8):1309-13"

Fanning

A fanning is a phenomenon in which the pigment spreads out in a fan shape after the eyeliner is applied to the lower eyelid margin. It is said to occur when the pigment penetrates deeply (say about 1.5 mm) beyond the papillary dermis and flows into the lymphatic system.

The photo below shows an example of fanning on the right side only. This case was treated with 8 cycles of Q-switched alexandrite laser (7.5 J/cm2). In another case, it has been treated by excising and grafting pigmented skin （Extensive lower eyelid pigment spread after blepharopigmentation. Ophthalmic Plast Reconstr Surg. 1999 Nov;15(6):445-7）.

Figure 17

The reproduction of a figure in "Complications of eyelash and eyebrow tattooing: reports of 2 cases of pigment fanning. Cutis. 2001 Jul;68(1):53-5".

Infection

 In a report in Japan in 2021, when complications were counted from 1188 eyebrows and 243 eyeliners, 7 cases (0.6%) of infections occurred in the eyebrows　（Complications of permanent makeup procedures for the eyebrow and eyeline. Medicine (Baltimore). 2021 May 7;100(18):e25755）.

 Although it is not mentioned in the paper, one reason is that many facilities use foreign-made dyes without resterilization. If the process of subdividing and re-sterilizing before use as described above is followed, the incidence rate should be further reduced.

 Atypical Mycobacteriois is one of the infections that are not treated with ordinary antibiotics. Case reports of atypical mycobacteriosis in tattoos are quite a lot. The source of infection is the ink or the water used for dilution, and there are also reports that the causative bacteria have been identified from unopened ink （Outbreak of Tattoo-associated Nontuberculous Mycobacterial Skin Infections Clin Infect Dis. 2019 Aug 30;69(6):949-55, Tattoo-Associated Nontuberculous Mycobacterial Skin Infections—Multiple States, 2011-2012. MMWR Morb Mortal Wkly Rep 2012;61:653-6）.

 This means that the ink was contaminated during manufacturing. The U.S. FDA does not mandate sterilization of tattoo and permanent makeup pigments. Again, when using dyes made in the United States or other foreign countries, doctors should take responsibility for sterilizing them in the manner described above.

Figure 18

 Atypical mycobacterial infection that occurred after permanent makeup. The reproduction of a figure in "A Chinese tattoo paint as a vector of atypical mycobacteria-outbreak in 7 patients in Germany. Acta Derm Venereol. 2011 Jan;91(1):63-4".

Allergy

The patch test positive rate is very low. It is thought that the pigment binds to proteins in the skin as a hapten, and the substance after being changed by enzymes or photochemical reactions becomes an allergen （Patch test study of 90 patients with tattoo reactions: negative outcome of allergy patch test to baseline batteries and culprit inks suggests allergen(s) are generated in the skin through haptenization. Contact Dermatitis. 2014 Nov;71(5):255-63）.

Clinical and histological features of allergic reactions include granulomatous reaction, lichenoid reaction, pseudolymphomatous reaction, and urticaria (hypersensitivity reaction) (cutaneous allergic reactions to tattoo ink. J Cosmet Dermatol. 2009 Dec;8(4):295-300.). The first three are difficult to distinguish from the clinical appearance.

Allergic reaction as a complication of permanent makeup presents a completely different aspect from contact dermatitis caused by ordinary cosmetics. This is due to the difference between cosmetics that only touch the skin and can be washed off, and pigments that remain in the skin for a long period of time.

There is another easily overlooked issue with allergies. This will appear later when you try to remove the pigment with a laser, and it is related to the fact that the pigment is decomposed, and the particles become finer.

Decomposed and finer particles flow to the regional lymph nodes. Regional lymph node swelling may occur after tattoo removal with a Q-switched laser (Transient immunoreactivity after laser tattoo removal: report of two cases Lasers Surg Med. 2008 Apr;40(4):231-2）, and delayed or immediate allergic symptoms may develop throughout the body （Immediate cutaneous hypersensitivity after treatment of tattoo with Nd:YAG laser: a case report and review of the literature Ann Allergy Asthma Immunol. 2002 Aug;89(2):215-7, Allergic reactions to tattoo pigment after laser treatment Dermatol Surg. 1995 Apr;21(4):291-4）.

Irradiating permanent makeup and tattoos with Q-switched lasers does not mean that the pigments disappear. After being broken down into smaller particles or transformed into different chemicals by the energy of the laser light, they circulate through the lymphatic system. Some will eventually be excreted, while others will remain deposited in lymph nodes and other tissues.

Therefore, especially in cases where allergies are suspected, irradiation with a Q-switched laser to erase permanent makeup pigments may instead induce systemic allergies and complicate the problem.

The principle of allergy treatment is to remove the allergen, and the idea of ​​excreting the pigment out of the body is correct. However, as a specific method, it is desirable to use surgical excision, CO2 laser ablation, or fractional-laser discharge enhancement instead of Q-switched laser　(Treatment of tattoo allergy with ablative fractional resurfacing: a novel paradigm for tattoo removal J Am Acad Dermatol. 2011 Jun;64(6):1111-4).

In addition, there is a case report that a patient suspected of having an allergy to permanent makeup on the lips received the corona vaccine three times, but the rash worsened each time. The enhanced immune response may also have influenced allergic reactions.

Sarcoidosis

Sarcoidosis or sarcoid reaction may occur at the site of permanent makeup, and although the reason is unknown, there are many clinical reports in Japan.

A typical eruption is a hypertrophic scar-like flat rise, but the lesion may spread beyond the treatment site.

Differentiation should be made from pigment-induced allergic reactions, pseudolymphoma, and mycobacterial and fungal infections. Diagnosis is by confirmation of non-caseating epithelioid granuloma by skin biopsy and exclusion of infection by culture or molecular techniques.

Scrutiny is necessary because there is a condition called systemic sarcoidosis in which similar granulomas occur in various organs. Since eruption on permanent makeup sites may develop initially and later progress to systemic sarcoidosis, sufficient follow-up is necessary even if no lesions are confirmed in other organs （Intermediate Uveitis Associated with Tattooing of Eyebrows as a Manifestation of Systemic Sarcoidosis: Report of Two Cases.　Ocul Immunol Inflamm. 2021 Jul 4;29(5):902-905）.

There is a dermatological term "Koebner phenomenon". It refers to a phenomenon in which a rash is induced by an external stimulus, and sarcoidosis includes the Koebner phenomenon. It is possible that the eruption that accompanies the site where the needle is pricked in permanent makeup is exactly the result of this Koebner phenomenon.

On the other hand, it is not necessarily the case that permanent makeup is contraindicated for sarcoidosis patients. Sarcoidosis is not contraindicated in a 2018 paper summarizing the risks of tattooing for people with various skin and systemic conditions　（A Practical Guide About Tattooing in Patients with Chronic Skin Disorders and Other Medical Conditions Am J Clin Dermatol. 2018 Apr;19(2):167-180）.

Although there is a risk of Koebner's phenomenon, it is thought that it does not necessarily provoke a rash, but sufficient explanation and consent will be necessary. It is because even if the  patient with sarcoidosis knows the diagnosis, the patient does not necessarily know about Koebner's phenomenon.

Other skin conditions that exhibit Koebner phenomenon include psoriasis.

Figure 19

Various eruptions of sarcoidosis or cutaneous sarcoid reaction. Left: “A case of multiple skin sarcoid reactions caused by permanent makeup and swelling of hilar lymph nodes” Clinical Dermatology 71 (4), 307-312, 2017. Middle: “Skin sarcoid reactions formed by permanent makeup” Dermatology Clinic 35 (2), 193-196, 2013. Right: “Cases considered to be cutaneous sarcoid reactions due to permanent makeup” Dermatology Clinic 35 (2), 193-196, 2013. Photo reproduction from each article .

 Even dermatologists find it difficult to distinguish whether the eruption that occurs after permanent makeup is an allergy, an infection, sarcoidosis, or lymphoma, based only on the clinical appearance. As the doctors and nurses who perform the treatment do not necessarily specialize in dermatology, they can simply write a letter of introduction to a specialist or university hospital so if they encounter a suspicious case. But an outline of how diagnosis and treatment are carried out should be grasped. There is a paper summarizing the algorithm, so I will introduce it （Diagnostic Approach for Suspected Allergic Cutaneous Reaction to a Permanent Tattoo J Investig Allergol Clin Immunol. 2019;29(6):405-413）. However, it is only one way of thinking, and of course this algorithm is not absolute.

Figure 19

 Algorithm for dealing with skin lesions on tattoos.

If the period from treatment to onset is as short as one month or less, an allergy or infection should be suspected. Antibiotics are administered if signs of infection such as pustules are formed. If unsuccessful, skin biopsy is done.

If more than a month has passed since the onset of symptoms, a biopsy is performed first. If allergy is suspected due to itching or eczema-like appearance, a patch test should be tried, although the positive rate is low.

If histological examination reveals granulomatous lesions, special staining is performed to confirm the possibility of mycobacteria or fungi. At the same time, consider the possibility of sarcoidosis and perform a whole-body examination.

Despite this progress, it is not uncommon for the cause of granuloma formation to remain unknown. It is sometimes case reported as a “granulomatous reaction after permanent makeup or tattoo.”

Figure 20

An example of granuloma reaction. The reproduction of a figure in "Granulomatous tissue reaction following cosmetic eyebrow tattooing J Dermatol. 1991 Jun;18(6):352-5".

Herpes simplex

There is a case report pointing out that permanent makeup on the lips may have triggered the recurrence of herpes simplex （Activation of Herpes Simplex Infection after Tattoo. Acta Dermatovenerol Croat. 2018 Apr;26(1):75-76）.

Skin cancer

As mentioned above, permanent makeup pigments may contain carcinogenic substances such as PAH as impurities, and like some azo pigments, they may change into carcinogenic substances in the body. Is skin cancer likely to occur in permanent makeup sites?

There are many case reports of skin cancer at tattoo sites. According to a 2012 review of 50 cases from past literature, 23 of the 50 cases were squamous cell carcinoma and keratoacanthomas, 16 were malignant melanoma, and 11 were basal cell carcinoma. However, these are only case reports, and it is not known whether the risk is high.

A 2020 epidemiological study in New Hampshire, USA, showed that tattooed areas are at increased risk of developing basal cell carcinoma (Cosmetic Tattooing and Early Onset Basal Cell Carcinoma: A Population-based Case -Control Study from New Hampshire. Epidemiology. 2020 May;31(3):448-450). Yellow and green pigments had a high carcinogenic risk, and black pigments did not appear to be different from the control.

I myself do not have a clinical feeling that skin cancer is more likely to occur in areas with tattoos or permanent makeup. However, it may be that risks emerge in strictly controlled epidemiological studies.

Anaphylactic shock

Anaphylactic shock is by no means limited to permanent makeup, and in treatments that use drugs, although it is not frequent, it can occur.

There are not many case reports, but that may be due to the judgment that the content is not new enough to be kept in the medical record. There are the following papers.

“Anaphylactic reaction to permanent tattoo ink. Ann Allergy Asthma Immunol. 2009 Jul;103(1):88-9”,“From the Tattoo Studio to the Emergency Room.Dtsch Arztebl Int. 2016 Oct 7;113(40):672-675”

For the diagnosis and treatment of anaphylactic shock, please refer to the “Anaphylaxis Guidelines 2022 of the Japanese Society of Allergology.

https://anaphylaxis-guideline.jp/wp-content/uploads/2022/12/anaphylaxis_guideline2022.pdf

There are two main points: distinguishing it from the vasovagal reflex and keeping adrenaline on hand.

For the former, it is good to check the pulse rate. If it is a vasovagal nerve reflex, the patient has bradycardia. Put the head down in the Trendelenburg position and respond by talking to the patient to reassure.　For this reason, it is desirable (but not essential) that the treatment bed can be of head-down construction.　In case of tachycardia, consider the possibility of anaphylaxis, and without hesitation, inject 0.01 mg adrenaline per kg of body weight (0.5 mg for a person weighing 50 kg) intramuscularly. As for adrenaline, even if it is a prefilled syringe, the price is inexpensive at several hundred yen per bottle. Though many clinics do not have it on hand because it will often expire without being used, it is a necessity as long as treatments using drugs are performed.